Assessment of long-term donor-site morbidity after harvesting the latissimus dorsi flap for neonatal myelomeningocele repair

Quality of Life After Lower Leg Reconstruction With the Latissimus Dorsi Free Flap in Pediatric Patients

BACKGROUND

The latissimus dorsi free flap is a widely used reconstructive technique for complex lower leg defects in the pediatric population due to its reliability and anatomical features. However, the impact of this technique on the postoperative quality of life in children and adolescents, who require appropriate lower extremity function during their developmental period, remains to be analyzed.

METHODS

Patients who underwent microsurgical lower leg reconstruction using the latissimus dorsi flap were analyzed retrospectively. The quality of life of these patients was assessed prospectively using the Lower Extremity Functional Scale (LEFS) at a minimum of 18 months after surgical reconstruction.

RESULTS

Sixteen pediatric patients who had severe lower extremity injuries and underwent latissimus dorsi free flap reconstruction met the inclusion criteria. The mean follow-up period was 33.9 months (22-64 months). Two patients experienced postoperative complications: one had partial flap necrosis and surgical site infection, while the other developed a surgical site infection. The LEFS scores ranged from 26 to 80, with a mean score of 64.6. Remarkably, 14 of 16 patients achieved LEFS scores consistent with at least the 10th percentile when compared with normative data. Patients with severe associated fractures presented with the lowest scores.

CONCLUSIONS

Based on our findings, the latissimus dorsi flap is reaffirmed to be an excellent choice for lower leg reconstruction in the pediatric population. It effectively restores the quality of life in patients who have experienced moderate to severe lower extremity injuries.

Prospective Pilot Study of Robotic-Assisted Harvest of the Latissimus Dorsi Muscle: A 510(k) Approval Study with U.S. Food and Drug Administration Investigational Device Exemption

BACKGROUND

There are no U.S. Food and Drug Administration (FDA)-approved indications for robotic plastic surgery. This study was designed to demonstrate safety and efficacy of the robotic latissimus dorsi harvest for FDA approval.

METHODS

This prospective, single-arm study was conducted under an investigational device exemption through the FDA for obtaining 510(k) approval. The primary safety endpoint was adverse events attributable to harvest. Primary efficacy endpoints included muscle viability after harvest and conversion to open technique. Secondary endpoints included postoperative pain and upper extremity function.

RESULTS

Fifteen patients enrolled, with a mean age of 50 ± 10 years and a mean body mass index of 25 ± 4 kg/m2. There were no adverse events, all muscles were viable after harvest, and there were zero conversions to open procedures. Visual analogue scale scores for pain progressively decreased postoperatively and returned to baseline, indicating resolution of postoperative pain. Physical therapy assessment demonstrated recovery of function in all range-of-movement domains by 36 weeks. There was no difference in function of the operated extremity between baseline and 36 weeks' follow-up for Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire (p = 0.87); QuickDASH Work Module (p > 0.05); and QuickDASH Sports Module (p > 0.05).

CONCLUSIONS

The use of the da Vinci Robotic Surgical System is safe based on zero adverse events attributable to harvest and efficacious based on 100 percent muscle viability after harvest and zero conversions to open technique. There appears to be little to no long-term functional deficit or pain from muscle harvest. Given these results and their own prestudy guidelines, the robotic latissimus dorsi qualifies for 510(k) submission by Intuitive Surgical and approval by the U.S. FDA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Revisiting pedicled latissimus dorsi flaps in head and neck reconstruction: contrasting shoulder morbidities across mysofascial flaps

Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.

Morphometric Features of the Latissimus Dorsi Muscle in Fetal Cadavers With Meningomyelocele for Prenatal Surgery

PURPOSE

Latissimus dorsi (LD) flaps are frequently used in the prenatal meningomyelocele (MMC) repairs; on that basis, this study aims to reveal the morphometric features of LD, thoracodorsal artery (TDA) and nerve (TDN) in fetal cadavers with MMC defects, with an anatomical perspective.

METHODS

The study was conducted on 7 formalin-fixed human fetal cadavers (4 males and 3 females) with MMC defects, aged from 18 to 27 weeks of gestation. The size of LD, TDA, and TDN including their area, length, and width were measured by a digital caliper and digital image analysis software. Our direct measurements were compared with the corresponding estimations of a previous study in the literature which provides regression formulae based on gestational age.

