Search

Introduction: The reconstruction of extensive scalp defects often requires free tissue transfer, offering single-stage and reliable reconstruction. The aim of this study is to evaluate the outcomes of free tissue transfer in scalp reconstruction. Patients and Methods: Thirteen patients were included in the study. Patient age, gender, smoking status, comorbidities, defect etiology, the specific type of flap used, the chosen recipient artery and vein, the need for revision, and flap success were reviewed. Results: The majority of the patients were male (76.9%). Defect reconstruction was performed using the latissimus dorsi musculocutaneous flap in 10 (71.4%) cases, which was followed by anterolateral thigh (ALT) and vertical rectus abdominis flaps. Two patients needed expansion of latissimus dorsi flaps. Superficial temporal vessels were used as recipient vessels in most patients. Three patients required anastomosis revision, all of which resulted in flap success. Conclusion: The high success rate observed in this study may be attributed to close monitoring of patients in the postoperative period and quick, early decision-making for revisions when necessary. The latissimus dorsi flap is the best option when large area coverage is needed, while the ALT flap is preferred when minimizing donor site morbidity is a priority. The vertical rectus abdominis myocutaneous flap offers the advantage of a long pedicle for anastomosis, though it comes with higher donor site morbidity. The superficial temporal artery and vein are reliable recipient vessels for scalp reconstruction.

Background: This is a rare case of the surgical treatment of a subacute presentation of a latissimus dorsi tendon rupture via a posterior single-incision approach. Indications: The patient had extensive conservative, nonoperative treatment that failed, and ultimately a surgical intervention was required to return to his activities of daily living. Technique Description: The patient is positioned in a lateral decubitus position. A 10-cm incision is created along the posterior axillary fold. Sharp and blunt dissection is utilized to carefully mobilize the chronic tendon rupture. The tendon is captured with 2 suture tapes utilizing a locking Krackow whipstitch. The tendon footprint is identified between the pectoralis major and teres major. The insertion point is prepared with a Cobb to debride the soft tissue and decorticate the bone bed to optimize healing. Two endobuttons are loaded with the suture tapes and then passed through unicortical holes drilled in the tendon bed. Care is taken to ensure the 90° external rotation of the tendon is achieved. A tendon-slide technique is used to reduce the tendon to the humerus. Afterward, a free needle is used to pass 1 limb of the suture through the tendon before tying an additional knot for added fixation. Results: The patient was able to resume his activities of daily living without pain at the 4-month mark. Conclusions: After the failure of extensive nonoperative management, surgical treatment of a subacute complete rupture of the latissimus dorsi tendon via a single, posterior incision is an effective method of returning a patient to their painless activities of daily living. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication. [ABSTRACT FROM AUTHOR]

Background: This paper aims to conduct a systematic review of the current literature to evaluate the clinical outcomes of concurrent latissimus dorsi and teres major (LD/TM) tendon transfer in reverse shoulder arthroplasty (RSA), and to compare that to isolated RSA. Methods: A comprehensive search on PubMeb, Web of Science, Embase and CINAHL was performed from inception up to January 20, 2023, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Cohort studies, case-control studies, randomized controlled trials and case series that were written in English, which involved patients who underwent RSA with LD/TM transfer were included. Quality of studies was appraised using the Cochrane Risk Of Bias In Nonrandomized Studies of Interventions tool. Systematic review of Constant-Murley Score (CMS) and range of movement (ROM) was conducted. Results: Eight studies with a total of 265 patients were included. The average mean follow-up time was 42.5 months, with a range of 6 months to 136 months. Of the studies that reported outcomes of RSA with LD/TM transfer, five reported the CMS, five reported external rotation (ER) ROM and six reported forward flexion ROM. Comparing postoperative to preoperative scores, there was an improvement above the minimal clinically important difference for CMS (mean difference (MD) range = 22.40 to 41.80), ER (MD range = 29° to 36°) and forward flexion (MD range = 50° to 75°). Three studies that compared postoperative ER between RSA with and without LD/TM reported no significant difference. Conclusion: RSA with LD/TM transfer has good clinical outcomes postoperatively, but there is insufficient comparative data to suggest that it is superior or inferior to an isolated RSA.

Background The deep inferior epigastric perforator (DIEP) and latissimus dorsi (LD) flaps are two widely used autologous breast reconstructions. Despite studies on flap-volume changes, the time of the first measurement is not immediately after surgery. Therefore, this study aimed to investigate the change in volume over time from the immediate postoperative period using a three-dimensional (3D) scanner.

Introduction Implant-based breast reconstructions (IBBRs) increased last years despite the growing indications for radiotherapy in the treatment of breast cancer. As a result, complications and reconstructive failures associated to IBBR have increased. Autologous breast reconstruction (ABR) using fat-augmented latissimus dorsi (FALD) has become popular in recent years.

