LATISSIMUS DORSI FLAPDr. Shahid Mahmood

Dr. Javed Akhtar RanaPGR,OMFS Department, PIMS,ISLAMABAD

INTRODUCTION

• The latissimus dorsi myocutaneous flap (LDMF) is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and postmastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck, either as a pedicled flap or as a microvascular free flap

HISTORY:

• First Described by Tansini in 1896 for chest wall reconstruction.

• Developed for use in the head and neck by Quillen et al in 1978

ANATOMY:

• Innervation: The thoracodorsal nerve.

• Blood supply: Thoracodorsal artery via the subscapular artery.

• Artery: Can be up to 2 or 5 mm if harvested up to the subscapular artery.

• Vein(s): Comparable to the artery. A single venae commitans.

• Pedicle length: Up to 15 centimeters.

SURFACE ANATOMY

Muscle Attachments

The muscle originates from the posterior iliac crest and from the spinous processes of the lower 6 thoracic vertebrae, the lumbar and sacral vertebrae, and the thoracolumbar fascia arising from the dorsal iliac crest.

insertion• . The latissimus inserts anteriorly into the

lesser tubercle and intertubercular groove of the humerus between the teres major and pectoralis major muscles

VASCULARITY

INNERVATION

Thoracodorsal Artery

LOCATION

SURFACE MARKING

PATIENT PREPARATION

PREP • Standard prep, 10% providone iodine• Prep the head and neck separately from free flap

operative site.• A surgical assistant will be lifting the ipsilateral

arm during the axillary dissection; therefore, the entire arm needs to be sterile.

• Prep back from hairline to level of iliac crest 3 cm past midline and staple a waterproof barrier and drape up the midline from the bottom to the top of the back prep.

• Prep ipsilateral thigh for possible skin graft.• The entire prep of the back is done prior to

starting the head and neck procedure so that all that needs to be done to harvest the flap is to roll the patient and deflate the bean bag.

DRAPE• Head drape• Patient will need to be in the lateral position at times

during the procedure, so place towels and drapes so the entire face (from below eyes to both mastoid tips), both sides of neck, chest, shoulder over deltoid including ipsilateral arm, axilla, and back to midline on down to ilium are included in the operative site.

• Towels to square off operative site including ipsilateral arm, chest, abdomen, and back to midline (also include ipsilateral thigh for possible skin graft)

• Patient will be in a lateral decubitus position with contralateral axillary roll during flap harvest.

• Impervious drape underneath patient as far as possible so back stays sterile while patient is supine

• Split sheet

PROCEDURE

FLAP HARVESTING

TUNNELING (Pedicled Flap)

INDICATIONS

Reconstruction of

A. Lateral neck defects

B . Parotid defects

C. Temporal bone defects

COMPOSITE FLAP

Combined muscle flap with musculus latissimus dorsi and musculus serratus

ADVANTAGES

• The possibility of independent skin paddles being able to address complex defects (eg, through-and-through oral cavity defects)

• Rib or scapula bone is available.• Minimal donor site morbidity occurs.• It can be combined with other subscapular

flaps, when indicated.

ADVANTAGES

• Large volume of tissue is available for reconstruction.

• Long vascular pedicle offers excellent range for pedicled flaps.

• High caliber pedicle makes free flap vascular anastomoses technically more feasible, even in patients with significant atherosclerotic disease.

DISADVANTAGES• Requires lateral decubitus position• Palpable abnormal lump arising in the latissimus dorsi

(LD) donor site scar.

CONTRAINDICATIONS• If possible, the flap should be harvested from the side of

the nondominant hand. Relative contraindications would include patients who require significant upper-arm strength for employment or sports activities (competitive tennis players and swimmers).

POST OP CARE

• We allow the patient to use the ipsilateral arm postoperatively and no special dressings are required. The donor area should be inspected daily for hematoma formation. This donor area often forms a seroma, necessitating the use of drains for often more than a week. We often leave them in for 2 weeks or longer until the output is diminished. Seromas should be aspirated.

POST OP CARE

• Donor site drains are generally removed in five to seven days. If a seroma develops and the incisions are healed, this can frequently be dealt with by serial aspirations.

• A physical therapy consult will facilitate rehabilitation of arm movement.

• If a pedicled latissimus flap has been used, the ipsilateral arm should be supported on pillows to abduct the humerus.

CASE REPORT

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