[Clinical analysis of breast reconstruction with endoscopic-assisted harvesting of latissimus dorsi muscle flap for breast cancer].

Objective: To investigate the benefits and drawbacks of breast reconstruction with endoscopic-assisted harvesting of the latissimus dorsi muscle flap for breast cancer and treatment experience of postoperative operation-related complications. Methods: A retrospective analysis was performed on clinical data of 26 female patients with breast cancer who met the selection criteria between September 2021 and March 2023 aging 48.7 years (range, 26-69 years). All tumors were unilateral, with 17 on the left side and 9 on the right side. The tumor size ranged from 1.0 to 7.0 cm, with an average of 2.7 cm. The pathological staging included T 1 in 11 cases, T 2 in 14 cases, and T 3 in 1 case; N 0 in 10 cases, N 1 in 11 cases, N 2 in 2 cases, and N 3 in 3 cases; no distant metastasis (M 0) occurred when first diagnosed. Among them, 10 cases underwent breast conserving surgery, and 16 cases underwent nipple-sparing mastectomy. All patients underwent breast reconstruction with endoscopic-assisted harvesting of the latissimus dorsi muscle flap. The operation time, incision length, and postoperative drainage volume in 3 days were recorded. Breast-Q "Satisfaction with back" scale was conducted to evaluate patients' satisfaction with back at 6 months after operation. Results: The operation time was 280-480 minutes (mean, 376.7 minutes), the incision length was 10-15 cm (mean, 12.2 cm), the postoperative drainage volume in 3 days was 500-1 600 mL (mean, 930.2 mL). There were 4 cases of postoperative seroma, 1 case of incision rupture, 1 case of paresthesia of the thoracic wall, and 1 case of edema of the ipsilateral upper limb. All patients were followed up 12-30 months (mean, 20.1 months). No latissimus dorsi muscle flap necrosis, latissimus dorsi muscle atrophy, or shoulder joint dysfunction occurred during follow-up; 2 patients had recurrence of lymph nodes in the ipsilateral axilla after operation, but no distant metastasis occurred. Breast-Q score at 6 months after operation was 64-100 (mean, 79.5). The average score was 78.6 (range, 64-100) in patients underwent nipple-sparing mastectomy and 81.0 (range, 78-100) in patients underwent breast conserving surgery. Conclusion: Breast reconstruction with endoscopic-assisted harvesting of the latissimus dorsi muscle flap for breast cancer is proven to be a surgical approach with safety and cosmetic effects with mild postoperative operation-related complications and considerable patient satisfaction.

Robotic nipple sparing mastectomy and immediate breast reconstruction: significant attempts with the latissimus dorsi muscle without island flap.

BACKGROUND: This study presents preliminary results of robot-assisted nipple-sparing immediate breast reconstruction (R-NSMIBR) with gel implant combined with latissimus dorsi muscle flap without island flap and validation of the safety and utility of this novel surgical modality. METHODS: Records pertinent to R-NSMIBR with gel implants combined with latissimus dorsi muscle flap surgery for breast reconstruction between September 2022 and May 2023 were examined. A total of 13 patients who underwent R-NSMIBR were analyzed, nine of which were performed without skin island. RESULTS: We divided the patients with and without skin islands into two groups and recorded the operation time and bleeding respectively. The mean total operative time for R-NSMIBR was 436.5±56.88 minutes and 355.75±69.68 minutes. As experience in learning increased, time required to create the operating space and position the robotic arm decreased significantly. Not creating an island of skin also saves a great deal of surgical time. Average total blood loss was 37.5±6.45 mL and 26.25±7.5 mL. No cases of nipple-areolar complex necrosis or perioperative complications or no local recurrences were reported. There were no local recurrences or deaths that occurred during a mean follow-up period of 3±1 months. CONCLUSIONS: All the patients expressed satisfaction with the aesthetic outcome following surgery. There were no significant differences between two groups. This surgical method shows promise for future promotion in the field.

