| Objective:to explore the reliable range of latissimus dorsi tissue flap by using Mimics software combined with CT enhanced scan and based on three-dimensional reconstruction technique to clarify the abdominal area of latissimus dorsi and its anatomical relationship with the surrounding tissue.Methods:firstly,9 volunteers were scanned with chest and abdominal CT,and18 latissimus dorsi CT scanning data were obtained.The DICOM data were imported into Mimics Medical21 software to construct latissimus dorsi and its adjacent structures for three-dimensional reconstruction.The reconstruction images were measured and statistically analyzed.Secondly,the latissimus dorsi muscle was dissected on the gross specimen,the thoracodorsal artery was dissociated,the course and entry point of the thoracodorsal artery were observed,and the morphological characteristics and adjacent structure of the latissimus dorsi muscle were observed.A total of 30 patients who underwent latissimus dorsi tissue flap repair in our department from January 2010 to January 2021 were analyzed retrospectively.there were 21 males and 9 females,aged from 12 to 59 years,with an average of 35.1 years.Clinical data were analyzed statistically.SPSS20.0 was used for statistical analysis,the measurement data was expressed by mean±standard deviation(±s),the two samples were compared by t-test,the counting data were expressed by rate(n%),and there was no statistical difference between the two groups.Results:1.In 9 cases,18 pieces of latissimus dorsi muscle abdomen were reconstructed and combined with gross anatomy,the results showed that the abdomen of latissimus dorsi muscle was located in the dorsal chest wall and abdominal wall,and the upper end of humerus tubercle was a flat triangular muscle with thicker upper and lateral sides.It gradually thinned from the superior and lateral to the medial and inferior side.Latissimus dorsi muscle length 15.66～24.11cm,average cm;width 15.07～19.89cm,average 16.96±1.46 cm,diagonal length 29.15～40.76cm,average 35.13±3.55 cm;area303.23～457.28cm~2,average 370.69±45.25cm~2,volume about 137.36～299.26cm~3,mean 207.22±63.00cm~3.The line from the upper axillary apex of the ventral anterior edge of the latissimus dorsi muscle to the midpoint of the anterior edge of the latissimus dorsi muscle is located within the 1cm range of the posterior axillary line;the midpoint of the anterior edge is between the 7th and 8th ribs;the midpoint of the upper margin is 3.05±1.32 cm;between the subscapular angle and the subscapular angle,and 3.65±0.75cm from the posterior midline;the midpoint of the posterior edge is between the11th and 12th ribs,averagely 2.93±0.74cm from the posterior midline.The average distance from the lower angle to the posterior median line is 10.53±0.30cm between the upper margin and the lower edge of the fourth lumbar vertebra.2.According to the law of the location,the location map of latissimus dorsi muscle flap was drawn.Point An is the midpoint of the armpit;point B is the intercostal space directly above the subscapular angle(2～3cm),which is the body surface projection of the midpoint of the superior edge of the latissimus dorsi muscle;point C is the midline4cm,which is the upper margin of the latissimus dorsi muscle,and point D is the midline 3cm,which is the midpoint of the posterior margin of the latissimus dorsi muscle,and point E is the 10cm of the posterior midline of the fourth lumbar vertebra,which is the surface projection of the lower ventral horn of the latissimus dorsi muscle.The F point is the intersection of the posterior axillary line and the 7th intercostal area,which is the body surface projection of the midpoint of the anterior edge of the latissimus dorsi muscle.AF is the body surface projection of the upper part of the anterior edge of the latissimus dorsi muscle,which is flat to the posterior axillary line.3.Among the 18 cases,11 cases(61.11%)could be successfully segmented to the bifurcation point and 10 cases(55.55%)could be segmented to the muscle entry point.It was found that the thoracodorsal artery was bifurcated at the level of the fourth rib and the posterior axillary line was about1.78±0.59cm;at the fifth rib level,the posterior axillary line was about 2.14±0.94 cm into the muscle,and the average distance between the bifurcation point and the muscle entry point was 2.31±0.72cm.4.None of the 30 patients with latissimus dorsi tissue flap had vascular crisis,of which27 cases survived and 3 cases had distal or marginal necrosis.2 cases needed skin grafting to repair the donor area,and the rest were closed and sutured at one stage.The area of skin defect was 6cm×2cm～25m×20cm.One case of simple muscle flap was removed with the assistance of endoscope,the area was 25cm×27cm.There were 19cases of myocutaneous flaps,of which 4 cases were pedicled and 15 cases were free,with an area of 7cm×3cm(27cm×8cm+15cm×6cm).There were 9 cases of chimeric perforator flap,of which 8 cases were free and 1 case was pedicled.The area(15cm×4cm+12cm×4cm)～(flap 24cm×6cm+13cm×6cm,muscle flap 19cm×10cm).The pedicled thoracodorsal artery plus free inferior epigastric perforator flap was found in1 case,the size of which was 82cm×8cm.The texture of the surviving tissue flap was good.The scar in the donor area was hidden,there was no obvious depression deformity,and there was no limitation of shoulder movement.Conclusion:Mimics combined with CT enhanced scanning can reconstruct the muscular vessels and observe the anatomy on the three-dimensional view.The ventral distribution of latissimus dorsi muscle is regular.The upper part of the ventral margin of latissimus dorsi muscle is located within the anterior and posterior 1cm of the posterior axillary line;the midpoint of the anterior edge is located between the 7th and8th ribs;the midpoint of the superior margin is located between the subscapular angle line and the subscapular angle upward;the upper margin stop point is located between the 8cm 9 ribs,about 3.5cm from the posterior midline;the midpoint of the posterior edge is between the 11th and 12th ribs,about 3cm from the posterior midline.The lower angle is about 10cm between the superior edge and the lower edge of the fourth lumbar vertebrae and the posterior median line.It can provide guidance for the design of latissimus dorsi tissue flap before clinical operation,and the latissimus dorsi muscle flap and myocutaneous flap with reliable blood supply can be designed within this range. |
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