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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:
-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
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A Case of Post Maxillary Cancer Ablation; Defect Reconstruction:
-Flap Design
-Flap
Application & Delay
-Pedicle
Division after 3 Weeks
-After
-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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