Anatomical study of the latissimus dorsi muscle flap / Estudio anatómico del colgajo del músculo latísimo del dorso

SUMMARY: The latissimus dorsi is a broad muscle that originates from the inferior thoracic spinous processes, thoracolumbar fascia, iliac crest, and inferior ribs. It inserts on the inferior aspect of the intertubercular groove of the humerus through a thin tendon. The study was conducted on 10 cadavers (7 male and 3 female). These specimens were dissected and examined to study the gross anatomical characteristics of the latissimus dorsi muscle. The dimensions of the latissimus dorsi muscle and its surface area were measured in all the cadavers. The branching pattern of the thoracodorsal vessels was recorded. The pedicle length and caliper were measured using Vernier calipers. On the 20 dissected sides, the thoracodorsal artery was found to be one of the terminal branches of the subscapular artery that originates in the axillary region. In 19 (95 %) cases, the thoracodorsal artery terminated in a bifurcation, giving off a medial and a lateral branch. The average size of the elevated flap of the latissimus dorsi muscle was 18 cm x 36 cm. The average pedicle length was 9.5 cm (range: 5 cm-14 cm), and the average diameter at its origin was 2.5 mm (range: 1.5 mm-3.5 mm). The average diameter of the vena comitans was 3.3 mm. The current study focuses on the anatomical features of the latissimus dorsi muscle and its blood supply to increase the success rate of operations in clinical practice.

RESUMEN: El músculo latísimo del dorso se origina en los procesos espinosos de las vértebras torácicas inferiores, la fascia toracolumbar, la cresta ilíaca y las costillas inferiores y se inserta en el surco intertubercular del húmero a través de un delgado tendón. El estudio se realizó en 10 cadáveres (7 mujeres y 3 hombres). Estos especímenes fueron disecados y examinados para estudiar las características anatómicas macroscópicas del músculo latísimo del dorso. En todos los cadáveres se midieron las dimensiones del músculo y su superficie. Se registró el patrón de ramificación de los vasos toracodorsales. La longitud del pedículo y el calibre se midieron con paquímetro Vernier. En los veinte lados disecados, se encontró que la arteria toracodorsal era una de las ramas terminales de la arteria subescapular que se originaba en la región axilar. En 19 (95 %) casos, la arteria toracodorsal terminaba bifurcándose en dos ramas, una rama medial y otra lateral. El tamaño promedio del colgajo elevado del músculo latísimo del dorso era de 18 cm x 36 cm. La longitud promedio del pedículo era de 9,5 cm (rango: 5 cm-14 cm), y el diámetro promedio en su origen era de 2,5 mm (rango: 1,5 mm-3,5 mm). El diámetro medio de la vena comitans era de 3,3 mm. El estudio actual se centra en las características anatómicas del músculo latísimo del dorso y su irrigación para aumentar la tasa de éxito de las operaciones en la práctica clínica.

The SCIA-based conjoined flap for covering extremely large lower limb defects / 中华显微外科杂志

Objective:To investigate the results of the superficial circumflex iliac artery(SCIA)-based conjoined flap for covering extremely large lower limb defects.Methods:From February 2017 to June 2019, 15 patients were admitted, who suffered from severe degloved injury for the lower limb, including 9 males and 6 females with a median year of 45 (ranged, 36-67 ) years old. All were taken thorough and radical debridement and covered by the VSD device during the emergency operation. The dimension of defects was ranged from 25.0 cm ×8.0 cm to 50.0 cm ×15.0 cm. Using the lower abdominal wall or side chest wall as the donor site, the conjoined flap was dissected when the wound surface became granulating. The perforator match fashions included bilateral SCIA, and ipsilateral SCIA and thoracodorsal artery(TA). The donor sites were primary closure. The follow-up was accomplished by the same surgeon.Results:Fourteen flaps survived completely without significant complications, and distal necrosis was observed in one longitudinal flap, which was healed with the skin graft in the second stage. All flaps were available for a mean follow-up of 18 (ranged 16-24) months. The aesthetic outcomes were achieved on the recipient site without hairy appearance and hyper-pigmentation. A concealed line scare was left on the donor site, without the hernia and limited function. At the last follow-up, 7 cases were excellent and 1 case was good, evaluated with the LEFS criteria. And 6 cases were excellent and 1 case was good, assessed by the AOFAS criteria.Conclusion:The simultaneous reconstruction of extreme lower limb defects and better salvage treatment could be achieved by the SCIA-based conjoined flap. And as a versatile flap, it was blessed with concealed donor site, various design fashions, and larger dissection size in selected cases.

