Extremity Soft-tissue Reconstruction With the Conjoined Latissimus Dorsi–Groin Flap

Summary:

Extensive soft-tissue defects in the extremities pose a significant challenge in reconstructive surgery. The combined latissimus dorsi (LD) and groin flap technique, a method developed by Harii et al in 1981, has shown promise in treating such defects. The purpose of this study was to illustrate the technique and results of using combined LD and groin flaps to reconstruct extensive upper and lower extremity defects. We present 4 cases of extensive soft-tissue defects treated with the combined LD–groin flap. The report details the surgical approach, including patient positioning in the semisupine position, flap design, blood supply considerations, and operative results. Our study included patients ranging in age from 20 to 84 years who successfully underwent extremity reconstruction with operative times ranging from 4 to 12 hours and 50 minutes. Various vascular supplies were used based on the defect location in a consistent semisupine position. Cases included an 82-year-old man and an 84-year-old woman with lower extremity necrotizing fasciitis, a 24-year-old man with a complex upper extremity injury, and a 20-year-old man with a severe lower leg wound. Each demonstrated effective flap implementation and recovery with customized flap designs and microvascular anastomoses. The conjoined LD–groin flap technique is effective in treating severe extremity injuries, providing extensive coverage with manageable operative times. Its adaptability to long-axis defects and semisupine positioning contributes to its efficacy in complex reconstructions. With continued advances in microsurgery, this technique has the potential for wider application in reconstructive scenarios.

The management of extensive soft-tissue defects, particularly in the extremities, is a significant challenge in reconstructive surgery. Traditional reconstruction methods often struggle to provide adequate coverage for larger, more complex injuries. The advent of combined flap techniques, such as the conjoined latissimus dorsi (LD) and groin flap, has introduced a novel approach to addressing these complicated cases. This technique, first described by Harii et al¹ in 1981, provides a synergistic solution by combining the extensive tissue coverage of the LD flap with the versatility of the groin flap, overcoming the limitations of single-flap approaches.

The utility of the combined LD–groin flap has been demonstrated in various challenging scenarios, from lower extremity reconstructions to complex upper extremity injuries, as highlighted in studies by Amendola et al² and Katsaros et al.³ Despite its advantages in providing a robust vascular supply and substantial tissue volume, the technique is not without its challenges, particularly in terms of operative time and patient positioning during surgery.⁴

Our study aimed to present a series of cases using the combined LD and groin flap technique, focusing on its use in the semisupine position to optimize surgical efficiency. We intend to contribute to the existing literature by demonstrating the effectiveness of the technique in complex extremity reconstructions and discussing its potential broader applications in the field. (See Video 1 [online], which demonstrates the clinical application of the conjoined LD–groin flap technique, including preoperative defect assessment, flap design, and postoperative outcomes.) (See Video 2 [online], which displays the anatomical design and vascular considerations of the conjoined LD–groin flap, focusing on the key surgical landmarks and blood supply.)

Video 1. This video displays the clinical application of the conjoined latissimus dorsi-groin flap technique, including preoperative defect assessment, flap design, and postoperative outcomes.

Download video file ^{(40.8MB, mp4)}

Video 2. This video illustrates the anatomical design and vascular considerations of the conjoined latissimus dorsi-groin flap, focusing on the key surgical landmarks and blood supply.

Download video file ^{(18.7MB, mp4)}

PATIENTS AND METHODS

This case series includes 4 patients ranging in age from 20 to 84 years with extensive soft-tissue defects in the extremities. Selection criteria included the severity and complexity of the defects requiring extensive coverage. The reconstructive approach used was the conjoined LD–groin flap, a technique chosen for its robust tissue volume and vascular reliability.

Surgical Technique

Patients were placed in the semisupine position to optimize access to both the donor and recipient sites. The anatomical design and vascular pedicles of the combined flap are illustrated in Figure 1. The combined flap design was tailored to each case, using the LD flap for volume and the groin flap for reach and flexibility. Microvascular anastomoses were performed based on defect requirements to ensure sufficient blood supply (see Video 2 [online]).

Fig. 1.

Schematic illustration of combined latissimus dorsi (LD) and groin flaps for soft- tissue reconstruction of the extremities. A, Flap with the groin as the pivot point, showing anastomosis of the subscapular vessels to the descending branch of the lateral circumflex femoral vessels (yellow arrow), popliteal vessels (green arrow), or anterior tibial vessels (blue arrow). B, Flap designed to cover the defect with the axillary vessels as the pivot point.

The semisupine position was consistently used to enhance surgical efficiency. This approach facilitated precise vascular planning and improved surgical access. Comprehensive illustrations of the surgical design and vascular considerations are provided in Video 2 (online). Postoperative care included regular monitoring for flap viability and wound healing, with follow-up assessments to evaluate functional and aesthetic outcomes.

RESULTS

This case series included 4 patients, 20–84 years of age, who underwent successful reconstruction of extensive extremity soft-tissue defects using the conjoined LD–groin flap. Operative times ranged from 4 to nearly 13 hours, reflecting the complexity of each case (Table 1):

Table 1.