Background: Necrotizing fasciitis is a rare and potentially life-threatening soft tissue infection, even more so when associated with fungal causative agents. Onset has been identified in nosocomial settings following elective surgery, but not in esthetic surgery. Case presentation: We here present a case of necrotizing fasciitis related to Candida albicans infection which occurred in an immunocompetent patient who received a cosmetic breast augmentation mastopexy combined with a Brazilian Butt Lift using autologous fat grafting. The case was managed with aggressive wound exploration and debridement. Treatment was delayed by the diagnostic challenge and the difficulty in identifying the causative agent, but the patient fully healed and recovered once the C. albicans was isolated in culture tests and appropriate antimycotic treatment was implemented. Conclusion: Considerations should be made regarding the possibility of implementing an antimycotic option for first-line empirical treatment despite the rarity of fungal etiology because of the threat of diagnostic delay and worse outcome.

Abstract Background Chest wall sinus with infection is a refractory disease caused by a variety of susceptible factors, and the treatment is still challenging. For clinically complex cases, although there are various surgical methods to choose from, it is still very difficult to achieve clinical cure, especially for patients with older age and many underlying diseases. Complete resection of chest wall sinus and application of repair and reconstruction technology may bring hope to refractory cases. Case presentation Herein, we report a case of a 67 year-old woman who had undergone breast cancer surgery and a history of multiple cycles of radiotherapy and chemotherapy. One year ago, she had a fistula in the left chest wall with yellow purulent fluid. After admission to our hospital, chest computed tomography (CT) showed the formation of the left chest wall sinus, accompanied by high-density images of the left clavicle, part of the ribs and part of the sternu. According to the patient's symptoms, signs and imaging examination, we preliminarily diagnosed the patient as chest wall sinus with infection and chronic osteomyelitis. Therefore, in the first-stage operation, the patient underwent left chest wall sinus resection, left partial rib resection, left partial clavicular resection and left partial sternal resection, After surgery, the wound surface was changed with gauze dressing with sensitive antibiotic solution every day until the wound surface was clean and new granulation was formed. In the second-stage operation, the wound surface was appropriately expanded, and the pedicled latissimus dorsi myocutaneous flap was transferred to the chest wall defect. Finally, the skin paddle was sutured without tension to the normal skin around the chest, and two drainage tubes were placed. Anti-infection, anti-spasm, anti-coagulation and other treatments were given after operation, and the survival of myocutaneous flap, wound healing and sinus disappearance were observed. Conclusion The application of pedicled latissimus dorsi myocutaneous flap in the treatment of intractable chronic chest wall sinus is an effective method. It does not change the shape of the thorax. The clinical effect is satisfactory in the near and medium term, which is worthy of clinical promotion.

Background: To optimize patients' functional external rotation outcomes, reverse total shoulder arthroplasties (rTSAs) including a latissimus dorsi tendon transfer were undertaken with promising early results and no significant increase in complications in comparison to traditional rTSAs. This was especially utilized for patients with a pronounced combined loss of elevation and external rotation. The purpose of this study is to evaluate and synthesize the findings of all relevant publications assessing the outcomes of rTSAs with associated latissimus dorsi transfer. Methods: We thoroughly searched the literature within the PubMed database using a standardized methodology. For our inclusion criteria, we included any study regarding rTSAs that contained functional outcome scores for postoperative range of motion (such as elevation, external rotation, etc.) or postoperative outcomes such as complications (reoperation, infection, etc.) and patient satisfaction. For the extraction of data, we used pilot-tested Google Forms to record extracted data. These data were then converted to spreadsheets (Microsoft Excel [Microsoft, Redmond, WA, USA]). This was done on 2 separate scenarios by 2 authors to ensure accuracy. We used the modified Coleman Methodology Score to assess the methodological quality of the studies in our samples. Meta-analysis mathematics and statistical analysis were performed using Stata software 17 (StataCorp, College Station, TX, USA). Results: Our search returned a total of 12 studies containing data of 213 shoulders receiving RTSAs with a latissimus dorsi transfer. Functional outcomes were available for 160 shoulders. The mean preoperative elevation of the affected shoulder was 73.57 degrees, and the mean postoperative elevation was 141.80 degrees. For external rotation, the mean preoperative average was −6.71 degrees, and the mean postoperative average was 22.73 degrees. The absolute Constant score average was 31.56 preoperatively, while the postoperative value was 68.93. In our sample, 25 patients (11.73%) required a revision of the RTSA implant due to complications. Discussion: Combined loss of elevation and external rotation can be a severely debilitating condition for those with a glenohumeral pathology. Latissimus dorsi transfer for this condition has been proven to be an effective modality. The reoperation and complication rate appears to be sizable, and as such surgeons should consider this when considering this modality for their patients.

