latissimus dorsi

Very few experiences were reported for RLDF immedi- ate breast reconstruction with no more than 17 proce- dures [9–12]. The main differences in robotic surgical technique that should be underlined included a single incision realized around NAC for SSM and the use of a single site trocar. In Selber et al.’s study [10], seven pa- tients were reported with RLDF reconstruction per- formed through an axillar incision for NSM without the use of a single site trocar. Chung et al. [12] reported 12 RLDF procedures through a 5–6-cm axillar incision without CO2 gas insufflation for three delayed breast re- constructions, four IBRs with NSM, and five cases of chest wall deformity. Clemens et al. [13] reported 17 RLDFRs in delayed-immediate breast reconstruction after SSM and placement of a tissue expander through anterior mastectomy incision without a single site trocar. Endoscopic non-robotic LDFR was reported in several studies [4–8], and in 2007, Missana et al. reported a study including 52 patients [4] and more recently by others with smaller series [6–8]. Nakajima et al. [8] re- ported a study with 168 LDF video-assisted reconstruc- tions but only for reconstruction after partial mastectomy. Finally, Dejode and Barranger [15] reported one case of endoscopic 3D latissimus dorsi-flap harvest- ing for SSM with immediate breast reconstruction.

major region and was therefore referred to our hospital [Figure 1]. An magnetic resonance imaging (MRI) examination of the left thigh revealed a fistulating process in subcutaneous region of the left upper thigh extending down to the gluteus maximus muscle. Also, bacteria culture of wound exudates showed a staphylococcus aureus contamination. We performed several debridements of the scar tissue and the fistula down to the trochanter major and intermittent negative pressure wound therapy (NPWT) [Figure 2]. Histological examination revealed a chronic granulating and ulcerating soft tissue infection without proof of an osteomyelitis. In a two-step procedure, defect reconstruction was achieved using a free latissimus dorsi flap [Figure 3]. Due to missing recipient vessels in the defect area, AV loop was created from the left femoral vessels using a saphenous vein graft in the first step. Postoperatively patency of the AV loop was checked using Doppler ultrasound. After four days a free myocutaneous latissimus dorsi flap was microsurgically anastomosed to the AV loop. Therefore the AV loop was cut into two legs, and the arterial anastomosis of the subclavian artery and the arterial AV loop leg was performed under microscope magnification using 8-0 suture material. The venous anastomosis of the subclavian vein and the venous AV loop leg was performed using a 4.0 mm coupler device. The latissimus dorsi muscle was used to seal the tissue defect down to the trochanter major whereas the skin island was inserted to close the skin defect without the requirement of a split skin graft. Postoperatively flap perfusion was checked using capillary refill of the skin island and Doppler ultrasound. The flap was adequately perfused at all times and no revision war necessary. Mobilization of the patient was performed using a dangling regime. Cefuroxim was administered intravenously during the hospital stay and afterwards in oral form for a total of six weeks postoperatively. Due to a postoperative anemia the patient received two red cell concentrates in the further course. The patient was discharged from the clinic 13 days after free flap transplantation. In the further course a wound healing disorder occurred in the ventral part of the skin island. MRI examination of the pelvic showed no recurrent fistula, whereas a subcutaneous infection could be observed leading to no further operative intervention.

The nature of the force of latissimus dorsi muscle contraction between canoeing and swimming is very different, and may significantly influence the muscle length, and hence the findings of this study. In order to control the canoe against fast moving water, the contraction of the latissimus dorsi is likely to be either isometric or relatively small concentric- eccentric contractions, all of high force. This is likely to provide considerable stimulus for muscle hypertrophy, and also for muscle stiffness (resistance to elongation) to develop within the latissimus dorsi to manage the high forces involved in controlling the canoe. The canoeist also has to control longer lever arms over which the force has to be generated, because of the presence of the paddle. In contrast, the lower resistance offered by the water during swimming and the large-range, low-force, concentric contractions required would develop less stimulus for muscle hypertrophy and stiffness as compared to canoeing. One possible explanation for this could be due to the passive resistance produced by the non- contractile elements of the musculo-tendinous unit of the muscle due to the relative sizes of the cross sectional area of the muscle. These elements represent a major contributing factor to the passive length-tension relationship of the muscle, and may comprise the elastic filaments and gap filaments spanning each half sarcomere, as well as the extensible protein titin, which is thought to be one important source of passive tension in muscle. 17

