Department of Medicine and Surgery, Research Unit of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico University of Rome, Rome, Italy.
Fondazione Policlinico Universitario Campus Bio-Medico, Operative Research Unit of Plastic, Reconstructive and Aesthetic Surgery, Rome, Italy.
Microsurgery. 2023 Sep;43(6):617-621. doi: 10.1002/micr.31070. Epub 2023 May 24.
Extensive tridimensional defects of the abdominal wall are usually addressed with soft tissue flaps combined with meshes. In this scenario, the additional value of dynamic abdominal wall reconstruction with functional flaps has yet to be demonstrated. In this paper the authors describe for the first time a unique case of total abdominal wall reconstruction with the free functional L-shaped latissimus dorsi (LD) flap, designed to increase the surface area of skin flap coverage while minimizing donor site morbidity, highlighting technical tips and long-term outcomes. A 65-year-old patient underwent abdominal wall resection for a dermatofibrosarcoma protuberans, leaving her with a 23 × 15 cm full-thickness defect. After placing a mesh, a myo-cutaneous free LD Flap with an L-shaped configuration was planned. The flap was composed of Paddle A, designed vertically along the anterior margin of the muscle and Paddle B, designed over the inferior aspect of the LD muscle, extending obliquely from the midline and intersecting Paddle A laterally with a 60° angle. End-to-end anastomoses to the deep inferior epigastric artery and vein and thoracodorsal nerve coaptation to a sizeable intercostal nerve were performed. The LD muscle was sutured according to its native tension while the two skin islands allowed an almost complete resurfacing of the abdominal wall defect. Donor site was closed primarily. Post-operative course was uneventful. One year postoperatively, good abdominal contour was observed, with adequate abdominal tone at rest in laying and standing position. Muscle neurotization was confirmed with clinical examination showing voluntary contraction of the transplanted muscle and the patient reported very high functional outcomes at the hernia-related quality-of-life (HerQles) questionnaire. The free L-shaped LD flap represents an innovative solution to reconstruct extensive full-thickness defects of the abdominal wall while reducing donor site morbidity. Flap neurotization should be attempted whenever possible to improve functional outcomes of the procedure.
腹壁广泛的三维缺陷通常采用软组织瓣联合网片进行治疗。在这种情况下，功能性皮瓣的动态腹壁重建的附加价值尚未得到证实。本文作者首次描述了一例独特的全腹壁重建病例，采用游离功能性 L 形背阔肌（LD）皮瓣，旨在增加皮瓣覆盖面积的同时最大限度地减少供区并发症，强调技术要点和长期结果。一名 65 岁患者因隆突性皮肤纤维肉瘤行腹壁切除术，留下 23×15cm 全层缺损。放置网片后，计划采用 L 形构型的肌皮游离 LD 皮瓣。皮瓣由桨 A 组成，垂直于肌肉前缘设计，桨 B 设计在 LD 肌肉的下侧，从中线斜向延伸，与桨 A 成 60°角侧向交叉。进行端端吻合至腹壁下深动脉和静脉以及胸背神经吻合至一根较大的肋间神经。LD 肌肉按照其固有张力缝合，两个皮岛几乎可以完全覆盖腹壁缺损。供区直接关闭。术后过程顺利。术后 1 年，观察到良好的腹部轮廓，在仰卧和站立位时腹部张力适中。临床检查证实肌肉神经再支配，移植肌肉有自主收缩，患者在疝相关生活质量（HerQles）问卷中报告了非常高的功能结果。游离 L 形 LD 皮瓣是重建广泛全层腹壁缺损的一种创新解决方案，同时减少供区并发症。只要可能，应尝试皮瓣神经再支配以改善手术的功能结果。