Background We suggested an easy and effective harvesting technique to avoid injury to tissues adjacent to the latissimus dorsi (LD). Methods Between 2007 and 2017, breast reconstruction was performed with an LD flap using the “bottom-up” technique. Medical records were retrospectively reviewed. Data on postoperative complications, results, and follow-up were obtained. Nine cadaveric dissections were performed to assess positional relationships between LD and adjacent muscles based on the ribs where relevant muscles and LD attach. Overall, 78 LD flaps were harvested without complications. Results Average age was 45.4 years. The mean operation time was 260 minutes. There were no abnormalities or injuries in the adjacent fascia and muscles during the flap harvest. Drains were removed at an average of 21.9 days postoperatively. In all cadavers, there was conjoined fascia between the thoracolumbar and LD fasciae. The average level of the merging point between the LD and external oblique muscle (EOM) was 8.9 to 11.1 ribs. The average level of the overlapping point between the LD and serratus posterior inferior (SPI) was 9.5 to 11.1 ribs. Conclusions There are three dangerous zones during LD flap harvesting. The first zone is where the conjoined fascia encompasses the LD and thoracolumbar fasciae. The second zone is where the LD merges with the EOM and the serratus anterior. The third zone is the lower part where the LD merges with the SPI and EOM. The “bottom-up” technique enables a more meticulous and atraumatic operation by beginner flap surgeons.

Breast cancer-related axillary node dissection is the commonest cause of upper extremity lymphedema. The ability of lymphatics to regenerate spontaneously or reconnect with native lymphatics after free or pedicled flap reconstruction has been demonstrated on lymphoscintigraphy. Lymphatic anastomosis is not always needed in these flaps. In patients who underwent axillary clearance with risk factors for the development of lymphedema, we harvested a vascularized serratus anterior fascia flap during concurrent latissimus dorsi flap harvest (for breast or chest wall reconstruction). The vascularized fascia was wrapped around the axillary vessels to provide a conduit for lymphatic regeneration, protect the axillary vessels from radiotherapy, and reduce scarring and axillary cording. This procedure was performed on three patients with none of them experiencing upper limb lymphedema or cording.

Due to the infrequent occurrence of latissimus dorsi insertional avulsions or tendon ruptures, there is no clear evidence on the optimal surgical fixation strategy. A three suture unicortical button repair technique through a single incision offers an anatomic reconstruction of the broad insertional footprint with adequate exposure. This fixation strategy is the preferred technique by the senior author.

Introduction: The Axillary Arch Muscle (AAM), is a rare anomalous finding in the axilla also known as langer’s muscle. In the literature, it is explained as a narrow muscular slip that extends from the latissimus dorsi to the pectoralis major. Variations of this muscular anomaly have been observed. The abduction and external rotation like simulation of the arm in the cadaver suggest the possibility of neurovascular compression by the AAM. The AAM causing compression is considered an etiology of thoracic outlet syndrome by some authors. The symptoms generated by neural or vascular compression can be differentiated clinically. The purpose of this article was to compare the potential role of AAM in causing neural or vascular compression and discussion with the clinical studies which showed varied results. Aim: To find out the possible anatomy of axillary arch muscle and its relation with neurovascular structures. Materials and Methods: The descriptive cadaveric study was conducted in the Department of Anatomy at Seth G.S.M.C. and KEM hospital, Mumbai, India from November 2012 to November 2014. Study included 120 axillae of 60 embalmed cadavers (60 right and 60 left axilla). Axillary arch muscles were identified and their relations with neurovascular structure in an abducted position of the arm were noted and photographed. The simple statistical method of calculating percentages (%) of the collected data was applied to the study. Results: The dissection of the axillary region was carried out in 120 axillae which included 53 male and 7 female cadavers. The axillary arch muscles were identified in the three male axillae unilaterally. Its extent and relations with the neurovascular structure were different in all three cases. Its medial attachment was on the lateral border of latissimus dorsi, fascia over the latissimus dorsi, or the subscapularis muscle, while the lateral attachment was on fascia over coracobrachialis or biceps brachii. All the cases showed close relations with neural as well as vascular structures with the potential of causing compression in varied numbers. Conclusion: Though the existence of this muscle is rare, the findings of the present study will help clinicians, surgeons, and physiotherapists to be vigilant in diagnosing the cases with AAM amongst the individuals frequently adopting hyperabduction maneuvers in their occupations or sports thereby causing neurovascular compression.

Purpose of the study: Tissue reconstruction after burns, tumor excisions, infections or injuries is a frequent surgical challenge to avoid Ischemia-reperfusion injury. Lazaroids and sildenafil, through their mechanisms of action, have been studied for their protective effects on various organs subjected to IRI. In this study, we aimed to evaluate the therapeutic potential of U-74389G and sildenafil in a swine model of ischemia and reperfusion injury of latissimus dorsi flap. Materials and methods: Forty-two Landrace male pigs, weighing 28–35 kg, were equally (n = 6) randomized into the following groups: (a) Group I: control, (b) Group II: administration of U-74389G after ischemia, (c) Group III: administration of sildenafil after ischemia, (d) Group IV: administration of U-74389G and sildenafil after ischemia, (e) Group V: administration of U-74389G prior to ischemia, (f) Group VI: administration of sildenafil prior to ischemia, and (g) Group VII: administration of U-74389G and sildenafil prior to ischemia. Blood and tissue sampling was conducted before ischemia, 15 and 30 min after occlusion, 30, 60, 90, and 120 min after reperfusion. Results: Statistically significant reduction (p

Crush injuries of the lower extremity with extensive osseous and soft tissue damage impose a big challenge even for an interdisciplinary reconstructive approach. Multistep reconstruction with negative wound pressure therapy for soft tissue management and external fixation for osseous stability preceding free flap transfer leads to optimized outcome. We report the successful multistep reconstruction of a third-deree open right tibial fracture with extensive soft tissue defect with an arteriovenous loop preceding latissimus dorsi flap coverage with a perforator skin island after loss of an anterior lateral thigh (ALT) flap due to intima damage of the recipient vessels. The described method is a safe reconstructive concept after primary flap loss with persistent extensive tissue damage.

