Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification

BACKGROUND

Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken.

OBJECTIVE

This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF).

METHODS

Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA).

RESULTS

Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm).

CONCLUSIONS

By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.

[Methods of repairing large soft tissue defect with latissimus dorsi myocutaneous flap and management of secondary wound in donor site]

Objective: To explore the methods of repairing large soft tissue defect with latissimus dorsi myocutaneous flap and the management of secondary wound in donor site. Methods: From June 2015 to June 2019, 30 patients with soft tissue defect caused by various reasons or hyperplastic scar were hospitalized in the First Medical Center of Chinese PLA General Hospital, including 10 males and 20 females, aged 25-64 years, with 18 cases of head soft tissue defects caused by the growth and rupture of tumor, 7 cases of hypertrophic scar in trunk and limbs, and 5 cases of facial and neck soft tissue defects caused by trauma. The area of primary wound after debridement or enlarged lesion resection was 14 cm×10 cm-18 cm×16 cm. Preoperative evaluation of 20 patients showed that the wound was relatively large, and the donor site could not be directly closed by suturing after resection of conventional single-lobe latissimus dorsi myocutaneous flap, so the bilobed latissimus dorsi myocutaneous flap with area of 14 cm×5 cm-18 cm×8 cm was cut to repair the wound, and the donor site was directly closed by suturing. Preoperative evaluation of 10 patients showed that the donor site could be directly closed by suturing after resection of conventional single-lobe latissimus dorsi myocutaneous flap, so that conventional single-lobe latissimus dorsi myocutaneous flap with area of 11 cm×9 cm-13 cm×10 cm was resected to repair the primary wound, resulting in big tension in donor site and secondary wound with area of 6 cm×4 cm-8 cm×6 cm that couldn't be directly sutured, which was repaired with donor site local flap with area of 7 cm×4 cm-9 cm×6 cm, and the second donor site was directly closed by suturing. Intraoperative end-to-end anastomosis was performed between the thoracodorsal arteries and veins of the latissimus dorsi myocutaneous flap and the arteries and veins of the primary recipient wound. The survival of latissimus dorsi myocutaneous flaps and local flaps were observed after surgery, and the appearance and function of the donor and recipient areas were observed during follow-up. Results: All the latissimus dorsi myocutaneous flaps and local flaps survived in the patients after surgery. Follow-up of 6-12 months showed that the latissimus dorsi myocutaneous flap was similar in color to the surrounding normal skin, with soft texture and good elasticity. The donor site of 20 patients repaired with bilobed latissimus dorsi myocutaneous flaps were only left with linear scars, among which 2 patients had hypertrophic scars and none had functional impairment. The donor site of 10 patients repaired with single-lobe latissimus dorsi myocutaneous flaps and donor site local flaps had good appearance, left with linear scar, irregular shape, but no local traction or dysfunction. Conclusions: When repairing a large soft tissue defect, the bilobed latissimus dorsi myocutaneous flap or the single-lobe latissimus dorsi myocutaneous flap combined with the local flap transfer in the donor site can be used after preoperative evaluation so that the donor site wound can be closed at one time while repairing the primary wound. The donor site has less scar, and both the recipient and donor sites have good appearance and function after surgery.

Dermatofibrosarcoma protuberans (DFSP) arising from a keloid scar - A case report

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma with an indolent early course that may be misdiagnosed for benign skin pathology. In this case-report we highlight an instance of DFSP arising from a keloid scar de novo and present a reconstruction with a local pedicled LD flap. We subsequently appraise the related literature and discuss the diagnostic challenges.

[Effectiveness of posterior intercostal artery perforator flap in repair of donor defect after latissimus dorsi myocutaneous flap transfer]

Objective

To investigate the feasibility and effectiveness of the latissimus dorsi myocutaneous flap in repair of large complex tissue defects of limb and the relaying posterior intercostal artery perforator flap in repair of donor defect after latissimus dorsi myocutaneous flap transfer.

Methods

Between January 2016 and May 2017, 9 patients with large complex tissue defects were treated. There were 8 males and 1 female with a median age of 33 years (range, 21-56 years). The injury caused by traffic accident in 8 cases, and the time from post-traumatic admission to flap repair was 1-3 weeks (mean, 13 days). The defect in 1 case was caused by the resection of medial vastus muscle fibrosarcoma. There were 5 cases of upper arm defects and 4 cases of thigh defects. The size of wounds ranged from 20 cm×12 cm to 36 cm×27 cm. There were biceps brachii defect in 2 cases, triceps brachii defect in 3 cases, biceps femoris defect in 2 cases, quadriceps femoris defect in 2 cases, humerus fracture in 2 cases, brachial artery injury in 2 cases, and arteria femoralis split defect combined with nervus peroneus communis and tibia nerve split defect in 1 case. The latissimus dorsi myocutaneous flaps were used to repair the wounds and reconstruct the muscle function. The size of the skin flaps ranged from 22 cm×13 cm to 39 cm×28 cm; the size of the muscle flaps ranged from 12 cm×3 cm to 18 cm×5 cm. The wounds were repaired with pedicle flaps and free flaps in upper limbs and lower limbs, respectively. The donor sites were repaired with posterior intercostal artery perforator flaps. The size of flaps ranged from 10 cm×5 cm to 17 cm×8 cm. The second donor sites were sutured directly.