Resection to restoration: Assessing the synergy of polypropylene mesh (Marlex®) combined with methyl-methacrylate and latissimus dorsi flap for primary chest wall sarcomas.

BACKGROUND: Chest-wall sarcomas are treated with extensive resections and complex defect reconstruction to restore chest-wall integrity. It is a difficult surgical procedure that incorporates a multidisciplinary approach for the best outcome, preventing paradoxical chest movement issues and reducing complications. OBJECTIVE: We aimed to describe our experience of chest-wall reconstruction using polypropylene mesh (Marlex® Mesh) combined with methyl-methacrylate and soft-tissue coverage with a latissimus dorsi flap following sarcoma resection. PATIENTS AND METHODS: Among the 53 patients treated for primary chest-wall sarcomas at the European Institute of Oncology (IEO) in Milan, Italy, from 1998 to 2020, 14 cases underwent chest-wall resection and reconstruction using polypropylene mesh, methyl-methacrylate and the latissimus dorsi flap. Patients with locally advanced breast cancers, locally advanced lung cancers, squamous cell carcinomas, and other secondary chest-wall malignancies were excluded from the study, as were the patients with different types of chest-wall reconstruction. RESULTS: In this study, 14 patients (6 men and 8 women) with various primary chest-wall sarcomas were enrolled. On an average, 2 ribs (range: 1-5) were removed during the surgeries, and the chest-wall defects ranged from 20 to 150 cm2 with an average size of 73 cm2. The mean follow-up period for these patients was approximately 63.80 months CONCLUSION: The combination of Marlex® mesh filled with methyl-methacrylate and covered using latissimus dorsi myocutaneous flap provides safe, low-cost and effective single-stage chest-wall reconstruction after surgery for primary sarcomas.

Surgical outcomes of robotic versus conventional autologous breast reconstruction: a systematic review and meta-analysis.

Breast reconstruction is an integral part of breast cancer management. Conventional techniques of flap harvesting for autologous breast reconstruction are associated with considerable complications. Robotic surgery has enabled a new spectrum of minimally invasive breast surgeries. The current systematic review and meta-analysis study was designed to retrieve the surgical and clinical outcomes of robotic versus conventional techniques for autologous breast reconstruction. An extensive systematic literature review was performed from inception to 25 April 2023. All clinical studies comparing the outcomes of robotic and conventional autologous breast reconstruction were included for meta-analysis. The present meta-analysis included seven articles consisting of 783 patients. Of them, 263 patients received robotic breast reconstruction, while 520 patients received conventional technique. Of note, 477 patients received latissimus dorsi flap (LDF) and 306 were subjected to deep inferior epigastric artery perforator (DIEP) flap. There was a significantly prolonged duration of surgery (MD 58.36;95% CI 32.05,84.67;P < 0.001) and duration of anaesthesia (MD 47;95% CI 16.23,77.77;P = 0.003) among patients who underwent robotic surgery. There was a similar risk of complications between robotic and conventional surgeries. The mean level of pain intensity was significantly lower among patients who received robotic breast surgery (MD- 0.28;95% CI - 0.73,0.17; P = 0.22). There was prolonged length of hospitalization among patients with conventional DIEP flap surgery (MD- 0.59;95% CI - 1.13,- 0.05;P = 0.03). The present meta-analysis highlighted the feasibility, safety, and effectiveness of robotic autologous breast reconstruction. This included the successful harvesting of LDF and DIEP flap with acceptable surgical and functional outcomes.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Immediate Breast Reconstruction With Latissimus Dorsi Myocutaneous Flap and Silicone Implant Followed by Adjuvant Radiotherapy for Breast Cancer.