Background: Many flaps have been described for reconstruction of lower extremity defects, including, Latissimus Dorsi, Rectus abdominis, Anterolateral thigh perforator flaps, each having advantages and disadvantages. The defect location, size and specific geometric pattern of defect influences the type of flap that can be used. In this case series, we describe the specific situations where the use of chimeric latissimus dorsi–serratus anterior (LD + SA) free flaps are of advantage in providing complete wound cover. Materials and Methods: Case records of all patients who underwent LD + SA free flap transfer for lower extremity trauma at Amandeep Hospital, from Feb 2006 to Feb 2017 were reviewed. Patients were categorised based on the anatomical location and size of defect. The method of usage of the chimeric segments, recipient vessels and type of anastomosis were noted. Flap complications, if any were reviewed. Result: 47 patients with lower limb defects were included in the study. All cases were post traumatic in nature. Defect size ranged from 180 sq cm to 1050 sq cm. Average defect size was 487.70 sq cm. All patients underwent soft tissue reconstruction with LD + SA flap. Complete wound cover was obtained. Conclusion: Latissimus dorsi + Serratus anterior free tissue transfer is an effective, reliable method of providing cover to extensive lower limb traumatic defects with minimal donor site morbidity, with added freedom of inset and flap positioning. Specific use is seen in patients with broad proximal defect, long defect in the leg, defects involving adjacent anatomical areas and in large defect with dead space.

Purpose of Review: Tears of the latissimus dorsi and teres major are uncommon but significant injuries, most frequently seen in high-level, overhead throwing athletes. Diagnosis can be challenging, as there are no pathognomonic signs, symptoms, or physical exam findings associated with latissimus dorsi/teres major tears, and the clinician must have a high suspicion for this injury. While many of these tears can be treated non-operatively, a subset of these benefits from surgical intervention. Rehabilitation following operative and non-operative treatments of these injuries is extensive, and timing of return to sport can be variable from 3 to 12 months.Recent Findings: The literature surrounding latissimus dorsi/teres major injuries is sparse. Several small studies have shown good results in patients with mild to moderate tears that were treated non-operatively. Recent evidence has shown good results following operative repair of larger tears, with excellent return to sport rates. Furthermore, focused rehabilitation is imperative when treating patients with latissimus dorsi/teres major injuries to allow these athletes to return to sport.Summary: Latissimus dorsi/teres major tears are uncommon but significant injuries in the throwing athlete. Prompt diagnosis, proper treatment, and focused rehabilitation will allow these patients to return to sport in a safe and efficient manner. [ABSTRACT FROM AUTHOR]

Blazed up Herpes zoster lesions have been described in very few patients after free and pedicled flap transfer for reconstructive purpose. Although sensory recovery after flap reconstructions has been studied extensively most studies addressed subjective perceptions of sensation. Objective investigations of spontaneous reinervation of free and pedicled flaps are rare. We would like to present a witnessed herpes zoster infection of a latissimus dorsi skin flap 2 years after breast reconstruction.

The pedicled partial latissimus dorsi myocutaneous flap based on the transverse branch of the thoracodorsal artery is described as it offers several advantages for reconstruction of radiated partial mastectomy defects. It maintains bulk and vascularity while having a favorable morbidity profile compared to the total flap. Specifically, seroma rates and length of drain use should be reduced. The anatomical location of the transverse branch allows creation of the flap outside the radiated field. Further, the flap preserves the lateral and inferior portions of the latissimus dorsi and the muscle is not detached from its insertion allowing preservation of the posterior axillary fold. Finally, the transversely oriented skin paddle offers favorable scar healing.