Results

All the flaps survived smoothly and the wounds and donor sites healed by first intention. All patients were followed up 10-19 months (mean, 13 months). At last follow-up, the flaps had good appearances and textures. The muscle strength recovered to grade 4 in 5 cases and to grade 3 in 4 cases. After latissimus dorsi myocutaneous flap transfer, the range of motion of shoulder joint was 40-90°, with an average of 70°. The two-point discrimination of latissimus dorsi myocutaneous flap was 9-15 mm (mean, 12.5 mm), and that of posterior intercostal artery perforator flap was 8-10 mm (mean, 9.2 mm). There were only residual linear scars at the second donor sites.

Conclusion

The latissimus dorsi myocutaneous flap combined with posterior intercostal artery perforator flap for the large complex tissue defects and donor site can not only improve the appearance of donor and recipient sites, but also reconstruct muscle function, and reduce the incidence of donor complications.

The use of contralateral free extended latissimus dorsi myocutaneous flap for a tertiary failed breast reconstruction: Is it still an option?

BACKGROUND

Unsuccessful breast reconstruction management represents a complex challenge for the plastic surgeon. Although these events rarely occur, many patients are not suitable candidates for conventional flaps, because of either previous donor-site surgery or lack of sufficient tissue.

METHODS

In this study, a contralateral free latissimus dorsi musculocutaneous flap (CL-LDMF) was planned for correction of major lesions in the anterior chest wall. Twelve patients underwent secondary/tertiary breast reconstruction with CL-LDMF with a customized shape (horizontal, oblique, or "fleur-de-lis") depending on the amount of tissue necessary. The technique was indicated in patients with large thoracic defects who lacked a donor site and had undergone previous unsuccessful pedicled LDMF.

RESULTS

The mean follow-up time was 42.5 months (range: 18-72 months). Five local complications occurred in four of the 12 patients. Dorsal dehiscence was observed in one, local wound infection in one, small partial CL-LDMF necrosis in one, and dorsal seroma in one patient. All cases of complications were limited and treated with a conservative approach except for one implant extrusion 4 months after reconstruction. No total flap loss was reported. All patients achieved a satisfactory thoracic and breast reconstruction.

CONCLUSION

The results of this study demonstrate that free CL-LDMF is a reliable technique and should be considered in selected cases of tertiary reconstructions. The majority of complications were immediate, minor, and comparable to other reconstructive techniques. We believe that in selected patients, especially those who do not have available donor-site areas, free CL-LDMF is advantageous and should be part of the armamentarium of all plastic surgeons who deal with tertiary breast reconstructions.

The pedicled latissimus dorsi myocutaneous flap in head and neck reconstruction

The pedicled latissimus dorsi myocutaneous flap (PLDMF) is not the first-line reconstructive option for most clinicians; however, when treating salvage patients or those with depleted neck vessels, the PLDMF provides a valuable armamentarium. Unlike the pectoralis major myocutaneous flap or the lower island trapezius flap, the PLDMF has greater versatility in soft tissue design and a longer arc of rotation. These advantages are of great importance in managing advanced reconstructive cases.

Immediate chest wall reconstruction during pregnancy: surgical management after extended surgical resection due to primary sarcoma of the breast

BACKGROUND

Breast sarcoma during pregnancy is an extremely rare event and represents a complex problem because of a more advanced stage at presentation.

METHOD

This report presents the first case of a 24-year-old woman with a gestational age of 20 weeks with a fast growing tumour in her left breast (29 × 19 × 15 cm) and infiltrating the skin/pectoralis muscles. Radical mastectomy was performed with a gestational age of 22 weeks and a different design was planned for the latissimus dorsi musculocutaneous flap (LDMF) with primary closure in the V-Y pattern.

RESULT

Satisfactory chest wall coverage and contour were achieved. Final histopathological findings allowed a diagnosis of undifferentiated sarcoma. With a gestational age of 37 weeks, a healthy infant was delivered by means of a caesarean section. The patient is currently in the second postoperative year and no recurrence has been observed.

CONCLUSION

Management of a large breast sarcoma in a pregnant patient presents unique challenges in consideration of the potential risks to the foetus and the possible maternal benefit. The results of this study demonstrate that the VY-LDMF is a reliable technique and should be considered in cases of immediate large thoracic wound reconstruction.