Clinical application of a thoracodorsal artery chimeric perforator flap to repair extremity soft tissue defects complicated with a deep dead cavity / 中华创伤骨科杂志

Objective:To explore the curative effects of thoracodorsal artery chimeric perforator flap used to repair extremity soft tissue defects complicated with a deep dead cavity.Methods:From July 2014 to July 2019, 17 patients with extremity soft tissue defects complicated with a deep dead cavity were repaired by a thoracodorsal artery chimeric perforator flap at Department of Orthopaedics, Xiangya Hospital. They were 10 males and 7 females, aged from 2 to 39 years (mean, 20.2 years). There were 7 cases of traffic accident trauma, 5 ones of chronic osteomyelitis, 2 ones of crushing injury and 3 ones of radical resection of tumor. The defects were located at the lower extremity in 15 cases and at the upper extremity in 2. The wound sizes ranged from 5 cm × 3 cm to 24 cm × 9 cm. All the wounds were complicated somewhat with a dead cavity or exposure of deep tissues after debridement. The muscular component of thoracodorsal artery chimeric perforator flap was used to fill the dead cavity while the skin component to cover the superficial wounds. The flap donor sites were closed directly. The flap survival and donor site recovery were followed up regularly after operation. The curative effects were assessed according to the comprehensive evaluation criteria of hand surgery for flaps.Results:Necrosis of the distal flap occurred in only one case which responded to dressing change; the flaps survived uneventfully in the other 16 cases. The recipient and donor sites of flaps healed primarily in all patients. Venous crisis developed in one case which survived uneventfully after vascular crisis exploration. The 17 patients were followed up for 6 to 24 months (mean, 15.8 months). In all patients the flap presented with good color, texture and elasticity but without obvious swelling. At the last follow-up, the curative effects by the comprehensive evaluation criteria of hand surgery for flaps were excellent in 10 cases, good in 6 and fair in one. Only linear scar remained at the flap donor site and abduction of the shoulder was not affected.Conclusion:The thoracodorsal artery chimeric perforator flap is an ideal means for repair of extremity soft tissue defects complicated with a deep dead cavity because it can repair the deep dead cavity and body surface wounds at the same time only after anastomosis of a bundle of vascular pedicles.

Application of latissimus dorsi flap and thoracodorsal artery perforator flap in different wounds / 中华整形外科杂志

Objective@#To explore the application and choice of latissimus dorsi musculocutaneous flap and thoracodorsal artery perforator flap in different wound repair.@*Methods@#From March 2012 to February 2018, 8 cases of different wounds were repaired with island latissimus dorsi myocutaneous flap pedicled with dorsal thoracic artery, free latissimus dorsi myocutaneous flap, or thoracodorsal artery perforator flap combined with scapular flap. The patients includes 4 cases of trauma, 2 cases of tumor and 2 cases of osteomyelitis. Among them, 5 cases received pedicled grafting, 2 cases had anastomotic vascular free grafting combined with antibiotic bone cement chain bead, 1 case had thoracodorsal artery perforator flap combined with scapular flap.@*Results@#All 9 flaps of 8 patients survived. The size of the flaps ranged from 22.0 cm×7.5 cm to 28.0 cm×21.0 cm. All the donor and recipient areas healed well. After 2 months to 2 years follow up, all flaps have good blood supply, and the limbs′ function was normal. The appearance of flaps were satisfactory, with fully treated osteomyelitis, and no recurrence of the tumor was observed.@*Conclusions@#According to wound characteristics, selective application of thoracodorsal artery perforator flap, pedicled or free latissimus dorsi myocutaneous flap is effective for the repair of muscle, skin and soft tissue defects, as well as osteomyelitis, after tumor resection.

Clinical application of thoracodorsal artery perforator flap in repair of serious scar contracture of opisthenar / 中国修复重建外科杂志

Objective: To investigate the feasibility and effectiveness of thoracodorsal artery perforator (TDAP) flap for repairing serious scar contracture of the opisthenar. Methods: Between March 2015 and June 2017, 7 cases of serious scar contracture of opisthenar were repaired with TDAP flaps. There were 5 males and 2 females with an average age of 31 years (range, 11-48 years). The time from injury to operation was 8-67 months, with an average of 42 months. After the relocation of the joint and release of the scar, the size of soft tissue defect ranged from 5 cm×4 cm to 10 cm×8 cm. The size of TDAP flap ranged from 5.5 cm×5.0 cm to 10.5 cm×9.0 cm. Results: All flaps survived completely with primary healing at both donor site and recipient site. The flaps of 3 patients were bulky and underwent second-stage skin flap thinning at 3 months after operation. All 7 patients were followed up 6-32 months, with an average of 15 months. The skin flaps were soft and elastic. According to the upper limb function evaluation system recommended by Chinese Society of Hand Surgery, sensory function was classified as S3+ in 2 cases, S3+ in 1 case, S2+ in 3 cases, and S11+ in 1 case. The hand function was excellent in 2 cases, good in 4 cases, and fair in 1 case. There was no significant effect on shoulder movement. Conclusion: The TDAP flap is an ideal method for serious scar contracture of opisthenar.

