Overview of Latissimus Dorsi Flap
The latissimus dorsi flap surgery is a trusted method widely used by surgeons to rebuild parts of the body such as the head, neck, torso, and breast. This method involves using tissue from the latissimus dorsi muscle, which is an area in your back. This muscle has great blood flow (vascularized by the thoracodorsal vessels), making it a reliable source of tissue for the surgery. The tissue from this muscle is soft and bendable (pliable), gives a good amount of muscle mass, making it a strong choice over other options.
There are two ways the muscle can be used, either including the skin and the fat beneath the skin (myocutaneous version), or without them (myofascial version). This is useful, as it allows doctors to cater the surgery to the specific needs of each patient. It’s used commonly in patients who have had a mastectomy (removal of breast due to cancer), to rebuild the missing tissue. It’s also used for other types of reconstruction, like fixing facial nerves (facial reanimation) or repairing defects in chest or neck.
For larger needs, surgeons can go a step further and remove more muscle and blood vessels alongside the latissimus dorsi muscle (called a mega flap). For some cases, surgeons might even include other structures like bone from the shoulder blade (scapula), rib, and a muscle under your armpit called the serratus anterior.
Modern advancements have also seen this surgical method being used in creating a penis (neophallus construction) in transgender individuals. This highlights the versatility of the latissimus dorsi flap method, meeting various physical and functional needs of patients. It continues to be a critical part of modern surgical procedures.
Anatomy and Physiology of Latissimus Dorsi Flap
The latissimus dorsi is a large and powerful muscle in the body. It starts from the spine and the hip bone and stretches across the upper and middle part of the back to connect to the upper part of the arm bone. This muscle sits just above the ribs and the muscles between the ribs, and expands upwards and outwards towards the lower part of the shoulder blade (scapula) and the arm bone (humerus). It works together with the teres major muscle and the pectoralis major muscle to help move the arm inwards (adduction), rotate it towards the body (medial rotation), and pull it backwards (extension) at the shoulder.
The latissimus dorsi gets its blood supply from the thoracodorsal vessels and its signals from the thoracodorsal nerve. The thoracodorsal artery, which branches off from the subscapular artery, runs along the side of the back. This artery usually comes with one or two veins. It gives off branches that go downwards and across, with its last branches supplying the serratus anterior muscle (a muscle on the side of the chest). The blood vessels enter the muscle around 4 inches from where it attaches to the arm bone and spread along the deep surface of the muscle.
Why do People Need Latissimus Dorsi Flap
If you have large damaged areas in your head, neck, and chest regions, doctors might recommend a type of surgery that uses a part of your body called the latissimus dorsi flap to rebuild the area. This procedure is particularly beneficial when there’s a need to cover a large area with new soft tissue, such as when the entire scalp is involved.
When a Person Should Avoid Latissimus Dorsi Flap
Sometimes, a person can’t have a specific type of surgery involving the latissimus dorsi (a broad muscle on your back) because of certain conditions. For example, if a person had a previous injury or operation on the shoulder or back and it affected the blood supply to the area, it could make the procedure too risky. This is known as an absolute contraindication, which means the surgery should not be done.
Some other factors may not prevent the surgery, but they might make it more risky. These include smoking, diabetes, and having poor blood vessel health. Smoking affects the tiny blood vessels in tissues, so the person would need to have a conversation about quitting smoking before the procedure. Diabetes, especially when not well-controlled, and poor blood vessel health could up the odds of complications, including the risk that the muscle flap fails.
Another factor to consider is if a person needs radiotherapy (a form of cancer treatment using high-energy rays) after surgery. In these cases, using only the muscle flap with added split-thickness skin grafts (thin layers of skin) may not be the best choice. This is because skin grafts need at least 6 weeks to heal before radiation exposure. This could potentially delay starting the radiotherapy.
