Widely split latissimus dorsi muscle flaps for reconstruction of long soft-tissue defects in lower extremities

Free flaps for lower limb soft tissue reconstruction - A systematic review of complications in 'Silver Trauma' patients

BACKGROUND

There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years.

METHODS AND MATERIALS

Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar.

RESULTS

15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group.

DISCUSSION

There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps

BACKGROUND

The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap.

METHODS

Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed.

RESULTS

A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder.

CONCLUSIONS

Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Function-Sparing Free Split Latissimus Dorsi Flap for Lower-Extremity Reconstruction: Five-Year Consecutive Single-Surgeon Series

BACKGROUND

The free split latissimus dorsi flap for lower-extremity reconstruction has some advantages over the traditional latissimus dorsi flap. The flap is harvested with the patient in the supine position and is associated with minimal morbidity as the function of the remaining latissimus dorsi muscle is preserved through the posterior division of the thoracodorsal nerve.

METHODS

A consecutive single-surgeon 5-year series of free split latissimus dorsi muscle flaps for lower-extremity reconstruction (n = 42) was evaluated. Donor site morbidity was evaluated through assessment of the strength of the remaining latissimus dorsi at least 1 month after surgery. Shoulder function was evaluated postoperatively using the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Shoulder Pain and Disability Index (SPADI).

RESULTS

The mean age of the 42 patients was 40.7 years. The mean length and width of the flaps were 17.9 cm and 8.6 cm. The majority (71%) of the wounds were due to acute trauma. Of the 42 flap procedures performed, 95% (40) were successful. Assessment of remaining latissimus dorsi strength at least 1 month postoperatively, during 3 activities, showed a Medical Research Council (MRC) grade of 5 in all patients. The mean and median scores were 6.4 and 0 according to the DASH, 6.0/6.4 and 0/0 on the SPADI pain/disability scales, and 90.7 and 100 on the ASES.

CONCLUSIONS

The free split latissimus dorsi flap is a large reliable muscle flap with negligible donor site morbidity that is particularly advantageous for lower-extremity resurfacing following trauma.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

BACKGROUND AND AIM

The latissimus dorsi flap (LDF) has been employed very successfully over decades to cover large soft-tissue defects. Its donor-site morbidity has been extensively investigated in adults - but not in children - and is considered to be nonrestrictive. The aim of this long-term study was to assess donor-site morbidity with the modified Constant score more than 8 years after coverage of large myelomeningocele (MMC) defects with a reverse latissimus dorsi flap.

METHODS

Within the first days after birth, the reverse latissimus dorsi muscle flap was used uni- or bilaterally in three neonates to cover a large MMC defect. Bilateral shoulder function was tested more than 8 years postoperatively according to the modified Constant score.

RESULTS

The mean age at follow-up was 11.7 years. None of the patients experienced any pain or shoulder restrictions during normal daily activities. They all managed to position both of their arms comfortably above the head. Forward flexion was normal in all patients as was abduction and external rotation. Dorsal extension was minimally reduced on the operated side. Internal rotation was symmetric in all patients; the extent of active movement varied from excellent to poor.

CONCLUSIONS

Our long-term data suggest that there is no specific and significant impairment of shoulder function after using the distally pedicled reverse LDF for neonatal MMC repair.

Refined harvest technique for a segmental latissimus dorsi muscle flap with a lengthened pedicle

The latissimus dorsi (LD) muscle flap is one of the most versatile flaps used for reconstruction of soft tissue defects. With knowledge of its anatomy, harvest of the segmental LD muscle has been introduced as a reliable technique with the advantage of muscle preservation. We devised a new harvest technique for the segmental LD flap using a limited transverse incision to elevate a less bulky distal segment of the muscle with a sufficient pedicle length obtained by intramuscular dissection of the vascular pedicle. Two cases, in which this technique was effectively applied to reconstruct plantar defects after wide excision of malignant melanoma with a maximally efficient use of donor and recipient tissues, are presented. Satisfactory results were gained with stability in walking. When the defect size permits use of a segmental muscle and the long pedicle is needed, this pedicle-lengthened segmental LD muscle harvest technique would be a valuable method.

Latissimus Dorsi Muscle and Its Short Perforator-Based Skin Compound Free Flap

Some authors have described the latissimus dorsi muscle and its short perforator-based skin compound flap based on the same thoracodorsal vessels. This flap procedure involves separating the skin island from the underlying latissimus dorsi muscle and rotating the skin island over the musculocutaneous perforator emerging from the latissimus dorsi muscle. As with all surgical procedures, there are various advantages and disadvantages. However, to the best of the authors' knowledge, there are no reports on the use of the flap in a consecutive series. Between 1997 and 2005, the flap was used to reconstruct below-knee structures in 26 patients (23 males and 3 females) by the 2 senior authors at the Chonnam National University Medical School. The clinical outcomes of this procedure were evaluated. Satisfactory results were obtained in most patients. However, there were 2 marginal necroses in the excessively large skin flaps, 1 partial necrosis over the distal edge of a skin flap, and 1 total flap failure caused by infection. The marginally and partially necrotized skin flaps were treated successfully with split-thickness skin grafts. However, another flap procedure was required to cover the defect in the case of flap failure. The donor sites were closed primarily in all patients, and the skin flaps were rotated between 40 degrees and 180 degrees. This flap allows the surface of the latissimus dorsi musculocutaneous flap to be expanded without additional donor morbidity. In addition, the flap procedure is safe and easy to perform. Moreover, the flap provides sufficient flexibility, even though it has less independent flap mobility than the chimeric flap. Therefore, the flap may be a convenient and reliable alternative for the reconstruction of large and irregular-shaped wounds.

Reconstruction for lower extremity limb salvage in soft tissue carcinoma

Limb salvage procedures for the lower extremity have a 95% success rate and have essentially supplanted primary amputation as the primary treatment for limb-threatening malignancies. En bloc tumor resection involving major neural and vascular structures that once led to amputation are now successfully reconstructed using free-tissue transfer in combination with neoadjuvant and adjuvant chemoradiation therapies and brachytherapy. Planning for reconstruction of complex lower extremity wounds begins at the time of diagnosis and extends to postoperative rehabilitation. Developing a successful reconstructive plan requires a team approach with accurate assessment of the anticipated loss of critical structures, wound location, defect size, and an understanding of the local and distant tissues available for reconstruction. Comprehensive assessment of the anticipated wound combined with an understanding of the distant and local tissues available for reconstruction allows the reconstructive surgeon to select tissues from the entire body that have improved functional and aesthetic outcomes for patients.