A Cadaveric Study On Lateral Thoracic Artery

Introduction: Lateral thoracic artery is one of the branches of second part of axillary artery which arises near thelateral border of pectoralis minor.Aim and Objectives: To study the variations in the origin of Lateral thoracic artery and note its pattern.Materials and methods: 54 axillae from embalmed cadavers allotted for dissection were used for the study.There were 22 male and 5 female cadavers, with ages ranging from 60 to 80 years, specimens of both sides wereused.Results: The commonest variation was common trunk for Lateral thoracic artery and Thoracodorsal Artery(9.5%).Conclusion: The study was carried out to show important variations in the branching pattern of lateral thoracicartery, in order to orient the surgeons performing reconstructive plastic surgery and modified radial mastectomy.

Reconstruction of the soft tissue defects of limbs using the free thoracodorsal artery perforator flaps / 中华显微外科杂志

Objective To investigate the clinical effects of reparing the complicated soft tissue defects of limbs with free thoracodorsal artery perforator (TDAP) flaps.Methods From April,2009 to March,2014,19 limbs (including 8 upper limbs and 11 lower limbs) soft tissue defects with bone and tendon exposure were repaired with free TDAP flaps in the secondary stage.There were 12 thoracodorsal artery perforator flaps,5 polyfoliate perforator flaps,1 chimeric muscle flap,and 1 chimeric muscle polyfoliate flap.The sizes of the flaps ranged from 5.0 cm×6.0cm-20.0 cm×l 1.0 cm.Seventeen wounds of the dornor site were closed directly,and the other 2 were closed with skin grafts.Results Sixteen flaps survived successfully.Two flaps had venous congestion and survived at last after taking the stitches out.One flap had partial necrosis and repaired by skin graft finally.The clinical results were satisfactory after 12-18 months following-up,and the scars of the dornor sites of all but 3 patients were not obvious.All the shoulder function were normal.Conclusion The TDAP flap has dependable blood supply,good texture,less dornor site morbility.The polyfoliate TDAP flap can be used for repairing irregular defect.The chimeric latissimus TDAP flap can be used for the function reconstruction.The free TDAP flap is suited for repairing soft tissue defects of the limbs.

Improving the repairing effect of thoracodorsal artery perforator flap through ultra-thin flap technology / 中华显微外科杂志

Objective To discuss the application of ultra-thin flap technology in the thoracodorsal artery per forator flap,and appraise the effectiveness in clinical practice.Methods From May,2013 to December,2015,10 patients with soft-tissue defects of the four limbs were treated with ultra-thin thoracodorsal artery perforator flap.The classification of the perforating vessels was done by Kimura method.The flap blood supply was measured and the patients' satisfaction of the appearance of flap was investigated through questionnaires.Results The flap of 8 cases (5 cases of type Ⅰ and 3 cases of type Ⅱ) could be evenly thinned,and the flap of 2 cases (type Ⅲ) could only be thinned at the edge beyond the part with perforator as the center and a radius of 3 centimeters.The flap of 9 cases completely lived.While in 1 case (type Ⅲ),a small part of the edge of the flap was necrosed(2 cm×1 cm),and coalesced well after change dressing.The donor site was sutured directly in 7 cases and covered with skin graft in 1 case.Eight patients were followed-up from 6 to 12 months.The treatment effect was satisfied.And there were no side effects on the functioning of donor sites.Seven patients were highly satisfied with the appearance of the flap (satisfaction rate was 87.5％).Conclusion Ultra-thin flap technology can be adopted to cut thin thoracodorsal artery perforator flap,and can remarkably improve the effect in clinical practice.