Purpose: Although latissimus dorsi (LD) flaps are extensively used in a wide range of interventions, fetus studies on this subject are quite limited. This study aims to obtain detailed information about the morphometric features of LD, thoracodorsal artery (TDA) and nerve (TDN).Methods: The study was carried out on both sides of 50 formalin-fixed human fetuses (22 male/28 female) with a mean gestational age of 24.5 ± 4.7 (range 18-36) weeks, which were in the inventory of Anatomy Department of Mersin University Faculty of Medicine. Dimensions of LD, lengths and width of TDA and TDN were measured. Surface area of LD was calculated using digital image analysis software.Results: All samples had LD muscle. Neither gender nor side-significant differences were observed in relation with the numerical data of LD, TDN and TDA. Linear function of surface area was calculated as “y = − 1767.532 + 114.582 × Age (weeks)”. LD was attached directly to the posterior part of iliac crest in 59 of 100 sides meanwhile in the rest 41, it was attached by the thoracolumbar fascia. TDA gave a branch to serratus anterior in 96 cases and 2 branches in 4 cases. TDN passed superficial to TDA in 84 and deep to TDA in 16 samples. TDN had bifurcation in 93, trifurcation in 6 and tetrafurcation in 1 side.Conclusion: Data obtained from this study can be useful for estimating the sizes of LD and related neurovascular structures, especially in neonate surgeries. Linear function of LD surface area can be helpful to design the flap dimensions in newborn surgeries. A throughout knowledge about the branching pattern of TDN and its location-wise relation with TDA should be kept in mind to prevent possible complications during harvesting LD flaps and TDN grafts. [ABSTRACT FROM AUTHOR]

The latissimus dorsi flap is popular due to the versatile nature of its applications. When used as a pedicled flap it provides a robust solution when soft tissue coverage is required following breast, thoracic and head and neck surgery. Its utilization as a free flap is extensive due to the muscle's size, constant anatomy, large caliber of the pedicle and the fact it can be used for functional muscle transfers. In facial palsy it provides the surgeon with a long neurovascular pedicle that is invaluable in situations where commonly used facial vessels are not available, in congenital cases or where previous free functional muscle transfers have been attempted, or patients where a one-stage procedure is indicated and a long nerve is required to reach the contra-lateral side. Although some facial palsy surgeons use the trans-axillary approach, an operative guide of raising the flap by this method has not been provided. A clear guide of raising the flap with the patient in the supine position is described in detail and offers the benefits of reducing the risk of potential brachial plexus injury and allows two surgical teams to work synchronously to reduce operative time.

Objective: To assess the efficacy of a modified pedicled latissimus dorsi myocutaneous flap (LDMF) in the reconstruction of defects of the head and neck region. Methods: The retrospective analysis of 17 consecutive patients operated between 2010 and 2014 in the Plastic and Reconstructive Surgery Department of a tertiary care center was performed. Among them, four (23.5%) were initially diagnosed with trauma, while 13 (76.5%) had squamous cell carcinoma originating from the head and neck region. Tumor recurrence, necrosis of the free flap, advanced age, presence of a comorbidity, and previous history of radiotherapy were indicators for a pedicled LDMF. The pedicled LDMF technique was performed via the modified subcutaneous tunnel method in all patients. Demographic, clinical, and peroperative data as well as complications in and a survey of our patients were documented. Results: Our series comprised 11 males (64.7%) and six females (35.3%); the average age was 64.29±5.43 (range, 51 to 72) years. Seroma (5/17, 29.4%) and partial flap necrosis (3/17, 17.6%) were the most common complications, while the rate of mortality during the follow-up period was 17.6% (3/17). One patient died during the early postoperative period, while two died during their oncological treatment and followup. No remarkable functional disabilities or restrictions were postoperatively observed. Conclusion: Our results showed that a pedicled LDMF can constitute a safe and effective alternative for the reconstruction of head and neck defects in selected patients. However, further controlled clinical trials on larger series are warranted to precisely unveil the indications, contraindications, and outcomes of a pedicled LDMF. [ABSTRACT FROM AUTHOR]

Injuries to the latissimus dorsi and teres major muscles, while rare, are debilitating. They are seen in a variety of sports, although disproportionately in the throwing shoulder of baseball pitchers. There have been 25 case reports and 2 case series published on the nonoperative and operative management of these injuries. Latissimus dorsi and teres major muscle anatomy, function, and common injury patterns are well described in these case reports. Also well detailed are the typical patient presentation, physical examination, and imaging findings. Latissimus dorsi tendon injuries are sometimes treated operatively, whereas latissimus dorsi muscle belly or isolated teres major injuries are treated nonoperatively. Nonoperative treatment includes oral anti-inflammatories and shoulder physical therapy. A number of surgical patient positions, approaches, and fixation constructs have been described, although 2 techniques of positioning and surgical approach are used most commonly. Fixation is most often performed with suture anchors. Return-to-play timing, shoulder strength, and healing on magnetic resonance imaging are variable. No standard of care currently exists for the treatment of latissimus dorsi or teres major injuries. If treating a patient with an injury to either muscle, the clinician should be familiar with accumulated experience as reported in the published literature. [ABSTRACT FROM AUTHOR]

Because of some reasons local flaps are not suitable in the cases with upper extremity injuries. lattismus dorsi flaps are recommended in these cases. We present a twenty eight years old male with upper extremity trauma with type 3C left homerus fracture and destruction of triceps. Reconstruction made using lattismus dorsi flap and in a two month follow up we find a 30o Extention lag comparing to the right elbow while the patient had cosmetically satisfaction. [ABSTRACT FROM AUTHOR]

A typical muscle variation of latissimus dorsi - the axillary arch is represented by the muscular or fibromuscular slip detached from the anteroinferior border of the musculus latissimus dorsi passing over the axilla under the axillary fascia crossing the medial side of the brachial plexus to continue as a septum intermusculare mediale brachii distally to the medial epicondyle of humerus. The full extent of the muscle is rarely present. Slips of muscle extend from the latissimus dorsi at the inferior angle of scapula to insert into pectoralis major (Langer), coracobrachilis, biceps or coracoid process forming what is described as a common variant - the muscular axillary arch. We report three cases of variants of latissimus dorsi, one of which has not been reported in the literature before.

