Complications of latissimus dorsi myocutaneous flap breast reconstruction

Two qualitative rapid appraisal techniques were used in a community-based study to investigate health beliefs, attitudes and practices in a rural district in Nepal. Pregnancy and childbirth remain non-medical activities managed at home. Deaths may be avoided by better access to hospital emergency services. Health awareness of some problems, e.g. oral rehydration and diarrhoeal disease, is high; but of others, e.g. association of haemoptysis with tuberculosis, is poor. These methods require few resources, are efficient in time and manpower required, and generate useful relevant information on a target population. They are recommended for district health development programmes elsewhere.     

Technical aspects of the latissimus dorsi myocutaneous flap in breast reconstruction

The authors review the technical refinements that have come about through their increased use of the latissimus dorsi flap for reconstruction of the female breast following mastectomy, referring to over 90 of their cases. These refinements involve careful selection of patients in whom the flap is used; planning the flap, including determination of the limits of the muscle; and the location and shape of the skin island. Placement of the patient on the table and the position of her arms and hips are discussed. The dissection and transfer of the flap, as well as closure of the donor defect, can present particular problems, which are outlined. Implant placement, wound closure, and postoperative care of the patient are also discussed.     

Sensate myocutaneous latissimus dorsi flap

A case using a sensate myocutaneous latissimus dorsi flap for oral defect reconstruction is reported. Preparation of the cutaneous branches of a latissimus dorsi autologous transfer and their subsequent anastomoses with sensitive nerves at the recipient site resulted in superficial and deep sensibility of the transfer, following a short rehabilitation period. As early as 4 months postoperatively, pain and pressure sensations could be evoked in the flap. Sharp and blunt discrimination and sense of vibration were found 6 months postoperatively. Nine months postoperatively, caloric differentiation could be elicited.     

Free innervated latissimus dorsi muscle flap for reconstruction of full-thickness abdominal wall defects

The aim of this study was to develop a maturation protocol for immature oocytes and assess the protocol with cryopreserved oocytes. Nuclear maturation (mature spindle and aligned chromosomes) occurred irrespective of the treatment regime: 71-89% of oocytes matured in vitro had a normal spindle and chromosomes compared with 87% matured in vivo. Fertilization rates were not significantly different from those of in-vivo matured oocytes. Of the maturation treatment regimes investigated, the initial treatment producing best development to blastocyst (cytoplasmic maturation) involved a 2 h incubation in standard maturation medium (SMM) containing 7.5 IU follicle stimulating hormone (FSH) followed by 14 h in SMM plus 7.5 IU FSH:luteinizing hormone with follicular cells [62% (range 49-69)]. The addition of 1 ng/ml epidermal growth factor (EGF) in this protocol resulted in development [75% (range 71-81)] that was not significantly different from in-vivo matured oocytes [82% (range 73-90)]. Exposure of the oocytes to 1.5 M dimethylsulphoxide (DMSO) did not affect fertilization or development rates. Following a slow-cool/thaw freezing regime, 81% (range 74-89) of the oocytes were morphologically normal, i.e. had a spherical shape with an intact zona and oolemma; they had, however, lost their previously attached cumulus and corona cells. Maturation of frozen-thawed oocytes in the presence of EGF gave good fertilization rates but poor development rates [80% (range 77-86) and 37% (range 33-40) respectively]. In conclusion, the best maturation, both nuclear and cytoplasmic, occurred in the presence of a combination of gonadotrophins, EGF and follicular cells. Oocytes cryopreserved using a slow-cool/thaw regime can be matured to produce blastocysts after in-vitro fertilization.     

Autogenous latissimus breast reconstruction

Two schemes for efficient and productive isolation for mutant human recombinant tumor necrosis factor-alpha (TNF-alpha R32H) from Escherichia coli cells were developed. The methods include membrane filtration, ion-exchange chromatography and gel filtration, and centrifugation with subsequent free-flow electrophoresis as an alternative procedure. The target product was obtained as active trimer with total yield more than 50% and greater than 98% purity according to PAGE, size-exclusion chromatography, HPLC, and HPCE.     