BACKGROUND: About 30% to 50% of women with breast cancer undergo mastectomy, and approximately 50% of them will receive adjuvant radiotherapy (ART). This study evaluates the medium- and long-term impact of ART after immediate breast reconstruction (IBR) with latissimus dorsi myocutaneous (LDM) flap and silicone implants. METHODS: Clinical, surgical, and oncological data were retrospectively collected and analyzed based on the medical records of 176 patients who had undergone IBR with LDM flap and silicone implants. RESULTS: The data showed that 7.4% of patients had a history of previous radiotherapy, 56.3% received ART, 31.8% developed capsular contracture with a mean follow-up of 58.1 months, and 14.2% of surgeries were categorized as procedures with a prolonged operating time, lasting above 1 SD of the observed mean. Those who experienced prolonged operating time (odds ratio, 4.72; 95% confidence interval, 1.72-12.93; P = 0.003) and those who received ART (odds ratio, 7.38; 95% confidence interval, 3.18-17.10; P < 0.001) were more likely to develop capsular contracture. Thirty-two patients (18%) underwent capsulectomy with implant replacement, and 7 patients (4%) had the implant removed. The mean time between IBR and reoperation was 29.1 months. Patients who received ART were 2.84 times more likely to experience reconstruction failure or undergo implant-related reoperation ( P = 0.002). CONCLUSIONS: The results indicated that IBR with LDM flap and silicone implant followed by ART is a safe procedure, resulting in low rates of reconstruction failure. However, ART increased the likelihood of capsular contracture development and implant-related reoperation, having a negative effect on reconstructed breasts.

Rectovaginal Fistula: What Is the Role of Martius Flap and Gracilis Muscle Interposition in the Therapeutic Strategy?