RESULTS

The fetal cadavers with MMC had bilateral LD. No significant differences were found in the numerical data of anatomical structures between the sides or the sexes. LD size (ie, area, length and width) was approximately 3% to 10% smaller in the fetuses with MMC defects than that of the normal fetuses. Unilateral LD flap in a 22-week-old fetus with a large MMC was evaluated as insufficient to close the defects.

CONCLUSION

Ten percent shrinkage in the area of LD might be too critical to be disregarded by surgeons during the closure of MMC defects. The dimensional findings about LD (area, length, and width) may be helpful in planning of LD flap harvesting for the repairs of MMC.

Evaluation of Donor Morbidity following Single-Stage Latissimus Dorsi Neuromuscular Transfer for Facial Reanimation

BACKGROUND

Single-stage latissimus dorsi neuromuscular transfer has been a valuable option for dynamic smile reanimation. However, there is a paucity of studies evaluating the potential donor morbidity in such cases. The present study aimed to comprehensively analyze the donor morbidity following functional latissimus dorsi muscle transfer.

METHODS

Patients who underwent single-stage functional latissimus dorsi muscle transfer for smile reanimation between 2002 and 2016 were reviewed. Postoperative complications and functional impairments at the donor sites were evaluated. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was used for assessing postoperative donor-site function.

RESULTS

Sixty patients, including 12 pediatric (18 years or younger) patients, were analyzed. Mean length of a harvested thoracodorsal nerve was 14.9 cm. Fourteen patients were treated with a dual innervation technique, in which both a descending and a transverse branch of the thoracodorsal nerve were harvested. Donor complications were observed in seven cases; all of them were seromas and resolved by simple aspiration. No other complications including scoliosis and sensory and/or motor disturbances in the upper extremities were encountered. Fifty patients responded to the Quick-Disabilities of the Arm, Shoulder and Hand questionnaire at a median follow-up of 51 months. The average score was 2.64, and all but three patients scored less than 10. No variables, including patient age (pediatric versus adult) and the use of a dual-innervation technique, affected the donor morbidities, including the functional deficits.

CONCLUSION

Single-stage latissimus dorsi neuromuscular transfer for facial reanimation might be associated with a low rate of complications and minimal functional morbidity at the donor site.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Adipofascial Flaps With Acellular Dermal Matrix Compared With Myocutaneous Flap Reconstruction in Lumbar Myelomeningocele Defects

BACKGROUND

Adipofascial flaps (AFF) with acellular dermal matrix (ADM) have the potential to reconstruct neural tube defects without sacrificing muscle that may be critical for long-term function. Comparative studies between myocutaneous flap (MF) reconstruction, the accepted standard reconstructive technique, and AFF/ADM remain under-reported. The aim of this study was to evaluate the safety and efficacy of myelomeningocele reconstruction using muscle sparing AFF/ADM versus MF.

METHODS

A retrospective comparison was conducted on consecutive myelomeningocele patients reconstructed with MF or AFF/ADM over an 84-month period. Data analyzed included: basic demographics, defect size, reconstructive technique, complications, and length of follow-up. A supplemental meta-analysis based on systematic review of literature was performed to compare alternative reconstructive options.

RESULTS

Twelve patients were identified who met inclusion criteria. Median age, weight, and defect size at reconstruction in the AFF/ADM group (n = 6) was 37.5 weeks, 3.25 kg, and 20.0 cm, respectively, and in the MF group (n = 6) was 37 weeks, 3.6 kg, and 22.5 cm (P > 0.5). For the AFF/ADM versus MF groups, median follow-up was 33.8 versus 22.6 months, reoperation rate was 0% versus 17% (P = 1.0), and complex skin flap closure rate was 17% versus 100% (P = 0.015). No cerebrospinal fluid leaks or surgical site infections occurred in either group. Meta-analysis of the literature revealed no statistically significant difference in complications rates between muscle and nonmuscle flap reconstruction (P > 0.5); potential long-term sequelae of muscle flap harvest were not included.

CONCLUSIONS

Muscle sparing AFF with ADM is a safe and effective surgical alternative to muscle flaps for lumbar myelomeningocele reconstruction.

An Ideal Flap Alternative for Closure of Myelomeningocele Defects: Dorsal Intercostal Artery Perforator Flap

BACKGROUND

Dorsal intercostal artery perforator (DICAP) flap is an ideal flap to be used for posterior trunk defects since it leads to lower donor-site morbidity and shorter operative times, offers easy surgical planning, and uses a reliable and easily identifiable artery.