The use of latissimus dorsi muscle flap in reconstructive heart surgery

Dynamic cardiomyoplasty is a technique for ventricular assistance indicated for the correction of left ventricle aneurysm and for cardiomyopathies in which heart transplantation is contraindicated. In this article, our first four patients to undergo cardiomyoplasty (from February 1991 until April 1992) with a left latissimus dorsi island flap, rotated into the thorax after a 3-week training period, are reviewed. Therapeutic indications were cardiomyopathy with contraindication for heart transplant in patients 1 and 4 and associated to surgery for left ventricle aneurysm for patients 2 and 3. Patient 1 died 4 months after surgery because of a cerebral embolism when he was at functional class II. The other three patients remain at functional class I, carrying out normal activities. All the data were evaluated with the paired t test. Ejection fraction values (obtained through echocardiography and scintigraphy studies) and maximum minute flow rate of blood (measured with an echo-Doppler) have increased significantly (p < 0.001, p < 0.05, and p < 0.01, respectively) after heart surgery. Clinical improvement has been found after cardiomyoplasty, which correlates with an increase in ejection fraction and maximum minute flow rate of blood.     

Chronic osteomyelitis of the spine managed with a free flap of latissimus dorsi. A case report

STUDY DESIGN: A patient with intractable spinal osteomyelitis who underwent surgery 12 times with persistent exposed bone is presented. OBJECTIVES: To demonstrate the effectiveness of free-flap grafting for managing difficult spinal osteomyelitis wounds. SUMMARY OF BACKGROUND DATA: Conventional procedures can usually achieve wound closure, but they may not work for advanced cases. METHODS: A free latissimus dorsi flap was transferred for reconstruction. The muscle component was used to obliterate the dead space and cover the exposed bone, and the skin component was used for tension-free closure of the wound. RESULTS: The wound healed dramatically. There was no recurrence of infection at 2-year follow-up evaluation. CONCLUSIONS: For an intractable spinal osteomyelitis wound, a free flap should be considered, although the surgery is difficult. Technical precautions in performing this operation are given.     

Reconstruction of intractable ulcer of the knee joint in Werner''s syndrome with free latissimus dorsi myocutaneous flap

In 1970 Aulhorn and Harms made fundamental recommendations for the night driving ability of motorists as well as for the corresponding examination methods. Reduced night driving ability of persons over the age of 60, as well the established limits for twilight vision and glare sensitivity, and their relevance to night-time collisions has been re-examined. PATIENTS AND METHODS: A total of 117 normal volunteers between 10 and 79 years of age underwent ophthalmological examinations including measurement of contrast acuity and glare sensitivity by means of the Mesotest II (Oculus, Germany). RESULTS: Contrast acuity and glare sensitivity deteriorate in an age-dependent fashion. Thus, night driving ability decreased with increasing age. The majority part of persons over the age of 60 were not able to fulfill the actual criteria for night driving ability according to the recommendations of the German Ophthalmological Society (DOG). CONCLUSIONS: In the present population, nearly 40% of persons over the age of 60 have reduced night driving ability. Since Lachenmayr showed in the BAST study the correlation of reduced night driving ability and car accidents, this emphasizes the importance of ophthalmological check-ups for motorists at this age.     

Optimal electrical stimulation for latissimus dorsi muscle after cardiomyoplasty

A new property of the presequence of the mitochondrial precursor protein cytochrome oxidase subunit IV is presented. This mitochondrial presequence induces interbilayer contacts between large unilamellar vesicles consisting of phosphatidylcholine and cardiolipin. The presequence-vesicle aggregates can be dissociated by applying a membrane potential across the bilayers (negative inside). These effects require the presence of cardiolipin and are not observed for other negatively charged phospholipids. We propose a role for the presequence in the formation and dissociation of mitochondrial contact sites.     