Introduction: Pelvic floor defects following pelvic exenteration constitute a challenge to the reconstructive surgeon. Whenever the common reconstruction options such as the gluteus maximus myocutaneous flap (GLM) and the vertical rectus abdominis myocutaneous flap (VRAM) are not feasible, free tissue transfer will be the only remaining option. Being one of the most reliable and versatile flaps used for microsurgical reconstruction, the free latissimus dorsi (LD) muscle flap provides an adequate solution to this problem. Patients and methods: We describe our experience with 12 consecutive patients who underwent the free transfer of LD free flap for secondary reconstruction of the pelvic floor and perineum following pelvic exenteration for management of locally advanced pelvic malignancies in Klinikum Oldenburg from 2007 to 2014. Results: Recurrent cancer of the anal canal was the most common pathology necessitating the performance of pelvic exenteration. Thrombosis of the vascular anastomosis was reported in two cases and ended with total flap loss in one of them. Functional limitations arose in two patients postoperatively. The mean hospital stay was 25 days. Conclusion: Free LD myocutaneous flap provides an adequate solution for reconstruction of pelvic defects resulting from radical oncological resections in cases where the use of locoregional flaps, such as the gluteus maximus flap and the vertical rectus abdominis flap, is not feasible because of an extensive defect, disruption of the vascular pedicle, or due to planning for bilateral stomas placement. [ABSTRACT FROM AUTHOR]

Aim Boerhaave's syndrome, or spontaneous oesophageal rupture, is a rare but serious condition. The pathology involved is a complete, transmural laceration of the oesophagus. The overall mortality rates are still high (range: 10-60 per cent). Outcomes of oesophageal perforations depend on the duration between diagnosis of perforation and treatment. Primary repair has been identified as the best treatment option, especially for presentation before 24 h. Mediastinal pleura, gastric fundus, pericardial flap and intercostal muscle flap are frequently used. Reversed latissimus dorsi (LD) muscle flap is another feasible option, especially when the intercostal muscle is inadequate and the length of perforation is long. Patients and Methods A patient presented with Boerhaave's syndrome with left posterolateral thoracotomy done. Intraoperation found a 4-cm, full-thickness perforation over the distal oesophagus. Primary repair and reinforcement with reversed LD muscle flap was performed. Results The patient had an uneventful recovery. Water-soluble contrast enema confirmed no leakage. He was discharged on postoperative day 10. Conclusion Primary repair and reinforcement with reversed LD muscle flap is a feasible option when the intercostal muscle is inadequate and the length of the oesophageal perforation is long. [ABSTRACT FROM AUTHOR]

For two-stage, implant-based, delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a good option for patients who wish to avoid a traditional latissimus dorsi donor-site incision. The purpose of this study was to compare outcomes of RALDH and the traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy. A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications, and outcomes were assessed. One hundred forty-six pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed robotically during the study period (average follow-up 14.6 ± 7.3 mo). Latissimus dorsi breast reconstruction following radiation was performed in 64 patients using TOT and 12 using RALDH. Surgical complication rates were 37.5% in TOT versus 16.7% in RALDH (p = 0.31) including seroma (8.9% versus 8.3%), infection (14.1 versus 8.3%), delayed wound healing (7.8% versus 0), and capsular contracture (4.7% vs. 0). Robotic-assisted harvest of the latissimus dorsi muscle is associated with a low complication rate and reliable results for delayed reconstruction of the irradiated breast while eliminating the need for a donor-site incision. [ABSTRACT FROM AUTHOR]

Introduction Infected abdominal defects are a challenge to surgeons. In this study, we describe 10 cases in which the latissimus dorsi myocutaneous flap was used for successful reconstruction of abdominal wall defects severely infected with methicillin-resistant Staphylococcus aureus ( MRSA). Methods Retrospective review of 10 patients with abdominal wall defects that were reconstructed using the latissimus dorsi myocutaneous flap between 2002 and 2010. All patients had abdominal defects with hernias, combined with MRSA infections. The sizes of the flaps ranged from 120 to 364 cm2. The deep inferior epigastric artery was the recipient vessel in nine patients and the internal mammary vessels were used for one patient. Results There were no complications relating to the flaps, although there were other minor complications including wound dehiscence, haematoma and fluid correction. After reconstruction, there were no signs of infection during follow-up periods, and the patients were satisfied with the final results. Conclusion Reconstruction using the latissimus dorsi myocutaneous flap, including muscle fascia structures, is a potential treatment option for severely infected large abdominal wall defects. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction. Patients and methods: Prospective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months. Results: The reconstructed and healthy breasts decreased in volume in group 1 (−45.85 cm3 ± 48.41 cm3, p = 0.0004; −29.13 cm3 ± 14.98 cm3, p = 0.0009) and in group 2 (−31.5 cm3 ± 25.35 cm3, p = 0.0001; −15.4 cm3 ± 21.96 cm3, p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05). Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001). Conclusion: We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast. [Copyright &y& Elsevier]

