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Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps.

ABSTRACT: Large and life-threatening thoracic cage defects can result from the treatment of traumatic injuries, tumors, infection, congenital anomalies, and radiation injury and require prompt reconstruction to restore respiratory function and soft tissue closure. Important factors for consideration are coverage with healthy tissue to heal a wound, the potential alteration in respiratory mechanics created by large extirpations or nonhealing thoracic wounds, and the need for immediate coverage for vital structures. The choice of technique depends on the size and extent of the defect, its location, and donor site availability with consideration to previous thoracic or abdominal operations. The focus of this article is specifically to describe the use of the pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps for reconstruction of thoracic defects, as these are the workhorse flaps commonly used for chest wall reconstruction.

SUBMITTER: Bakri K

PROVIDER: S-EPMC3140231 | biostudies-other | 2011 Feb

REPOSITORIES: biostudies-other

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Project description:Microsurgical scalp reconstruction is indicated in patients with large scalp defects. The aim of this study was to compare the outcomes of scalp reconstruction in oncologic patients reconstructed with latissimus dorsi (LD), anterolateral thigh (ALT), and omental (OM) free flaps. Thirty oncologic patients underwent scalp reconstruction with LD (10), ALT (11), and OM (9) flaps. The length of the vascular pedicle, the operation time, the possibility of a two-team approach, the length of hospital stays, the complications, and the aesthetic results were evaluated. The OM flap was the flap with the shortest vascular pedicle length with a mean of 6.26 ± 0.16 cm, compared to the LD flap, which was 12.34 ± 0.55 cm and the ALT flap with 13.20 ± 0.26 cm (p < 0.05). The average time of surgery was 6.6 ± 0.14 h in patients reconstructed with OM, compared to the LD flap, which was 8.91 ± 0.32 h and the ALT flap with 7.53 ± 0.22 h (p < 0.05). A two-team approach was performed in all patients for OM flaps and ALT flaps, but only in two patients reconstructed with the LD flap (p < 0.001). In patients reconstructed with the OM flap, a very satisfactory or satisfactory result was reported in seven patients (77.8%). Eight patients reported a very unsatisfactory or unsatisfactory result with LD flap (80%) and 10 patients with ALT flap (90.9%) (p = 0.002). The mean hospital stay after surgery was not statistically significant (p > 0.05). As for complications, two patients reconstructed with OM flap, five LT flaps, and two ALT flaps developed complications, not statistically significant (p = 0.235). Omental flap, latissimus dorsi flap, and anterolateral thigh flap fulfill most of the characteristics for complex scalp reconstruction. The decision on which flap to use should be based on clinical aspects of the patients taking into account that the three flaps show similar rates of complications and length of hospital stay. Regarding the aesthetic outcome, OM flap or LD flap should be considered for reconstruction of extensive scalp defects.

Project description:BackgroundBreast reconstruction using the latissimus dorsi (LD) flap is one of the most popular and common breast reconstruction techniques among Asian patients. There are increasing numbers of cases wherein breasts need to be reconstructed to moderate to large sizes among the Asian population. Most reconstructive surgeons use abdominal-based flaps-such as the deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap, or LD flap with an implant-to supplement the volume. Here, we compare the usefulness of the boomerang LD (bLD) flap-a technique developed by modifying the design of the conventional extended LD flap-with that of the LD flap with implant (LDi).MethodsThis was a prospective cohort study including patients with breast cancer aged between 25 and 60 years who underwent unilateral total or skin/nipple-sparing mastectomy, or postmastectomy. The exclusion criteria were advanced breast cancer (stages 3 and 4); a history of cognitive impairment affecting ability to complete the self-reported questionnaire; a history of neurologic or musculoskeletal disorder; and a history of alcohol or drug abuse. Statistical analysis was performed, and correlations between the two technique types were analyzed [including age, body mass index, preoperative breast volume, operation time, flap elevation time, admission duration, adjuvant treatment (radiotherapy, chemotherapy), drain indwelling duration, and drain total sum volume].ResultsIn total, 85 patients who underwent immediate breast construction through the LDi group (n=63) or bLD group (n=25) techniques after total mastectomy between January 2015 and June 2022 were analyzed (mean age: LDi group, 46±7.7 years; bLD group, 45.6±7.8 years). We observed that the flap weight, operative time, mean admission duration, and drain indwelling duration were statistically significantly different in the bLD group (P<0.05). Body mass index, preoperative breast volume, specimen weight, flap elevation time, and drain total time were comparable between groups.ConclusionsBreast reconstruction using the bLD flap was found to be a suitable alternative technique for patients who desire an autologous tissue transfer (rather than an implant) but are contraindicated for abdominal-based flaps and do not mind long postoperative scars.

Project description:The latissimus dorsi flap (LDF) has gained popularity given its versatile nature and broad applicability in breast reconstruction. Its resurgence has been attributed to its ability to be enhanced using implant or high-volume fat grafting, rendering it a primary option for selected patients. The aim of this review is to tackle current indications and subjects of controversy regarding use of complete-autologous and implant-enhanced LDF in breast reconstruction. Also, a case-series showcasing the authors' experience with this versatile reconstructive option is presented. A search across Web of Science and PubMed MEDLINE from inception through January 3, 2023, was conducted. Articles reporting postoperative outcomes of autologous breast reconstruction with LDF were included. Regarding the case series, electronic medical records of patients who underwent total mastectomy and autologous breast reconstruction with LDF from January 2011 to December 2021 were retrospectively reviewed. Data on demographic and oncologic characteristics, and surgical characteristics and outcomes were extracted. Our review suggests that LDF is suitable for patients who lack alternative donor site, have a history of abdominoplasty or no access to microsurgery, smokers or obese. Latissimus dorsi (LD) harvesting has almost complete shoulder function recovery in the long-term. Thoracodorsal nerve division does not cause volume loss or animation deformity. Multisite multilayer fat grafting, beveling the edges of the skin paddle and fat, folding the LD muscle and plicating the paddle allow adequate projection and contour achievement. Our case-series included 234 reconstructions. Almost half of the patients had immediate fat transfer during reconstruction (51.3%). The rate of recipient site hematoma was 3.0%, seroma was 7.7%, wound disruption 32.1%, wound disruption events requiring unplanned procedures was 13.7%, and surgical site infection (SSI) was 12.4%. The LDF is reliable and safe for immediate or delayed breast reconstruction or salvage after reconstruction failure. Its versatility, reliable anatomy, easy dissection, and relative low complication rate have revived this modality as valuable opportunity for breast reconstruction in this era.

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Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps.

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