Structure of the latissimus dorsi muscle and respiratory function

The aim of this study was to evaluate whether respiratory function influences the structure of the latissimus dorsi muscle (LD). Twelve patients (58 +/- 10 yr) undergoing thoracotomy were studied. Lung and respiratory muscle function were evaluated before surgery. Patients showed a forced expired volume in 1 s (FEV1) of 67 +/- 16% of the reference value, an FEV1-forced vital capacity ratio of 69 +/- 9%, a maximal inspiratory pressure of 101 +/- 21% of the reference value, and a tension-time index of the diaphragm (TTdi) of 0.04 +/- 0.02. When patients were exposed to 8% CO2 breathing, TTdi increased to 0.06 +/- 0.03 (P < 0.05). The structural analysis of LD showed that 51 +/- 5% of the fibers were type I. The diameter was 56 +/- 9 microns for type I fibers and 61 +/- 9 microns for type II fibers, whereas the hypertrophy factor was 87 +/- 94 and 172 +/- 208 for type I and II fibers, respectively. Interestingly, the histogram distribution of the LD fibers was unimodal in two of the three individuals with normal lung function and bimodal (additional mode of hypertrophic fibers) in seven of the nine patients with chronic obstructive pulmonary disease. An inverse relationship was found between the %FEV1-forced vital capacity ratio and both the diameter of the fibers (type I: r = -0.773, P < 0.005; type II: r = -0.590, P < 0.05) and the hypertrophy factors (type I: r = -0.647, P < 0.05; type II: r = -0.575, P = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Superior gluteal artery perforator free flap for breast reconstruction

The purpose of this paper is to present a new method of breast reconstruction utilizing skin and fat from the buttock without muscle sacrifice. Cadaver dissections were done to study the musculocutaneous perforators of the superior gluteal artery and vein. Eleven breasts were reconstructed successfully with skin/fat flaps based on the superior gluteal artery with its proximal perforators. Long flap vascular pedicles allow the internal mammary or thoracodorsal vessels to be used as recipient vessels. This new technique has several advantages over the previously described gluteus maximus myocutaneous flaps, including long vascular pedicle and no muscle sacrifice.     

Balloon assisted endoscopic harvest of the latissimus dorsi muscle

In this study, we present our experience with balloon assisted endoscopic harvest of the latissimus dorsi muscle for extremity reconstruction. The balloon performs most of the dissection under the muscle and creates the optical work space used in the endoscopic dissection. Over the course of this series the operative time has been reduced and averaged 2 hours and 44 minutes. The reconstructive goals were met in all cases. The average axillary incision length was 5.6 cm, and there were an average of 1.3 one-centimeter or smaller counter incisions.     

The quadrifoliate flap: a combination of scapular, parascapular, latissimus dorsi and scapula bone flaps

A short arm stump was lengthened with a composite flap with four different tissue units based on the subscapular artery.     

Vertical double flap design for repair of wide defects of the lower limb, using combined ascending scapular and latissimus dorsi flaps

Two cases are presented in which a scapular osteocutaneous flap and a latissimus dorsi musculocutaneous flap were applied as combined flaps with a single pedicle, to repair massive soft-tissue defects resulting from tibial hemisection in the lower limb. In each case, the oval-shaped donor site was divided into two parts (an ascending scapular flap and a latissimus dorsi flap, respectively) to repair the resected area, using a vertically designed, combined flap from the dorsolateral region. Consequently, after flap elevation, the donor site could be closed primarily and functions of the affected limb could be completely reconstructed. For reconstruction of defects too large to be covered with a single flap, the vertical double flap design of a combined ascending scapular and latissimus dorsi flap is a good alternative. It has the merits of easy dissection, broad area skin coverage and it also provides a composite flap that contains a scapular bone graft. Moreover, it allows a simple microsurgical anastomosis, as well as direct closure of the donor site. In addition, when the recipient site is on the lower leg, flap elevation can be carried out simultaneously with surgery at the recipient site. This means that the operative time can be shortened.     

Quantification of early damage in latissimus dorsi muscle grafts

Acute damage in the latissimus dorsi muscle may account for variable clinical results following dynamic cardiomyoplasty and an ischemic cause has been suggested. Using established techniques, we set out to demonstrate and to quantify the acute muscle damage in a rodent model. The left latissimus dorsi muscle of 5 Sprague-Dawley rats was mobilized on its thoracodorsal vascular pedicle, thus interrupting the regional blood supply to its distal part. The undisturbed contralateral muscle served as a matched control. After 24 hours, the muscle was excised and divided into proximal, middle, and distal thirds. Damage was graded histologically and quantified by nitroblue tetrazolium macrohistochemistry. Both methods of assessment correlated well (r=-0.936; P < 0.001) and demonstrated significant damage, principally in the middle and the distal regions of the ischemic muscles. Therefore, the rodent model appears to be useful for investigating the pathogenesis and prevention of acute ischemic damage in the latissimus dorsi graft under conditions resembling the clinical scenario.     