Summary: Background: Thoracodorsal artery perforator (TAP) flaps without latissimus dorsi muscle – have been used for reconstruction of the extremities, head and neck as free style flaps, and as pedicled flaps for reconstruction of the chest wall and axillary wounds. This retrospective study aimed to analyse the clinical applications and relevant anatomic findings of TAP flaps. Methods: From April 2007 to August 2011, 67 free or pedicled TAP flaps were transferred in 67 patients for reconstruction of wounds of the extremities, chest wall and axilla. Eight were used as free flaps for reconstruction of extremities, and 59 used as pedicled flaps for reconstruction of axillary or chest wounds. Patient ages ranged from 7 to 55 years (26.04 ± 12.83). Perforator arteries were detected and identified with a hand-held Doppler. The size of flaps ranged from 6 by 9 to 14 by 18 cm ((8.66 ± 2.05) by (12.62 ± 2.03)). Flaps were designed with the perforator artery included, with all flaps based on one or two perforator arteries. Results: All of the flaps survived. There were no problems with vascular spasm or occlusion. Significant venous congestion was not observed in any of the cases. Two cases developed minor wound dehiscence but healed with conservative therapy. None of the donor sites developed seromas. Conclusions: The thoracodorsal artery flap without associated latissimus dorsi muscle can provide a thin, large and reliable flap with robust blood supply. The TAP flap can significantly reduce donor site morbidity. [Copyright &y& Elsevier]

Summary: Introduction: The aim of this study is to assess our results of autologous breast reconstruction using a combined muscle sparing latissimus dorsi flap (MSLD) and fat tissue transfer. Methods: A prospective study was performed on 20 patients over a period of 1 year. Three objective criteria were analyzed: morphometric, surgical procedure and postoperative latissimus dorsi function. A subjective assessment was done using a 4-level scale for patients’ and surgeons’ satisfaction. Results: Mean age of patients was of 45±1.2 years. The average Body Mass Index (BMI) was 21.9±2.2. The average weight of mastectomy specimen was 348.3±135.6 g. The average duration of the surgical procedure was 149±32.1minutes. The average length of hospitalization was 4.5±1.4 days. The average quantity of dorsal drainage during the hospitalization was 117.7±41.5 cm3, and a Visual Analog Scale (VAS) of pain of 2±0.9 over 10. Patients from our series had 0.8±0.9 dorsal punction per patient, with an average volume of seroma of 51.2±70.8 cm3. Fat grafting was used in every case with an average number of 1.2±0.4 procedures per patient. The mean of injected volume was 250.1±132.8 cm3. No complications occurred in the postoperative period. There was no difference of latissimus dorsi functional assessment at 3 months and 1 year postoperative. Conclusion: Combined MSLD and fat transfer is a reliable and an efficient technique for autologous breast reconstruction. The donor site morbidity is low, the postoperative recovery is fast and functional integrity of latissimus dorsi muscle is preserved in all cases. This technique can be used in immediate or delayed autologous breast reconstruction, and is particularly useful for bilateral breast reconstruction. [ABSTRACT FROM AUTHOR]

Latissimus dorsi transfer is our preferred treatment for active disabled patients with a posterosuperior massive cuff tear. We present an arthroscopically assisted technique which avoids an incision through the deltoid obtaining a better and faster clinical outcome. The patient is placed in lateral decubitus. After the arthroscopic evaluation of the lesion through a posterior and a posterolateral portal, with the limb in traction we perform the preparation of the greater tuberosity of the humerus. We place the arm in abduction and internal rotation and we proceed to the harvest of the latissimus dorsi and the tendon preparation by stitching the two sides using very resistant sutures. After restoring limb traction, under arthroscopic visualization, we pass a curved grasper through the posterolateral portal by going to the armpit in the space between the teres minor and the posterior deltoid. Once the grasper has exited the access at the level of the axilla we fix two drainage transparent tubes, each with a wire inside, and, withdrawing it back, we shuttle the two tubes in the subacromial space. After tensioning the suture wires from the anterior portals these are assembled in a knotless anchor of 5.5 mm that we place in the prepared site on the greater tuberosity of the humerus. A shoulder brace at 15° of abduction and neutral rotation protect the patient for the first month post-surgery but physical therapy can immediately start. [ABSTRACT FROM AUTHOR]