BACKGROUND: Although numerous treatments exist for the management of rectovaginal fistula, none has demonstrated its superiority. The role of diverting stoma remains controversial. A few series include Martius flap in the armamentarium. OBJECTIVE: Determine the role of gracilis muscle interposition and Martius flap in the surgical management of rectovaginal fistula. DESIGN: Retrospective cohort study of a pooled prospectively maintained database from 3 centers. PATIENTS: All consecutive eligible patients with rectovaginal fistula undergoing Martius flap and gracilis muscle interposition were included from 2001 to 2022. MAIN OUTCOME MEASURES: Success was defined by the absence of stoma and rectovaginal fistula. RESULTS: Sixty-two patients were included with 55 Martius flap and 24 gracilis muscle interposition performed after failures of 164 initial procedures. Total length of stay was longer for gracilis muscle interposition by 2 days ( p = 0.01) without a significant difference in severe morbidity (20% vs 12%, p = 0.53). Twenty-seven percent of the Martius flap interpositions were performed without a stoma, which did not have an impact on overall morbidity ( p = 0.763). Per patient immediate success rates were not significantly different between groups (35% vs 31%, p > 0.99). The success of gracilis muscle interposition after the failure of the Martius flap was not significantly different from an initial gracilis muscle interposition ( p > 0.99). After simple perineal procedures, the immediate success rate rose to 49.4% (49% vs 50%, p > 0.99). After a median follow-up of 23 months, no significant difference was detected in success rate between the 2 procedures (69% vs 69%, p > 0.99). Smoking was the only negative predictive factor ( p = 0.02). LIMITATIONS: By its retrospective nature, this study is limited in its comparison. CONCLUSIONS: This novel comparison between Martius flap and gracilis muscle interposition suggests that Martius flap presents several advantages, including shorter length of stay, similar morbidity, and similar success rate. Proximal diversion via a stoma for Martius flap does not appear mandatory. Gracilis muscle interposition could be reserved as a salvage procedure after Martius flap failure. See Video Abstract . FSTULA RECTOVAGINAL CUL ES EL ROL DEL COLGAJO DE MARTIUS Y LA INTERPOSICIN DEL MSCULO GRACILIS EN LA ESTRATEGIA TERAPUTICA: ANTECEDENTES:Si bien existen numerosos tratamientos para el manejo de la fistula rectovaginal, ninguno ha demostrado su superioridad. El papel del estoma de derivación sigue siendo controvertido. Pocas series incluyen colgajo de Martius en el armamento.OBJETIVO:Determinar el rol de la interposición del músculo gracilis y del colgajo de Martius, en el manejo quirúrgico de la fístula rectovaginal.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente en 3 centros.AJUSTES/PACIENTES:Se incluyeron todos los pacientes elegibles consecutivos con fistula rectovaginal sometidos a colgajo de Martius y la interposición del músculo gracilis desde 2001 hasta 2022.RESULTADOS PRINCIPALES:El éxito se definió por la ausencia de estoma y fistula rectovaginal.RESULTADOS:Se incluyeron 62 pacientes con 55 colgajo de Martius y 24 con interposición del músculo gracilis realizados después de fracasos de 164 procedimientos iniciales. La duración total de la estancia hospitalaria fue dos días más larga para la interposición del músculo gracilis ( p = 0,01) sin una diferencia significativa en la morbilidad grave (20% frente a 12%, p = 0,53). El 27% de los colgajos de Martius se realizaron sin estoma, sin impacto en la morbilidad global ( p = 0,763). Las tasas de éxito inmediato por paciente no fueron significativamente diferentes entre los grupos (35% vs. 31%, p = 1,0). El éxito de la interposición del músculo gracilis después del fracaso del colgajo de Martius no fue significativamente diferente de una interposición del músculo gracilis inicial (p = 1,0). La tasa de éxito inmediato aumentó al 49,4% (49% frente a 50%, p = 1,0) después de procedimientos perineales simples. Después de una mediana de seguimiento de 23 meses, no se detectaron diferencias significativas en la tasa de éxito entre los dos procedimientos (69 % frente a 69 %, p = 1,0). El tabaquismo fue el único factor predictivo negativo ( p = 0,02).LIMITACIONES:Por su naturaleza retrospectiva, este estudio tiene limitaciones en su comparación.CONCLUSIÓN:Esta novedosa comparación entre colgajo de Martius y la interposición del músculo gracilis sugiere que el colgajo de Martius presenta varias ventajas, incluida una estancia prolongada más corta, una morbilidad similar y un éxito. La derivación proximal a través de un estoma para el colgajo de Martius no parece obligatoria. La interposición del músculo gracilis podría reservarse como procedimiento de rescate después de una falla de colgajo de Martius. (Traducción-Dr. Aurian Garcia Gonzalez ).

Is Immediate Breast Reconstruction With a Latissimus Dorsi Myocutaneous Flap Safe for Starting Adjuvant Chemotherapy in Patients With Breast Cancer?

INTRODUCTION: Immediate breast reconstruction following mastectomy reduces perceptions of mutilation and femininity issues in oncological patients, but surgical complications should not delay chemotherapy. This study evaluated postsurgical complications in patients who underwent radical breast surgery followed by immediate reconstruction with latissimus dorsi myocutaneous flaps and silicone implants, along with resulting impacts in delaying chemotherapy. MATERIALS AND METHODS: This retrospective study utilized a prospectively maintained database. Clinical, surgical, and oncological data from 196 women were collected according to the operated side. Patients were grouped according to the time elapsed between surgery and the first cycle of adjuvant chemotherapy: ≤ 60 days (group 1), 61 to 90 days (group 2), or > 90 days (group 3). RESULTS: A total of 198 immediate reconstructions were performed on 196 patients between August 1, 2010 and March 31, 2020; after surgery, 47.4% had minor complications and 7.1% had major complications. Ninety-six patients (48.5%) received adjuvant chemotherapy. The mean time elapsed between surgery and the first chemotherapy cycle was 65.4 days (median: 59), with 52.7% of the patients assigned to group 1, 37.4% to group 2, and 9.9% to group 3. The occurrence of major postoperative complications significantly affected the start of chemotherapy (64.0 vs. 94.5 days; P = .044). Additionally, patients with 2 or more comorbidities were more likely to experience major complications (OR: 3.35; 95% CI: 1.03-10.95; P = .045) than those with 1 or 0. CONCLUSION: Major postoperative complications significantly delayed initiation of adjuvant chemotherapy in oncological patients who underwent radical breast surgery followed by immediate reconstruction with a latissimus dorsi myocutaneous flap and silicone implants.