Patient Demographics and Operative Details

Case	Age, y	Sex	Main Cause	Skin Defect Location	Flap Type	Recipient Vessels	SA Muscle Usage	Operative Time (min)
1	82	M	Necrotizing fasciitis	Left thigh and lower leg	LD–groin, SA	LCFA/V	Yes	360
2	84	F	Necrotizing fasciitis	Right thigh	LD–groin, SA	Tibial A/V	Yes	261
3	24	M	Trauma	Left upper extremity	LD–groin	Radial A/cephalic V	No	244
4	20	M	Trauma	Left lower leg	Free LD–groin	Dorsalis pedis A/V	No	770

A, artery; LCFA, lateral circumflex femoral artery; SA, serratus anterior; V, vein.

• Case 1: An 82-year-old man with necrotizing fasciitis of the lower extremity received a combined pedicled LD, groin, and serratus anterior flap after debridement. He underwent microvascular anastomosis from the subscapular vessels to the lateral circumflex femoral vessels. Further visual details of this case are included in Video 1 (online).

• Case 2: An 84-year-old woman with similar right thigh necrotizing fasciitis was treated with the same flap technique. She underwent a microvascular anastomosis from the subscapular vessels to the anterior tibial vessels and was discharged in 29 days. The lower extremity functional scale score was 78.8% (63 of 80) at 16 months postoperatively (see Video 1 [online]).

• Case 3: In a 24-year-old man with an upper extremity injury, the LD and groin combined flap was used, pedicled to the thoracodorsal artery. Microvascular anastomoses were performed connecting the superficial circumflex iliac vessels to the radial artery and the cephalic vein. Because of the higher ulnar nerve injury, prompt repair was performed to prevent claw hand deformity, and further tendon transfers are planned to address the resulting ulnar nerve palsy. The patient made a good recovery and was discharged after 62 days. The QuickDash score was 29.5 (see Video 1 [online]).

• Case 4: A 20-year-old man with a severe lower leg injury underwent a free flap procedure. Microvascular anastomoses were performed by connecting the thoracodorsal vessels end-to-side to the popliteal vessels, and the superficial circumflex iliac vessels to the anterior tibial vessels. The lower extremity functional scale score was 97.5% (78 of 80) at 12 months postoperatively (see Video 1 [online]).

DISCUSSION

The use of the conjoined LD–groin flap in our case series underscores its significant utility in reconstructive surgery for extensive soft-tissue defects. In keeping with the seminal principles of Harii et al,¹ this technique has shown great promise in the management of complex cases. The series demonstrated not only the versatility of this flap in terms of defect coverage, but also its adaptability to different patient ages and injury types. Combined flaps are summarized. All are useful for defects that cannot be covered by a single flap⁵ (Table 2).

Table 2.

Summary of Combined Flaps and Their Applications

Type	Description	Principles of Vascular Anatomy	Indications
Type I	Pedicled LD flap + free groin flap	Pedicled LD flap is supplied by thoracodorsal vessels; free groin flap by SCIA	Head, neck, trunk, and upper limb: extensive soft-tissue coverage, bone reconstruction, functional muscle transfer, and lymph-node transfer
Type II	Free LD flap + pedicled groin flap	Free LD flap is supplied by thoracodorsal vessels; pedicled groin flap by SCIA	Trunk, perineal area, and lower limb: extensive soft-tissue coverage and, bone reconstruction
Type III	Both pedicled flaps	LD flap and groin flap are supplied by their respective pedicles	Trunk and upper limb: extensive soft-tissue coverage and bone reconstruction; division necessary for upper-limb reconstruction

SCIA, superficial circumflex iliac artery.

Our findings are consistent with the reported efficacy of combined flaps in reconstructive surgery, as highlighted in the works of Amendola et al² and Boonipat et al,⁴ further confirming the versatility of the technique. The vascular anatomy of the latissimus dorsi musculocutaneous flap has been well documented.⁶ The successful outcomes in our cases are also consistent with the observations of Katsaros et al³ regarding the reliability of the combined LD–groin flap in upper extremity reconstructions. The semisupine position during surgery, as advocated by previous studies, was instrumental in reducing operative times and improving surgical access.^3,2 For a comprehensive visual summary of our findings and techniques, refer to Video 1 (online), which provides an overview of the surgical design, procedures, and outcomes included in the case series.

Study Limitations

Despite its successes, this study has limitations. The small sample size and lack of a control group limit the generalizability of our findings. In addition, the technical complexity of the procedure may limit its widespread adoption to centers with specialized expertise in microsurgery.

Future Research

Future research should focus on larger, comparative studies to validate these findings and explore the potential integration of advanced imaging and surgical planning technologies. Such advances could further refine flap design and patient outcomes.

Challenges and Alternatives

Although the conjoined flap technique was effective, challenges such as the need for careful patient positioning and meticulous microvascular anastomosis were observed, particularly in cases with extensive injury zones. Alternatives such as arteriovenous (AV) loops with vein grafting, as explored by Lin et al⁷ and Hallock,⁸ offer solutions for long-axis defects.⁹ However, as cautioned by Khouri and Shaw,¹⁰ the use of longer vein grafts requires careful consideration due to the associated higher complication rates.

CONCLUSIONS

Our case series highlights the conjoined LD–groin flap as a versatile and effective option for the reconstruction of extensive soft-tissue defects. With continued advances in microsurgery, this technique has the potential to be further refined and widely applied to improve outcomes in complex reconstructive scenarios.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Informed consent was obtained from all patients for inclusion in the study.

ETHICAL APPROVAL

This case series report contains clinical data from patients who underwent reconstructive surgery. The procedures adhered to the ethical standards of the responsible committee for human experimentation and the Declaration of Helsinki of 1975 as revised in 2000.