Results: All patients demonstrated a significant improvement in the Constant score (p = 0.001), from a preoperative score of 33 points (range 10 – 55 points) to a postoperative score of 59 points (range 13 – 80 points). The subjective assessment score was good to excellent in 12 patients (85%), and 11 patients (78%) would be willing to undergo surgery again. Integrity of the transferred tissue was confirmed in 13 of the 14 cases using ultrasound and MRI. Surface electromyographic signal showed increased activation of the transferred latissimus dorsi when performing active movements of external rotation (p = 0.002) and abduction-elevation (p = 0.009).

Lobectomies were performed through posterolateral thoracotomies in 15 patients with complex aspergillo- mas, and partial resection through axilla thoracotomy in one patient with simple aspergilloma. After 2011, concomitant intrathoracic transposition of latissimus dorsi muscle flap was performed in 6 patients (38 %), in- cluding one patient with primary thoracoplasty resulting from a large residual pleural space. The mean operative time was 323 min (range, 93 to 625 min). Operative time was longer for patients with muscle flaps (mean 406 min, range, 315 to 625 min) than for patients with- out muscle flaps (mean 273 min, range, 93 to 392 min, p = 0.023, t-test, Table 3). Mean intraoperative blood loss was 725 mL (range, trace to 2225 mL). There was no statistical difference between patients with muscle flaps (mean 1017 mL, range, 381 to 2225 mL) and those without muscle flaps (mean 550 mL, range, trace to 1500 mL, p = 0.140, t-test, Table 3). There was no statis- tical difference between patients with preoperative embolization (mean 903 mL, range, 180 to 2225 mL) and those without preoperative embolization (mean 497 mL, range, trace to 1500 mL, p = 0.192, t-test).

Results: In this study 13 patients had avulsion of the C5-6 roots on magnetic resonance imaging. The patients presented after a period of 128.83±56.76 days. Substantial time elapsed and ruled out primary brachial plexus reconstruction or nerve transfers. The average elbow flexion improved from 6.67±5.69 degrees (range: 0-20 degrees) to 86.94±12.38 degrees (range: 65-110 degrees) following unipolar latissimus dorsi transfer. 12 patients (66.67%) developed M4 or M4+ power.

Giant phyllodes tumors are rare, and mastectomy is pre- ferred for complete tumor excision. Latissimus dorsi myocutaneous flap can be successfully used to recon- struct the breast after the removal of very large tumors and can provide excellent aesthetic results with a low risk of flap necrosis or donor-site morbidity, and can also be used for high-risk patients who may be unsuita- ble for TRAM or DIEP flaps.

Latissimus dorsi musculocutaneous flap can be elevated reversely and thus can be used for many purposes. Latissimus dorsi flap based on the secondary segmental vessels, which are termed "reversed"[9,10] or "distally based" [6] latissimus dorsi flaps, have been widely used to repair defects of the spinal, lumbar, and sacral regions [11], but in some critical conditions such as cardiomyo- plasty, delay is preferred to minimize the possibility of distal necrosis and to harvest a larger and a safer flap [12,13]. Delay increases the duration of flap viability, improves the viability and makes the flap circulation safer [14]. The pathogenesis of delay has not been understood although many theories have been proposed. The Microangiographic view of the flap in Group Ivdc