The use of Holmstrom's flap in breast reconstruction

The authors consider 12 cases of breast-reconstruction after mastectomy, made with the Holmstrom's flap, to verify the validity and the real utility of this way of reconstruction. It has been made a follow-up of 4 years, to verify, in course of time, the characteristics of the reconstructed breasts. All the patients have been operated in a general surgery department. The Holmstrom's flap has been prevalently used in patients, during immediate reconstruction. The breast reconstruction, made with this fascio-cutaneous transposition flap, requires the use of prosthesis. The operating time has a very short duration. The breast reconstruction, made with this method, requires a very short staying in hospital. The nipple-areola complex reconstruction has been made in a second time, few months later. The patients have been examined periodically, to verify, immediately, the result of the flap and, later, the quality of the new breast's shape and the occurrence of capsular contracture. The results achieved with this reconstructive method are a good shape and ptosis as to confer great naturalness to the new breast. The authors conclude that, even if they use the TRAM-flap as first choice in breast-reconstruction, the Holmstrom's flap is a reconstructive technique of great utility in immediate breast reconstruction, that is able to give very good aesthetic results.     

Optimization of synchronization delay in latissimus dorsi dynamic cardiomyoplasty

BACKGROUND: Optimal synchronization delay (SD) for triggering the implanted cardiomyostimulators in patients undergoing latissimus dorsi dynamic cardiomyoplasty has not been clearly defined. Generally a synchronization delay time of 45 to 60 ms is used in the current practice, in which the implanted cardiomyostimulator stimulates the latissimus dorsi muscle 45 to 60 ms after mitral valve closure acquired with M-mode echocardiography. We investigated the effect of shortening or prolonging the delay time on cardiac functions. METHODS: We studied 10 patients who were in their first 2 years postoperatively. Three values for SD (SD = 0 ms, 45 to 60 ms, and 150 to 160 ms) were echocardiographically evaluated for their influence on both systolic and diastolic left ventricular parameters. RESULTS: Ejection fractions were 0.27 +/- 0.07, 0.28 +/- 0.07, and 0.32 +/- 0.06; peak aortic velocities were 0.85 +/- 0.8, 0.86 +/- 0.11, and 0.92 +/- 0.8 m/s; and velocity-time integrals were 0.16 +/- 0.03, 0.16 +/- 0.03, and 0.19 +/- 0.03 m for the SD values of 0, 45 to 60 ms, and 150 to 160 ms, respectively. Diastolic parameters were also measured. Isovolumetric diastolic relaxation time was 97.5 +/- 49, 97.20 +/- 44, and 111.8 +/- 49 ms; deceleration time was 83.67 +/- 32, 88.48 +/- 35, and 92.68 +/- 34 ms; and ratio or velocity-time integral of e wave to velocity-time integral of a wave was 3.09 +/- 0.98, 2.48 +/- 0.69, and 2.38 +/- 0.65 for the SD values of 0, 45 to 60 ms, and 150 to 160 ms, respectively. Systolic functions were better when SD was set at 150 to 160 ms, but there was a diastolic compromise. On the other hand, diastolic parameters were more favorable when SD = 0 (i.e., cardiomyostimulator triggered without delay) but the systolic assist was suboptimal. Systolic and diastolic parameters seemed relatively well-balanced with the current practice of setting the synchronization delay at 45 to 60 ms. CONCLUSIONS: The most favorable systolic effects were obtained with a prolonged delay of synchronization (150 to 160 ms), at some expense of diastolic functions. On the other hand, with a short or absent delay, diastolic parameters were improved but systolic parameters became suboptimal. Therefore, the current practice of setting the SD between 45 and 60 ms after echocardiographic mitral valve closure is suggested for the optimal timing for cardiomyostimulator stimulation in patients who have undergone latissimus dorsi dynamic cardiomyoplasty. Yet a great deal of individualization is necessary, and fixed preset values cannot definitely be determined because one setting does not fit all patients.