Friday, 19 September 2014

Latissimus Dorsi Muscle Flap for Reconstruction

The Latissimus Dorsi Muscle is the largest muscle in the body. It is located towards the lateral torso & the back. It functions to adduct the arm or cause the arm to move towards the center of the body & internally rotate it or cause the arm to rotate inwards.

A very large myocutaneous (muscle & skin) flap (an isolated/mobilized piece of muscle & skin with the blood supply intact) may be elevated & harvested on a single pedicle (main artery & vein to that piece of muscle & skin). In this case the Subscapular Artery.

The Latissimus Dorsi Musculocutaneous Flap was first described by an Italian Professor of Surgery at the University of Padua (Italy); Professor Iginio Tansini in 1896 as a pedicled myocutaneous flap for Chest Wall & Breast Reconstruction & was then further popularized by Olivari in 1976. Nowadays, it has been further refined to be used as a free flap (the pedicle is cut off & reconnected using a operating microscope at the recipient site), free composite (in combination with bone) flap or as pedicled or free perforator flaps (Skin flaps that are completely free of muscle). Refer to the diagram below.
Cases & Harvesting Technique:

A Case of Post Fire-burn Neck Scar Contracture:


-Patient Positioning & Flap Design

-Harvesting Step 1: After incising over the skin marking down to the muscle sheet (covering), undermine the skin medially, starting from the medial side of the skin marking & over the Latissimus Dorsi (LD) muscle sheet (covering), until the medial (towards the body center) border of the muscle is seen.

-Harvesting Step 2: Elevate the Latissimus Dorsi muscle from the medial border, going under the muscle. Undermine & free the muscle up until the mid-line of the muscle & slightly beyond

-Harvesting Step 3: Locate & identify the pedicle & all the branches from it & ligate them except the continuation of the Thoracodorsal Artery into the body of the Latissimus Dorsi muscle

-Harvesting Step 4: Undermine the skin laterally starting from the lateral margins of the skin design & over the muscle sheet for about 3-4 cm beyond. Then divide the muscle about 2-3 cm from the skin marking (incised border), starting from the medial (central side), caudal (lower side), lateral (outer side) then cephalically (towards the top).

-Harvesting Step 5: Once all the muscle origin is freed, elevate the muscle & again confirm the pedicle, especially the demarcation or separation of the pedicle & the muscle insertion. Insert a large artery forceps here, making sure not to include the pedicle in it. Then divide the portion of muscle overt it, using a diathermy. After this step, the flap will only be supported by the pedicle & loose connective tissues around it. Care must be taken not to apply too much tension to it. However, the loose connective tissues may be carefully freed, up to the junction of the axillary artery to free the pedicle further.

-Harvesting Step 6: Donor site closure
-Harvesting Step 7: Recipient site preparation & flap application followed by closure

 A Case of Post Maxillary Cancer Ablation; Defect Reconstruction:

-Before (Defect; After Failed Ipsi-lateral & Contra-lateral Pectoralis Major Myocutaneous Flaps)

-Flap Design

-Flap Application & Delay

-Pedicle Division after 3 Weeks


-Before & After

*Both patients were discharge after a few weeks of hospital admission. They are now alive & well without much morbidities.

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