[Robotic-assisted harvesting of a latissimus dorsi muscle flap: a case report]. / Roboter-assistierte Hebung der M. latissimus dorsi ­ Lappenplastik: Ein Fallbericht.

Having established itself in various other areas of surgery as well as in urology, robotics is increasingly gaining importance in plastic surgery. The case presented in this manuscript describes the first published robotic-assisted harvesting of a latissimus dorsi muscle free flap in the German-speaking world. The aim is to increase the knowledge of robotics in plastic surgery and to support the introduction of robotic-assisted plastic surgery in Germany.

Biomechanical Comparison Between Superior Capsular Reconstruction and Lower Trapezius Tendon Transfer in Irreparable Posterosuperior Rotator Cuff Tears.

BACKGROUND: Superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT) have recently been used to manage irreparable posterosuperior rotator cuff tears (PSRCTs). There has been a paucity of comparative biomechanical considerations between the 2 procedures. PURPOSE: To compare the glenohumeral stability and biomechanical properties between SCR and LTT in PSRCTs involving the entire infraspinatus tendon region. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric shoulders were tested at 0°, 20°, and 40° of shoulder abduction. Maximum internal, external, and total humeral range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were compared among 4 conditions: (1) intact rotator cuff, (2) PSRCTs involving the entire infraspinatus tendon region, (3) LTT using Achilles allograft (12 N and 24 N of loading), and (4) SCR using fascia lata allograft. RESULTS: Although a decrease in total ROM was noted in LTT with 12 N compared with the tear condition, LTT with both 12 N and 24 N as well as SCR did not restrict total rotational ROM compared with the intact condition. LTT had decreased total ROM compared with tear condition at 20° of abduction (P = .042), while no significant decrease was confirmed at all abduction angles after SCR. SCR and LTT with 24 N decreased superior translation compared with the PSRCT condition at 0° and 20° of abduction (P < .037) but not significantly at 40° of abduction, whereas LTT with a 24-N load decreased glenohumeral superior translation at all abduction angles (P < .039). Both SCR and LTT decreased subacromial contact pressure compared with the tear condition (P < .014) at all abduction angles. SCR decreased subacromial contact pressure at 0° and 40° of abduction (P = .019 and P = .048, respectively) compared with LTT with 12 N of loading, while there was no difference between SCR and LTT with 24 N of loading in all abduction angles. SCR increased the contact area compared with the PSRCT condition at all abduction angles (P < .023), whereas LTT did not increase the contact area. CONCLUSION: SCR and LTT decreased glenohumeral superior translation and contact pressure compared with PSRCT conditions. The LTT was superior to SCR in terms of superior translation of the humeral head at a higher shoulder abduction angle, whereas the SCR showed more advantageous subacromial contact characteristics compared with LTT. CLINICAL RELEVANCE: These biomechanical findings provide insights into these 2 fundamentally different procedures for the treatment of young and active patients with PSRCTs involving the entire infraspinatus tendon region.

Latissimus dorsi myocutaneous free flap for the laryngopharyngectomy defect.