Breast reconstruction with pedicled perforator flaps / 中国癌症杂志

Comparing with free perforator flap, pedicled flap is a relatively simpler and safer technique, with lesser donor site morbidity. In recent years, the application of pedicled perforator flaps has emerged as a new option for breast reconstruction. Those pedicled perforator flaps include thoracodorsal artery perforator flap, intercostal artery perforator flap (lateral intercostal artery perforator flap, anterior intercostal perforator flap) etc. Serratus anterior artery perforator flap, superior epigastric artery perforator flap, and lateral thoracic artery perforator flap can also be raised technically. To enhance surgical accuracy, it is necessary to evaluate the location and quality of perforator vessels preoperatively. Proper flap design is of more importance for pedicled flap when compared with it's free flap counterpart. Although free flap approach remains the golden standard in breast reconstruction when considering autologous tissue transplantation, pedicled perforator flap has the apparent merits of minimized surgical trauma, less time-consuming and less stress for reconstructive surgeons.

Breast-conserving surgery with immediate partial breast reconstruction using pedicled thoracodorsal artery perforator flap: a clinical analysis of 33 patients / 中华外科杂志

Objective@#To explore the application value of pedicled thoracodorsal artery perforator flap in immediate partial breast reconstruction for breast cancer.@*Methods@#This study is a prospective case series studies. Totally 128 cases of primary breast cancer patients who prepared to receive the breast-conserving surgery combine with immediate partial breast reconstruction of pedicled thoracodorsalartery perforator flap were enrolled in Breast Cancer Prevention and Treatment Center of Peking University Cancer Hospital from June 2013 to March 2016. Finally, the operations had been completed successfully in 33 eligible cases. All patients were female with a median age of 40 years (ranging from 22 to 52 years). The perforator vessel location, the donor area design, the post-operative complications, the influence of radiation and chemotherapy had been evaluated.@*Results@#The average diameter of thoracic dorsal artery perforators measured by Doppler ultrasound before the operation was (1.5±0.4) mm (ranging from 0.6 to 2.7 mm). The average size of flaps was 15 cm×6 cm. The average time of operations was (271±72) minutes (ranging from 120 to 245 minutes). Drainage tube removed on (4.7±2.1) days after operation (ranging from 3 to 12 days). All patients received follow-up, and there was no local recurrence and distant metastasis during a median follow-up of 17(12) months (M(QR)) (ranging from 5 to 38 months). All TDAP flaps were survival, the wound complication rates was 6% (2/33).@*Conclusions@#The breast reconstruction of pedicled thoracodorsal artery perforator flap is a good choice of repairing local breast defect of breast conserving surgery.Its advantages are no-influence of latissimus dorsi function and little complications in donor area.

Anatomical Review of Latissimus Dorsi Free Flap for Oral Cavity and Facial Reconstruction

Case of Surgical Treatment with Free Flap on Large Size Facial Capillary Malformation

Capillary malformation is common vascular malformation. In case of facial capillary malformation, patients' cosmetic and functional deficits are quite significant. The standard treatment which has been applied so far for capillary malformation is pulsed dye laser with 585nm. But in case of advanced capillary malformation, surgical interventions are inevitable. The problem of large size facial capillary malformation is how to cover the remnant defect, which occurs after resection. In this case, authors have experienced surgical treatment of large size facial capillary malformation and covered the large facial defect with free thoracodorsal artery perforator flap. The flap was thick, so facial asymmetry remained after the first surgery. But with the secondary procedure, authors have made more symmetric figures. The patient was satisfied with the result. Using free flap to replace the defect after resection due to capillary malformation is useful for these kinds of cases.

Reconstruction of the Face Using Thoracodorsal Artery Perforator Free Flap after Resection of Arteriovenous Malformation

PURPOSE: The treatment of arteriovenous malformation (AVM) of the face remains a difficult challenge in plastic surgery. Incomplete resection resulting in uncontrolled bleeding, postoperative enlargement of the remaining malformation, and a poor functional and cosmetic result could be the problems confronted by the surgeons. METHODS: A 37 year-old male with large arteriovenous malformation in face treated with preoperative superselective transarterial embolization and free flap transfer. The size of the defect was 13 x 9 cm. Sclerotheraphy without resection were performed several times but the results were unsatisfactory. Resection was performed the next day of embolization. We were able to repair with the thoracodorsal artery perforator free flap. And facial muscle reconstruction performed by simultaneous muscle and nerve transfer. RESULTS: During the follow-up period 8 months the patient regained an acceptable cosmetic appearance. And he has shown no reexpansion of the malformation. CONCLUSION: The thoracodorsal artery perforator free flap could be a good choice for the reconstruction for massive defects of the face. A huge arteriovenous malformation could be safely removed and successfully reconstructed by the complete embolization, wide excision and coverage with a well vascularized tissue.