Equipment used for Latissimus Dorsi Flap
To perform a latissimus dorsi transfer, which is a type of surgery to improve shoulder function, the following tools are required:
* A surgical marker, used for drawing on the skin to guide the operation
* A scalpel (a Bard-Parker handle with a #15 blade on a #3), used for cutting skin and tissue
* A Doppler ultrasound probe for observing blood flow in the region
* Various types of forceps, including DeBakey, Gerald, and Adson-Brown, used for handling tissues
* Hemostats to stop bleeding
* Different types of dissection scissors, like Metzenbaum and Reynolds tenotomy, for cutting tissue
* Suture scissors like Iris and Mayo for cutting stitches
* Needle holders for managing needles during stitching
* Electrical devices for cutting and clotting bleeding tissues (bipolar and monopolar electrocautery)
* Retractors, such as Army-Navy, Richardson, and Senn, to move excess organs or tissue from the operation site
* Different types of suction tips (Goodhill and Frazier) to remove fluid or gas during operation
* Gauze sponges to absorb blood and other fluids
* Various types of sutures (stitches) for closing the wound, including ones for the outer skin layer, deep skin layer, and fascia which is a layer of tissue beneath the skin
* An optional dermatome, a device to remove a thin layer of skin for grafting.
For a free tissue transfer, a procedure where tissue is moved from one part of the body to another, the necessary equipment is:
* Microvascular instruments, which are small tools specifically designed for work with blood vessels, including needle holders, forceps, needle drivers, suture and adventitial scissors, vessel dilators, and vessel clamps
* Venous couplers, devices that help connect veins
* Saline that has been heparinized, which is a solution that helps prevent blood clotting
* Weck cell spears for absorbing and removing fluids
* Vessel loops to isolate and stabilize blood vessels
* Papaverine or 2% plain lidocaine, medications to enlarge blood vessels and numb the area respectively
* An operating microscope to help visualize tiny structures
* Nylon sutures (8-0 or 9-0) on a tapered needle to sew the wound closed.
Who is needed to perform Latissimus Dorsi Flap?
The process of moving a portion of muscle from the back, known as a latissimus dorsi flap transfer, usually calls for a minimum of four medical professionals in the operating room. These include a surgeon, who is in charge of the procedure, a surgical technician who assists the surgeon, a circulating nurse responsible for coordination and comfort care, and an anesthesia provider who ensures you’re asleep and pain-free during the operation. Additionally, there may be extra helpers who assist with holding tissues out of the way so the surgeon has a clear view during the operation.
Preparing for Latissimus Dorsi Flap
Before a patient has a latissimus dorsi flap transfer, which is a type of surgery involving the transfer of muscle from the back, it’s crucial for the doctors to conduct a thorough health check. This is to make sure the person does not have any health conditions that might increase their risk during surgery.
One of the things that your doctor will be looking for are any heart or lung problems that might make general anesthesia, the medicine used to put you to sleep during surgery, riskier. Your health providers might also test your blood type in preparation for a possible blood transfusion if necessary during the surgery.
In addition, doctors check factors like your nutrition levels, hormone levels, and other markers that might affect your body’s ability to recover after the surgery. All of these measures are necessary to keep you safe during the operation, and to make sure the surgery goes as well as possible.
Communication with the anesthesiologists, who administer anesthesia, is key before a latissimus transfer. These doctors are responsible for keeping your blood pressure and body’s fluid levels stable during surgery. This is important as it ensures the transferred muscle gets enough blood supply. If your blood pressure drops too low during the operation, they could use medication known as “vasopressors” to counter it, although some are concerned this might affect the microcirculation in the transferred muscle. However, based on the available information, patients who have had vasopressors seem to do just as well as those who haven’t so long as their fluid levels are well managed and aren’t dangerously low.
In some situations where your blood pressure might need to be ramped up, dobutamine, a type of drug, may be used as it has been found to be beneficial.
Finally, the doctors will make sure both your body and the transplanted muscle stay warm during the surgery to prevent the blood vessels from tightening up, which might reduce blood flow to the transplanted muscle. To prevent infection after the operation, the doctors will administer antibiotics before the procedure and continue with them for a few days after. All these practices aim to maximize your safety and the success of the operation.
How is Latissimus Dorsi Flap performed
When you’re having reconstructive surgery, the surgeon might do a procedure called a latissimus dorsi flap. This is where they move a flap of skin from your back (latissimus dorsi is one of your back muscles) to another place on your body where it’s needed. This could be somewhere that’s been damaged or needs more tissue for some reason. This could be due to an injury, an operation like a mastectomy (breast removal), or to cover a gap where tissue has been removed.
Depending on the patient’s situation and what the surgeon feels is best, the patient may be asked to lie on their stomach, their side, or their back during the procedure. This lets the surgeon best see and access the area being worked on. Doctors can also determine the best position for the patient by looking at the patient’s comfort, reducing the risk of any difficulties, or improving the overall outcome of the surgery.