BACKGROUND: Partial or total laryngopharyngectomy defects have traditionally been reconstructed using the radial forearm, anterolateral thigh, or jejunal free flaps. The latissimus dorsi myocutaneous free flap (LDMFF) is an option for high-risk patients with complex laryngopharyngeal ± cutaneous neck defects. METHODS: Retrospective single-surgeon case series from 2017 to 2022. Outcomes were assessed at both the back donor site and head and neck. RESULTS: Twenty-four patients were identified. Flap survival was 100%. There was 1 (4.2%) pharyngocutaneous fistula and 2 (8.3%) tracheo-esophageal peristomal fistulas. At last follow-up, 17 (71%) were sustaining weight on oral intake, and 7 (29%) were G-tube dependent with 4 of these able to do some type of oral intake. Seven (29.2%) had post-operative stricture/stenosis requiring dilation. There were only minor donor site complications, all managed conservatively. CONCLUSIONS: The LDMFF can be a robust reconstructive option, particularly for radiated high-risk patients with complex pharyngeal defects, including skin.

The FALD-V: A predictive formula for preoperative volume assessment of adipose tissue transplantation in FALD flap.

BACKGROUND: The fat-augmented latissimus dorsi (FALD) flap is an evolution of the traditional latissimus dorsi (LD) flap, which allows to obtain a total autologous breast reconstruction (BR) avoiding the use of breast implants. The aim of this study was to develop a predictive preoperative formula in order to estimate and optimize the amount of fat to be transferred during FALD flap BR, using only anthropometric measurements. METHODS: We conducted a prospective clinical study between September 2020 and April 2023. All patients underwent back pre-operative ultrasound scan to assess the subcutaneous skin paddle thickness (SPT) and a regression analysis was performed to evaluate which anthropometric variable had a better correlation with this thickness. RESULTS: Data from 66 FALD flaps were collected. The mean SPT was 11.95 mm (SD 4.56). A significant correlation between SPT and body mass index (BMI) was found (r = 0.640, p < 0.0001). Using the fat-to-capacity ratio (113%), the following formula (the FALD-V) was developed to predict the needed fat transfer into FALD flap: [-509 + 12.32 × BMI + 11.71 × skin paddle width + 17.43 × skin paddle height] × 1.13. The considered variables (BMI, skin paddle width and skin paddle height) were statistically significant (p < 0.001, p = 0.0483, p = 0.0154, respectively). The cross-validation confirmed the accuracy of the formula (r = 0.810). CONCLUSION: The FALD-V can be used as an innovative complimentary device in the planning of FALD flap one-stage total autologous BR. To enhance its application, a 3.0 WebApp at www.braflap.com (and www.breast-v.com) is available free of charge for both iOS and Android devices. LEVEL OF EVIDENCE: II.

Outcome of modified fleur-de-lis latissimus dorsi myocutaneous flap for breast reconstruction.

BACKGROUND: Reconstruction of breast following mastectomy is important in terms of rehabilitating patients of breast cancer. Numerous approaches have been used in the reconstruction process. A procedure that has gained interest of the patients is reconstruction of breast using the autologous form. Main objective of this study is to determine the outcomes of modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction. METHODOLOGY: This is a retrospective case series which was conducted at the Department of Plastic Surgery, SIMS/Services Hospital, Lahore, from January 2020 till December 2022. 184 patients age 25-60 years and Females with a history of mastectomy, who had to undergo creation of breast shape using a tissue flap from another part of the body at the site of breast following mastectomy were included. All patients were subjected to standard procedure of breast reconstruction with latissimus dorsi flap using modified fleur-de-lis technique and postoperatively weekly assessment in the first month and then monthly until 3 months was carried out and outcome of the study was analysed. RESULTS: The mean age and VAS score of the patients was 49.7 ± 9.17 and 6 ± 2.21, respectively. 57.1 % patients have DCIS, benign in 38 % patients and other tumours were present in 4.9 % patients. Immediate versus delayed reconstruction was done in 63.6 % versus 36.4 % patients respectively. Good aesthetic outcome was achieved in 80.3 % patients CONCLUSION: Modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction yielded a good aesthetic outcome in the majority of the patients.

Reconstruction with latissimus dorsi flap after complicated perianal fistulisation.