Anomalous Arterial Supply to the Serratus Anterior Muscle

PURPOSE: The latissimus dorsi flap and the serratus anterior flap have been used as combined flaps to reconstruct extensive defects. Because these two muscles are usually supplied by the subscapular- thoracodorsal vessels, the two flaps can be based on vascular pedicle that is long and anatomically reliable. In this case, we reported that serratus anterior possessed an anomalous arterial supply totally independent from the subscapular pedicle while raising combined latissimus dorsi and serratus anterior flap. METHODS: A 35-year-old male with extensive soft tissue defect in the left perineum and thigh visited. Muscle defects of the medial thigh were observed, and femoral nerve and vessels were exposed. Combined latissimus dorsi and serratus anterior free flap was raised to reconstruct defect. On raising flaps, artery supplying the serratus anterior muscle originated from the axillary artery directly, was lying on the undersurface of the serratus anterior muscle. RESULTS: Because two flap pedicles had no communication and latissimus dorsi muscle was large enough to cover soft tissue defect, we transferred only latissimus dorsi free flap with 1:3 meshed skin graft. Patient had limb salvage and satisfactory functional outcome. CONCLUSION: There are many variations of arterial pedicles of flaps. However, most of these variations remain within known anatomical consistence, thus is an indicator in planning the dissection of the vessels. According to documents, arterial pedicle to the serratus muscle not originated from the thoracodorsal artery is rarely reported, and in most of these cases, the arteries are originated from the subscapular artery. Thus pedicle directly originated from the axillary artery to serratus muscle is a very rare variation in its vascular anatomy.

Soft Tissue Reconstruction of Children's Extremity with Perforator free Flap

Perforator free flap (PFF) is currently a major reconstructive option for soft tissue reconstruction in adults. Although PFFs have been used commonly, most reconstructive surgeons still hesitate to perform PFFs in children. The main cause of concern is the perceived high failure rate related to the small diameter of children's perforator vessels. We present 8 consecutive cases of successful transfer of thoracodorsal artery (TDA) & anterolateral thigh (ALT) perforator flap in children. Between 2003 and 2005, 8 children(4 to 13 years old) with soft tissue defects of the extremities were reconstructed with TDA & ALT PFFs. All flaps completely survived. There were no problems relating to vascular spasm or occlusion. Range of motion of reconstructed extremities were fully recovered. Among 8 patients, only 1 patient was performed an additional flap thinning procedure. 8 cases of TDA & ALT perforator flaps were successfully transferred in children. PFF is an excellent option in reconstruction of children as well as in adults because of its thinness, long pedicle length, least donor site morbidity and acceptable donor site scar.

Thoracodorsal Artery as an Alternative in Complete Arterial Coronary Revascularization: 3 Cases / 대한흉부외과학회지

It is now widely accepted that the complete arterial coronary revascularization has better short and long term results compared to coronary bypass surgery using arterial graft mixed with vein graft mainly due to its superior patency rate. However, sometimes the internal thoracic artery and other conventionally used grafts might be unavailable or it may require caution in using bilateral internal thoracic artery especially in diabetic patient because of the possible risk of the mediastinitis or other associated morbidities. Moreover, there could also be a shortage for arterial graft in case of coronary reoperation. We report our first three cases using thoracodorsal artery(TDA) as an alternative graft in complete arterial coronary revascularization.

Reconstruction of various sized soft tissue or compound tissue defect using free serratus anterior muscle or composite flap

A wide variety of free muscle or composite flaps have been used clinically for the reconstruction of soft tissue or compound tissue defects since introduction of the microsurgical technique but there were still difficulties in their application due to donor site morbidity and flap bulkiness. Free serratus anterior muscle flap and free composite flap, including serratus anterior muscle have been applied to 17 patients with small or medium sized tissue defects or large sized compound tissue defects from June 1995 to July 1997. There were 11 male cases and 6 female. Average age was 27 years. Defect sites were the anterior tibial area in 6 cases, the dorsum of foot in 6, the medial malleolar area in 1, the heel area in 1, the foot in 2, and the thumb and 1st web space in 1. There were 12 free muscle flaps, 2 free serratus anterior and rib composite flaps, 2 free serratus anterior and latissimus dorsi combined muscle flap and 1 free serratus anterior and latissimus doris and rib composite flap. The average follow up period was 14 month. The survival rate was 100% in 16 cases, 80% in 1 case. There was no remarkable donor site morbidity and operative results were satisfactory in all cases. The advantages of this flap are consistent and reliable flap with minimal donor site morbidity, long constant large caliber pedicle, taking a thin flap, excellent malleability allowed a broad of range of inserting technique, and additional possibility of a composite flap.