The latissimus dorsi myocutaneous flap (LDMCF) is a useful method as oncoplastic breast surgery. LDMCF can supply adequate volume and be easily acquired. Be- sides, it has an advantage of low complication rates. LDMCF is, however, considered inappropriate for pa- tients with ptotic breast. Though the saline-filled pros- thesis is combined with LDMCF, the natural shape of drooping breast cannot be achieved. Therefore, bilateral reduction mammoplasty is widely used for breast cancer patients with large or ptotic breast [1-5]. The location of the tumor, however, is the limiting factor of reduction

The scapula flap possesses a number of advantages for reconstructive measures in general and for reconstruc- tion of disarticulation resections in particular. The high volume of soft tissue provided by the latissimus dorsi flap was found to be highly beneficial for reconstructing the significant facial soft tissue defects present in all 3 patients. It was anticipated from the preoperative evalu- ation of the soft tissue involvement, that the resulting defects could not be reliably reconstructed using a com- bined fibula and radial forearm flap in these cases. Moreover, the shape and surface contour of the scapular tip seem like the ideal option to restore the shape of the mandibular condyle [13].

First, a latissimus dorsi myocutaneous flap was harvested with the patient in left lateral position (Fig. 3a). We could not assert that the tumor was not infiltrating the pectoralis major muscle and the subcutaneous layer. Therefore, we decided to re- move these muscles. Parasternectomy and removal of the right second and third costochondral

Conclusions: A combined serratus anterior and latissimus dorsi myocutaneous free flap was applied to cover the raw surface and reinforce the abdominal wall and to fashion a new colostomy, as well as successfully filling the pelvic cavity with a large muscle body and long vascular pedicle. This is the optimal method for reconstructing severe abdominal wall defects that have many complications.

Background: Skin-sparing mastectomy (SSM) and latissimus dorsi (LD) flap immediate breast reconstruction (IBR) is a tailored surgical procedure. The surgical and patient-reported outcome (PRO) of SSM and LD IBR were assessed. Methods: Retrospective data of 146 SSMs performed by a single surgeon was reviewed. Among patients included in the data, 65 patients underwent SSM and LD IBR without a prosthetic implant. A survey estimating the degree of patient satisfaction (poor, fair, good, and excellent) as regards the cosmetic outcomes of surgery was performed. The patients were divided into two groups according to their degree of satisfaction (excellent group versus non- excellent group), and analysis was done to identify factors affecting the highest patient satisfaction.

plate was exposed (Fig. 3a). Then, lateral femoral flap grafting was delivered, as illustrated in Fig. 3b. Primary flap healing was obtained. The wound surface and punc- turing site were dried at 6 months after the flaps were healed, and no significant exudates were observed, as shown in Fig. 3c. X-ray demonstrated that the bone frac- ture was partially healed and partial bone absorption was detected. The external fixation stent was removed, whereas the internal fixator was retained, as illustrated in Fig. 3d. At 1.5 years after injury, two sinus tracts with slight yellow exudates were seen in the middle and lower segments of the lower extremity (Fig. 4a). CT scans re- vealed that the bone mineral density was decreased and the bone fracture was not healed. After dressing change, the internal fixator was removed and dressing change was administered, as shown in Fig. 4b. Delayed wound healing was achieved after multiple symptomatic treat- ment and fixed by using plaster cast. After 6 months, the bone scarring was observed and the bone defects were not healed. The bone scars and necrotic tibiofibular bone tissues were debrided. The latissimus dorsi myocu- taneous flaps were utilized to cover the wound surface and fill in the bone defects. The external fixation stent was retained. Primary wound healing was obtained in the wound surface and donor site, and no evident sinus tract was observed. The iliac bone flap grafting was delivered after 6 months. Primary wound healing was obtained in the donor site. X-ray during postoperative follow-up demonstrated that the bone defects were properly healed. The external fixation stent was re- moved following 6 months and fixed by using plaster cast (Fig. 5). At 8 months, the plaster cast fixation was removed and the patient was required to perform function training and exercise using the walking stick, as illustrated in Fig. 6. The situs with the inserted iliac crest flap was illustrated in Fig. 7.