Chronic fistulas are a dreaded complication to surgery. They are often persistent to treatment and involve several negative side effects and a significant reduction in quality of life. We present a case report of a 36-year-old male with a deep chronic fistula in the pelvis after pouch surgery. More than 60 procedures were performed under general anaesthesia without treatment effect. Through a multidisciplinary approach a complete rectum extirpation and reconstruction with a free latissimus dorsi flap was performed. The patient was seen at followup 18 months after the surgery; pain free and without relapse.

[Preliminary application of foldable pedicled latissimus dorsi myocutaneous flap for repairing soft tissue defects in shoulder and back].

Objective: To explore the feasibility and effectiveness of a foldable pedicled latissimus dorsi myocutaneous flap to repair soft tissue defects in the shoulder and back. Methods: Between August 2018 and January 2023, the foldable pedicled latissimus dorsi myocutaneous flaps were used to repair soft tissue defects in the shoulder and back of 8 patients. There were 5 males and 3 females with the age ranged from 21 to 56 years (mean, 35.4 years). Wounds were located in the shoulder in 2 cases and in the shoulder and back in 6 cases. The causes of injury were chronic infection of skin and bone exposure in 2 cases, secondary wound after extensive resection of skin and soft tissue tumor in 4 cases, and wound formation caused by traffic accident in 2 cases. Skin defect areas ranged from 14 cm×13 cm to 20 cm×16 cm. The disease duration ranged from 12 days to 1 year (median, 6.6 months). A pedicled latissimus dorsi myocutaneous flap was designed and harvested. The flap was divided into A/B flap and then were folded to repair the wound, with the donor area of the flap being pulled and sutured in one stage. Results: All 7 flaps survived, with primary wound healing. One patient suffered from distal flap necrosis and delayed healing was achieved after dressing change. The incisions of all donor sites healed by first intention. All patients were followed up 6 months to 4 years (mean, 24.7 months). The skin flap has a good appearance with no swelling in the pedicle. At last follow-up, 6 patients had no significant difference in bilateral shoulder joint motion, and 2 patients had a slight decrease in abduction range of motion compared with the healthy side. The patients' daily life were not affected, and linear scar was left in the donor site. Conclusion: The foldable pedicled latissimus dorsi myocutaneous flap is an ideal method to repair the soft tissue defect of shoulder and back with simple operation, less damage to the donor site, and quick recovery after operation.

Musculocutaneous Latissimus Dorsi Phalloplasty: Technique and Tips.

BACKGROUND: Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex. OBJECTIVE: This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty. MATERIALS AND METHODS: A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical. RESULTS: A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement. CONCLUSION: Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation.

Latissimus dorsi myocutaneous free flap for post-sacrectomy reconstruction: Outcomes compared with gluteal muscle flap.

BACKGROUND: Excision of sacral tumor results in extensive defects and vital organ exposure, requiring soft tissue reconstruction for dead space obliteration. Diverse reconstruction options, mainly regional flaps, have been utilized but are limited by high postoperative morbidity. A reliable reconstructive method with low morbidity and facilitated recovery has yet been sought for. In this study, we aimed to evaluate the use of free latissimus dorsi (LD) flap for post-sacrectomy defect reconstruction by comparing its outcomes with local gluteus maximus (GM) flap. METHODS: A retrospective review was conducted of all patients with sacral malignancy who underwent partial or total sacrectomy and immediate reconstruction with LD or GM flap between 2013 and 2022. Nineteen patients were analyzed, including 10 GM flaps and nine LD flaps. Postoperative outcomes were compared between the two groups. RESULTS: The average size of LD flaps was 173.8 cm2 . Seven patients developed complication in the GM group and two patients in the LD group. Complication rate at sacrectomy site was lower in the LD group (p = .003) showing complication-free sacrectomy site and two donor site seromas. The LD group resulted in shorter hospital stay (p = .033) and earlier ambulation than the GM group (p = .001). Mean follow-up period was 63 months for GM group and 17 months for LD group. Three patients in the GM group underwent re-operation, while no delayed complication was observed in the LD group. CONCLUSION: Free LD flaps may provide reliable outcomes with early recovery and may be considered an effective option for sacrectomy defect reconstruction.