They measure very carefully to make sure they have enough skin for the flap and that it’s in the right place. This involves using a piece of gauze to figure out the size of the flap, and marking on the skin where the flap will go. This is crucial for the success of the procedure.
Then they make a surgical cut along the side of your chest, under your armpit. They’ll go deeper, being careful about the different layers of muscle, until they get to the latissimus dorsi. This muscle is what gets moved. They then make a cut in the muscle that’s big enough to let blood vessels through but without cutting the vessels themselves. These vessels are crucial to keep the transferred tissue alive in its new location.
They then make more cuts and carefully lift the muscle, avoiding damage to its blood supply. If you’re having a free tissue transfer – where the flap is completely removed from its original site and put somewhere else – they’ll carefully cut the blood vessels and move the muscle to its new location. They then stitch these blood vessels into place to restore the blood flow.
If the flap isn’t completely detached (this is called a pedicled flap transfer) then the doctors will take out sections of the muscle that are in the way or could cause problems later on.
Once the flap is in place, it’s stitched in neatly. A good result from the operation means making sure there is no excessive bleeding at the flap or at the original site. Finally, your skin is closed back together. If you had a bet of skin removed, or if a large area was worked on, you may need a skin graft from another area of your body to close everything up.
After the operation, the doctors will check on you and the flap area regularly at first to make sure everything is going well. They’ll look at the color of your skin, check for any swelling, and use a handheld device to listen to the blood flow in the flap. They might also do a small prick test to make sure the flap is getting enough blood. Lowering your physical activity for a few weeks and keeping a check on your blood pressure can help in your recovery and reduce risks of complications.
Possible Complications of Latissimus Dorsi Flap
The biggest worry during flap surgery (a type of surgery where tissue is lifted from one body site and moved to another) is the failure of the flap. This can mean a partial or total loss of the flap due to problems with blood supply in the initial weeks of healing. Understanding the signs of problems early and starting treatment promptly is really important to save the flaps.
In cases where the blood supply to the flap is being blocked or where there is a twist in the blood vessels, immediate action is needed. Leeches can actually help in such situations. They can help remove venous blood (blood from your veins) and they also produce a substance called hirudin, which helps to prevent blood clotting. However, when using leeches, doctors need to give a preventative dose of a type of antibiotic called fluoroquinolone to avoid any risk of infection from a bacteria called Aeromonas hydrophila which these leeches commonly carry.
But, there’s a time limit to how much these treatments can help. If the flap doesn’t get enough blood for too long or doesn’t drain enough blood, it may be permanently lost.
This is even more critical in a specific kind of flap surgery called free latissimus dorsi flap. If the blood supply is cut off for more than six hours, it can seriously damage the small vessels delivering blood (microcirculation). The sooner the patient gets back to the operating room, the higher the chances of saving the flap. In some cases, a 90% recovery rate is possible if corrective treatments are started early enough. Most of these problems with blood supply occur within the first 48 hours after surgery.
When preparing for a quick return to the operating room, doctors can take several steps. This includes removing sutures (stitches) pressing on the blood vessel leading to the flap, and giving medications like aspirin and heparin. There are also certain solutions that can break up blood clots (like streptokinase or urokinase), which can be injected directly into the flap. If the clot removal doesn’t work initially, these solutions can be drained out from the vein in the flap and not into the rest of the body.
What Else Should I Know About Latissimus Dorsi Flap?
The latissimus dorsi flap is a technique used in reconstructive surgery that can treat a range of issues in the head, neck, and body. This method uses part of the latissimus dorsi, which is one of the largest muscles in your back. It can be moved (or “transferred”) to another place in the body directly, called a “pedicled transfer,” or removed and then attached, called a “free transfer.”
Sometimes, the surgeon will also use the skin and fatty tissue (subcutaneous tissue) on top of this muscle. This flap technique offers a practical and flexible solution for different kinds of reconstructive challenges.
One of the key benefits of this method is the large coverage it can provide thanks to the size of the muscle. Also, the skin over this muscle often matches in color and texture with skin in many other parts of the body, which can result in outcomes that look very natural and pleasing to the eye.
Another important advantage is the use of the latissimus dorsi flap for healing large wounds, especially when other options might not provide enough coverage or the necessary healing environment. This versatile technique is a valuable tool for surgeons who specialize in reconstructive surgeries.