Use of the serratus anterior fascia in immediate implant-based breast reconstruction

Using the serratus anterior fascia may be a safe and effective option to recreate the lateral breast profile during subpectoral breast reconstruction, with minimal functional impact on the donor site. However, the literature is scarce when it comes to studies on this fascia flap in implant-based reconstruction. This article aimed to review the use of the serratus anterior fascia in immediate implant-based breast reconstruction, searching the electronic databases PubMed, Embase, Lilacs, and SciELO. The search was carried out by combining the following keywords: 'breast reconstruction' and 'serratus anterior fascia'. In the Pubmed and Embase databases, the search yielded a total of 12 and 15 articles, respectively, of which seven were selected according to the scope of this article. We found no studies on serratus anterior fascia and breast reconstruction in the Lilacs and SciELO databases. All works have results favorable for the use of the serratus anterior fascia flap and agree that this technique can be considered in the algorithm for the coverage of the inferolateral portion during subpectoral breast reconstruction

One-stage reconstruction by dual-innervated double muscle flap transplantation with the neural interconnection between the ipsilateral masseter and contralateral facial nerve for reanimating established facial paralysis: A report of 2 cases.

The authors developed a one-stage double-muscle reconstruction technique for facial paralysis using a latissimus dorsi (LD) flap and a serratus anterior (SA) flap, which were dually reinnervated by the contralateral facial nerve (FN) and ipsilateral masseter nerve (MN). The procedure was performed for 61-year-old man 3-years after resection of a malignant tumor and a 24-year-old woman 10-years after temporal fracture with facial paralysis. A double-muscle flap comprising left LD and SA flaps was harvested, a 15-cm thoracodorsal nerve (TN) section was attached to the LD flap, and 5-cm and 1-cm sections of the long thoracic nerve (LTN) were attached to the proximal and distal sides of SA flap. The LD flap and SA flap were sutured along the direction of motion of the zygomaticus major and risorius muscles, respectively. The contralateral FN and ipsilateral MN were interconnected by nerve suturing: the medial branch of TN to the distal end of LTN, the proximal end of LTN to the ipsilateral MN, and the buccal branch of contralateral FN to the main trunk of TN. After surgery, good contraction of the transferred flaps resulted in reanimation of a natural symmetrical smile; no complications were observed during the 12-month follow-up period.

The versatility of the serratus anterior free flap in head and neck reconstruction.

OBJECTIVES/HYPOTHESIS: Review the literature on the use of the serratus anterior free flap in the head and neck reconstruction and describe new applications of the serratus anterior free flap. STUDY DESIGN: Case series with retrospective chart review and literature review. METHODS: A PubMed literature review was performed using the search terms "serratus free flap," "serratus skull base," "serratus scalp," and "serratus free tissue transfer." One hundred and seventy-six articles were identified, 22 of which included at least one head and neck reconstructive case utilizing the serratus free flap. Twenty-two articles were identified since 1982 that discussed the use of the serratus anterior free flap for reconstruction in the head and neck. However, most of these were harvested in conjunction with latissimus muscle. RESULTS: We present a case series of 15 patients in whom the serratus anterior muscle free flap was used alone for head and neck reconstruction. In seven of these patients, we used the serratus for coverage of the newly created pharynx after total laryngectomy, which has not previously been reported. CONCLUSION: The serratus anterior free muscle flap has great versatility in reconstruction of the head and neck. Because of its low donor site morbidity, thinness, and pliability, as well as its ease of harvest, it is ideal for reconstruction of the skull base and scalp. We have also found that it is ideal for muscle coverage of the newly reconstructed pharynx after total laryngectomy. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:568-573, 2017.

Coverage of Amputation Stumps Using a Latissimus Dorsi Flap With a Serratus Anterior Muscle Flap: A Comparative Study.