MATERIALS AND METHODS

The study retrospectively reviewed 52 patients with meningomyelocele defects that were closed with DICAP flap between January 2007 and May 2015.

SURGICAL TECHNIQUE

Each of the 4th to 12th posterior intercostal arteries can be used as dorsal perforators. The dominant direct cutaneous perforators derive from the 4th, 5th, 6th, 10th, and 11th posterior intercostal arteries. These perforators are located 5 cm medial to the spinous processes of the thoracic vertebrae and can be easily identified.

CONCLUSION

Dorsal intercostal artery perforator flap is a reliable flap alternative for the defects seen in neonates, including myelomeningocele, oncologic resections, burn defects, and radiation burns since it is a thin flap and offers easy surgical planning and shorter operative times.

Comparison of the Ramirez technique for the closure of large open myelomeningocele defects with alternative methods

BACKGROUND

To compare the Ramirez technique for the operative closure of large open myelomeningocele defects with conventional closure techniques in newborns. We hypothesized that the immediate surgical treatment with the Ramirez technique is superior to prior used operative techniques.

METHODS

From 2003 to 2010, 23 children (8 female, 15 male) underwent closure of large open myelomeningocele defects using the Ramirez technique (group A), while from 1993 to 2002, 23 children (6 female, 17 male) underwent conventional closure techniques (group B). All children were included in the retrospective analysis with a mean follow-up period of 3.4 years.

RESULTS

Perioperative variables were similar in both groups (P = ns). There were no hospital deaths in both groups. The operation time was significantly higher in group A (228.7 ± 76.8 versus 157.8 ± 70.3 min, P = 0.003). Mean length of hospital stay was significantly lower in group A (30.7 ± 16.4 days versus 52.0 ± 38.5; P = 0.02). Postoperative complication rate was significantly lower in group A (P = 0.01). Beyond postoperative day 10, liquor fluid leakage was significantly lower in group A (P = 0.05). During follow-up, there were no complications in group A. In group B, 2 children developed liquor fistulas.

CONCLUSIONS

The Ramirez technique allows efficient and safe closure of large open myelomeningocele defects and reduces incidence of postoperative liquor fistulae. The increased operation time and surgical efforts seem to be justified. Treatment of large myelomeningocele defects requires an interdisciplinary team including paediatrician-neonatologists, neurosurgeons and plastic surgeons.

Fetal surgery for myelomeningocele is effective: a critical look at the whys

Formerly, the disastrous cluster of neurologic deficits and associated neurogenic problems in patients with myelomeningocele (MMC) was generally thought to solely result from the primary malformation, i.e., failure of neurulation. Today, however, there is no doubt that a dimensional additional pathogenic mechanism exists. Most likely, it contributes much more to loss of neurologic function than non-neurulation does. Today, there is a large body of compelling experimental and clinical evidence confirming that the exposed part of the non-neurulated spinal cord is progressively destroyed during gestation, particularly so in the third trimester. These considerations gave rise to the two-hit-pathogenesis of MMC with non-neurulation being the first and consecutive in utero acquired neural tissue destruction being the second hit. This novel pathophysiologic understanding has obviously triggered the question whether the serious and irreversible functional loss caused by the second hit could not be prevented or, at least, significantly alleviated by timely protecting the exposed spinal cord segments, i.e., by early in utero repair of the MMC lesion. Based on this intriguing hypothesis and the above-mentioned data, human fetal surgery for MMC was born in the late nineties of the last century and has made its way to become a novel standard of care, particularly after the so-called "MOMS Trial". This trial, published in the New England Journal of Medicine, has indisputably shown that overall, open prenatal repair is distinctly better than postnatal care alone. Finally, a number of important other topics deserve being mentioned, including the necessity to work on the up till now immature endoscopic fetal repair technique and the need for concentration of these extremely challenging cases to a small number of really qualified fetal surgery centers worldwide. In conclusion, despite the fact that in utero repair of MMC is not a complete cure and not free of risk for both mother and fetus, current data clearly demonstrate that open fetal-maternal surgery is to be recommended as novel standard of care when pregnancy is to be continued and when respective criteria for the intervention before birth are met. Undoubtedly, it is imperative to inform expecting mothers about the option of prenatal surgery once their fetus is diagnosed with open spina bifida.