This reflects the findings for our population. An exam- ination using the Constant and Murley Score in our population showed no major alteration in the function of the shoulder on the donor side compared to the healthy non-donor side. In the dynamometer testing, the strength parameters of the donor side did not differ significantly from those of the contralateral side. One reason for this finding is that the synergists compensate for the function and strength of the latissimus dorsi muscle. However, handedness had an additional impact. In 82% of the cases, the latissimus dorsi flap was har- vested from the left side. The predominant side in Germany is the right hand in over 90% of the popula- tion; therefore, this side is already stronger by nature [53]. Therefore, the results showed only a physiological difference between the donor and the healthy contralat- eral non-donor side.

Some factors can deteriorate the early aesthetic out- come: the effect of radiotherapy reducing breast size and increasing the fibrotic, changes in body weight, and aging and gradual breast ptosis, which would worsen the cosmetic result increasing breast asymmetry. This has been experienced by Gendy, who observed an incre- ment of the cosmetic failure rate from 10 to 18%, in a period of 43 months, in patients treated with a partial mastectomy with latissimus dorsi miniflap reconstruc- tion [10].

The latissimus dorsi muscle (LDM) is a large flat muscle originating from the mid to the lower back. The insertion of the latissimus dorsi tendon (LDT) is located at the crest of the lesser tuberosity of the proximal humerus posterior to the pectoralis major tendon and anterior to the teres major tendon. The most important functions are adduction, extension, and internal rotation of the shoulder. The LDM is strongly involved and trained during horizontal and vertical pulling exercises such asrowing and pull-ups. During exercises stressing the LDM, isolated ruptures of its tendon are possible.

Between 1998 and 2001, tranfer of latissimus dorsi musculotendi- nous unit was performed in 7 patients who had an irreparable rota- tor cuff tear and no previous cuff surgery. There were five men and two women, aged 46–68 years (mean, 57). The right, dominant shoulder was involved in five cases and the left, non-dominant shoulder, in two. All patients had shoulder pain lasting 6–18 months at the time of surgery. The active range of motion was lim- ited in all cases, although to a variable extent (Fig. 1a, b) (Table 1). In one patient (case 3) active flexion, abduction and external rota- tion were considerably impaired; this was also the only patient with a positive lift-off test, indicating a tear of the subscapularis tendon. In the remaining patients, active motion averaged 86° in flexion, 74° in abduction and 22° in external rotation with the arm adduct- ed. Atrophy of supraspinatus and infraspinatus muscles was severe in four cases, moderate in two and mild in one.

chest wall defects reconstruction after radical breast amputation. The latissimus dorsi muscle flaps offers great variety and options to cover large defects in the mid-thoracic and upper-thoracic posterior trunk. It can be raised up to 30 cm × 40 cm in size and may be transferred as a muscular (eventually with additional skin grafts) or myocutaneous flap. The latter option makes postoperative monitoring considerably easier. It origins at the thoracical spinous processes, inferior ribs, and iliac crest. The latissimus dorsi muscle inserts at the intertubercular groove of the humerus. Its dominant vascular pedicle is the thoracodorsal artery, which is part of the scapular vascular system, whereas the non-dominant pedicles origin from intercostal and lumbar arteries. It is therefore a class V muscle according to the popular classification of Mathes and Nahai [16] ; thus, survival of the flap may also be based on the non-dominant pedicles [17] , which would allow

Zwar weist der M. teres minor nur eine geringe physiologische Querschnittsfläche auf, wodurch die potentielle Kraftentfaltung gegenüber den drei anderen Muskeln der Rotatorenmanschette relativ gering ist. Gleichzeitig verfügt er jedoch über das höchste Dehnungspotential. Ein intakter Teres minor kann daher unter Umständen die Effektivität des Latissimus dorsi Transfer in Außenrotation verbessern. 58