Amputation of the extremities is a definitive reconstructive option, and surgeons should aim to preserve maximum overall function. If the exposed bone cannot be adequately covered using local tissues, the stump can be reconstructed using a number of well-described free flap transfer techniques. Between January 2002 and December 2011, 31 patients with severe injuries to the lower extremities underwent above-the-knee, below-the-knee, and Chopart and Ray amputations. Bony stumps were covered using latissimus dorsi myocutaneous flaps alone (group 1), or together with serratus anterior muscle flaps (group 2). The groups were compared with respect to age, flap survival, skin flap size, immediate complications, wound sloughing, deep ulceration, need for bone amputation, limb visual analog scale score, time to prosthesis, and follow-up duration. The mean area of the latissimus dorsi skin flap was 255.9 cm, and immediate complications occurred in 8 (25.8%) patients. In the double-padding group, there were fewer cases of deep ulceration than in the single-flap group, and prostheses could be worn sooner. There were no statistically significant differences in other parameters. Successful reconstruction of amputation stumps requires an adequate, durable, weight-bearing, and well-contoured soft tissue cover. A latissimus dorsi musculocutaneous flap together with a serratus anterior muscle flap provides well-vascularized muscle tissue and a durable skin paddle, leading to less ulceration than conventional flap techniques.

Rates of Reconstruction Failure in Patients Undergoing Immediate Reconstruction With Tissue Expanders and/or Implants and Postmastectomy Radiation Therapy.

OBJECTIVES: Mastectomy rates for breast cancer have increased, with a parallel increase in immediate reconstruction. For some women, tissue expander and implant (TE/I) reconstruction is the preferred or sole option. This retrospective study examined the rate of TE/I reconstruction failure (ie, removal of the TE or I with the inability to replace it resulting in no final reconstruction or autologous tissue reconstruction) in patients receiving postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS: Between 2004 and 2012, 99 women had skin-sparing mastectomies (SSM) or total nipple/areolar skin-sparing mastectomies (TSSM) with immediate TE/I reconstruction and PMRT for pathologic stage II to III breast cancer. Ninety-seven percent had chemotherapy (doxorubicin and taxane-based), 22% underwent targeted therapies, and 78% had endocrine therapy. Radiation consisted of 5000 cGy given in 180 to 200 cGy to the reconstructed breast with or without treatment to the supraclavicular nodes. Median follow-up was 3.8 years. RESULTS: Total TE/I failure was 18% (12% without final reconstruction, 6% converted to autologous reconstruction). In univariate analysis, the strongest predictor of reconstruction failure (RF) was absence of total TE/I coverage (acellular dermal matrix and/or serratus muscle) at the time of radiation. RF occurred in 32.5% of patients without total coverage compared to 9% with coverage (P=.0069). For women with total coverage, the location of the mastectomy scar in the inframammary fold region was associated with higher RF (19% vs 0%, P=.0189). In multivariate analysis, weight was a significant factor for RF, with lower weight associated with a higher RF. Weight appeared to be a surrogate for the interaction of total coverage, thin skin flaps, interval to exchange, and location of the mastectomy scar. CONCLUSIONS: RFs in patients receiving PMRT were lowered with total TE/I coverage at the time of radiation by avoiding inframammary fold incisions and with a preferred interval of 6 months to exchange.

Use of a serratus anterior musculocutaneous flap for surgical obliteration of a bronchopleural fistula.

OBJECTIVES: Successful management of post-resection bronchopleural fistula (BPF) is a challenge, and various loco-regional flaps have been used to directly cover or to enhance closure of the bronchial stump. The serratus anterior muscle (SAM) is one of the workhorse flaps, although its use as a musculocutaneous flap has been debated. Here, we present our early experience with serratus anterior musculocutaneous (SAMC) flaps for the obliteration of BPF. METHODS: A retrospective review of patients with surgical management of BPF from April 2005 to June 2014 was performed. A de-epithelized SAMC flap has replaced the conventional SAM flap since August 2013. Nine of consecutive former SAM flaps and 5 consecutive later SAMC flaps were identified. A detailed review of the SAMC flap cases was performed to describe medical and surgical history, BPF diagnosis and location, and the outcome of the flap surgery. RESULTS: All five BPFs treated by SAMC flap were greater than 1 cm in diameter and all occurred on the right side. The leading primary diagnosis of a BPF was lung cancer, and the 4 lung cancer patients all underwent previous irradiation. The average size of the skin paddle was 19 × 6.6 cm(2), and the average volume of the skin paddle was 100.3 cm(3). Recurrence of the BPF was noted in 1 patient 6 weeks after surgery. In 4 of 5 patients, viable adipose tissue was confirmed by computed tomography scans. CONCLUSIONS: The SAMC flap holds merits of a local flap such as short operation time, relative safety, no need of position change and faster recovery, with increased freedom of flap transfer and additional volume, thus widening surgical indication of the large, recalcitrant BPFs. We suggest that the SAMC flap could be safely harvested and used for management of a BPF or similar intrathoracic lesion when extensive flap length or bulk is required.