Objective: The Latissimus dorsi muscle is usually considered as inserted on the iliac crest, but it is separated from it by the thoracolumbar fascia. In our experience based on the harvesting of pedicled Latissimus dorsi flaps to cover cervicofacial loss of substances, we have found that in some cases, the muscular fibers of the anterior border of the muscle are directly inserted on the iliac crest. In these cases, the harvesting of the flap could be more distal. Methods: To determine whether this direct muscular insertion is frequent or not, we performed dissections on 30 fresh cadavers of the lower insertion of the Latissimus dorsi muscle, and 6 dissections of human fetuses to study the ontogeny of these insertions. Results: The Latissimus dorsi muscle presented direct muscular insertions on the iliac crest in 13.33% of cases. The fetal dissections showed that before 30 weeks of development, the anterior part of the muscle was directly inserted on the iliac crest, and after it was separated from it by the thoracolumbar fascia. Although the harvesting of the Latissimus dorsi in continuity with the thoracolumbar fascia has been described in pedicled flaps, it is usually considered that it is impossible to harvest Latissimus dorsi musculocutaneous flaps in contact with the iliac crest, because there are no perforating vessels from the thoracolumbar fascia to the skin. According to our results, in some cases, it could be possible to harvest a pedicled musculo-cutaneous LD flap more distal that it is usually described. [ABSTRACT FROM AUTHOR]

The latissimus dorsi (LD) flap is a large and reliable myocutaneous flap with a consistently long vascular pedicle. However, the limitation of the thoracodorsal pedicle is that it has only one draining vein for anastomosis. We describe a simple technique of recruiting the tributary vein to the serratus anterior and using it as a second draining vein to alleviate congestion in lower limb reconstruction. The serratus anterior venous tributary segment is cut back to an avalvular segment which averages 5 mm in length. Provision of an additional venous outflow to the flap enabled a second venous anastomosis to the short saphenous vein (n=1), the long saphenous vein (n=2), a deep vein (n=1), and to a deep vein via a vein graft (n=1), respectively. Five patients with degloving injury of the lower extremity of sizes 150 cm2 (10 × 15 cm) to 260 cm2 (10 × 26 cm) underwent successful reconstruction using the LD muscle flap with the serratus anterior tributary vein as a second outflow vein. This serratus anterior venous tributary serves as a useful second outflow channel for alleviating venous congestion during lower limb reconstructive surgery and should be routinely preserved as a lifeboat. [ABSTRACT FROM AUTHOR]

Summary: We present a case of composite tissue transplantation of a latissimus dorsi flap between monozygotic twins. The recipient twin, a 19 year old male, suffered from a complex spinal kyphoscoliosis for which he had undergone multiple previous operations over many years. Soft tissue breakdown on his back causing metalwork exposure had necessitated the removal of his most recent spinal rod. This in turn led to rapid severe deterioration of his spinal deformity and consequent critical impairment of lung function. Robust soft tissue cover was required urgently in order to allow the insertion of a new spinal rod. His previous surgeries and body habitus precluded an adequate autologous reconstruction. Instead, reconstruction using composite tissue transplantation from his identical twin brother was successfully undertaken. We discuss the ethical, psychological and surgical issues involved in this case. [Copyright &y& Elsevier]

Summary: Wide resection of tumours in the anterior compartment of the thigh frequently requires en bloc removal of the quadriceps femoris muscle. Such resection can result in significantly decreased muscle power of knee extension. Functional muscle transfer is a beneficial tool for the reconstruction process. Until now, however, there have been few reports on the outcome of quadriceps muscle reconstruction using free innervated muscle transfer. We reviewed 14 patients (seven women and seven men, mean age 53 years). The extent of tumour invasion required resection of the entire quadriceps in four cases, of three heads in six cases and of two heads in the remaining four cases. Local recurrence occurred in one patient only, and there were no major complications. In the four patients with entire resection of the quadriceps, the postoperative muscle manual test (MMT) result was 0–1 (mean, 0.5), but this recovered to between 2 and 3 (mean 2.3) after a mean follow-up of 70 months. In the six cases with resection of three heads, the MMT test result was 2 and active knee extension recovered almost fully. Transfer of free, functional latissimus dorsi muscle is best indicated for cases in which the entire quadriceps or three heads are resected. Active knee extension can be expected to improve to an MMT score of 2 after reinnervation of the transferred muscle. Microsurgical reconstruction following resection of soft-tissue sarcoma provides adequate functional and coverage reconstruction, together with better local control by allowing wider surgical margins. [Copyright &y& Elsevier]

The posterior trunk roughly encompasses the upper back from the shoulders to the lumbar area above the iliac crests. Long-term outcomes in the treatment of defects of the spine and bony thorax have been proved superior if flaps were used. Many local muscle and fasciocutaneous flaps are available alternatives. A guideline, patterned according to arbitrary anatomic territories of the back, is suggested as a starting point for the selection of appropriate primary and secondary flap options. Depending on flap availability, the latissimus dorsi and trapezius muscles are the workhorse flaps for the upper back, whereas perforator flaps have become a useful alternative for the lumbar region in lieu of free flaps. [ABSTRACT FROM AUTHOR]