[Current role of the latissimus dorsi flap in traumatology: Analysis of the activity of a plastic surgery department in a military hospital]. / Place actuelle du lambeau de grand dorsal en traumatologie : analyse de l'activité d'un service de chirurgie plastique en hôpital militaire.

Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.

Defect-Oriented Versus Back Scar-Oriented Flap Design in Breast Reconstruction with Latissimus Dorsi Musculocutaneous Flap: A Patient-Reported Satisfaction Outcome Comparison Using BREAST-Q.

BACKGROUND: The design of the latissimus dorsi musculocutaneous flap in breast reconstruction has several options. To date, there have been no reports on the surgical outcomes with flap designed based on the defect shape of the mastectomy site and flap shape of the donor site. To compare patient satisfaction according to the flap design, we designed and conducted independent three sub-studies targeting fifty-three breast reconstruction patients using BREAST-Q© scale. METHODS: In study 1, there was no difference in patient satisfaction between the group with the flap designed according to the shape of mastectomy defect (defect-oriented group) that with the flap designed according to patient's wish regardless of defect shape (back scar-oriented group). In study 2, comparing the results based on the shape of the flap, vertically designed flap showed a statistically significant difference in the psychosocial well-being. In study 3, comparing the results based on the shape of the defect, no significant difference was noted. RESULTS: Even though designing a donor flap based on the shape and orientation of the mastectomy defect has no statistical significance in patient satisfaction or quality of life compared with that based on the patient preference in placement of the donor site scar, the group with the vertical donor design showed better psychosocial well-being than the group with other shapes of the donor flap. By considering the advantages and disadvantages of each flap design, enhanced patient satisfaction and durability and natural aesthetic goal can be achieved. This is the first study to compare the differences in results according to the flap design method during breast reconstruction. Patient satisfaction according to the design of the flap was investigated in the form of a questionnaire survey, and the results were displayed. In addition to breast shape, donor scars and complications were also investigated. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Calvarial and Soft-Tissue Reconstruction with Latissimus Dorsi-Rib Osteomyocutaneous Free Flap.

BACKGROUND: The latissimus dorsi-rib osteomyocutaneous free flap (LDRF) has been used for autologous reconstruction of large composite calvarial and scalp defects. In this study, the authors aim to present clinical and patient-reported outcomes after LDRF reconstruction. METHODS: An anatomical study was conducted to evaluate the distribution of the connecting perforators between the thoracodorsal and intercostal systems. An institutional review board-approved retrospective review of 10 patients who underwent LDRF with one or two ribs for treatment of cranial defects was conducted. Patient-reported outcomes regarding quality of life, neurologic status, and functional status were evaluated using validated surveys. One-way analysis of variance and post hoc Tukey tests were used for anatomical outcomes. Preoperative and postoperative scores were compared using paired t tests. RESULTS: The tenth rib (4.65 ± 2.01) followed by the ninth rib (3.7 ± 1.63) had the highest number of perforators. A combination of the ninth and eleventh ribs exhibited maximal perforator number and pedicle length. All patients had stable LDRF reconstructions. Eight patients completed both preoperative and postoperative questionnaires; Median clinical follow-up was 48 months (range, 34 to 70 months). Scores trended toward improvement but did not reach statistical significance on the Karnofsky Performance Scale ( P = 0.22), the Functional Independence Measure (Motor, P = 0.52; Cognitive, P = 0.55), or the Headache Disability Index ( P = 0.38). The minimum clinically important difference was surpassed, demonstrating improvement of function for 71% of patients on the Barthel Index and 63% on the Selective Functional Movement Assessment test. CONCLUSION: The LDRF can improve cognitive and physical functional status in complex patients with prior failed reconstructions for composite scalp and skull defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.