Overview
Introduction
The use of a pedicled latissimus dorsi flap for reconstruction of large soft-tissue defects following musculoskeletal tumor excision around the shoulder provides adequate well-vascularized and healthy tissue to maximize the chances of successful limb salvage and minimize the risks of wound problems and deep infection1-5.
Indications & Contraindications
Step 1: (Posterior Clockwise Rotation Technique): Preoperative Evaluation, Positioning, and Preparation
Verify the adequacy of the latissimus dorsi, confirm the feasibility of the flap in relation to the extent of the defect, and use a laparotomy pad to simulate the arc of flap rotation.
Step 2: (Posterior Clockwise Rotation Technique): Flap Design and Marking in Relation to Anatomic Landmarks
At the time of surgery, proper flap design and markings are critical for successful tumor excision and flap rotation.
Step 3: (Posterior Clockwise Rotation Technique): Tumor Excision and Flap Elevation
Confirm adequate tumor removal, prepare the recipient site for the flap, ensure the proper size and shape of the skin island, deepen the dissection circumferentially around the skin paddle, divide the latissimus from the thoracolumbar fascia, develop the natural plane of the flap, divide the branch for the serratus to increase rotation if necessary, and release the humeral insertion to further increase rotation if necessary.
Step 4: (Posterior Clockwise Rotation Technique): Posterior Flap Transposition and Inset into the Defect
Be sure to create an adequately sized tunnel and, when passing the flap through the tunnel, to avoid tension on the vascular pedicle and the skin island.
Step 5: Postoperative Care
Proper postoperative care includes monitoring the flap blood supply and output of drains, removing sutures, and ensuring satisfactory healing overall.
Step 1: (Anterior Counterclockwise Rotation Technique): Preoperative Evaluation, Positioning, and Preparation
The preoperative evaluation, positioning, and preparation are identical to those for the posterior clockwise rotation technique described above.
Step 2: (Anterior Counterclockwise Rotation Technique): Flap Design and Marking in Relation to Anatomic Landmarks
Make sure you understand the regional anatomy, ensure appropriate anterior flap rotation, and use the laparotomy pad technique to the simulate arc of rotation.
Step 3: Flap Elevation (Anterior Counterclockwise Rotation Technique)
The surgical principles of flap elevation and transfer are the same regardless of the location of the recipient site (see Step 3 for the posterior technique above).
Step 4: (Anterior Counterclockwise Rotation Technique): Anterior Flap Transposition and Inset into the Defect
Elevate the flap, create a large subcutaneous tunnel for anterior transfer, and ensure optimal flap inset into the shoulder defect.
Step 5: Postoperative Care (Anterior Counterclockwise Rotation Technique)
Perform as for the posterior technique.
Results
In 2007, we reported on a series of 33 consecutive patients treated from 1994 to 2004 with a pedicled latissimus dorsi flap following sarcoma excision in the shoulder region1.
Pitfalls & Challenges
Introduction
The use of a pedicled latissimus dorsi flap for reconstruction of large soft-tissue defects following musculoskeletal tumor excision around the shoulder provides adequate well-vascularized and healthy tissue to maximize the chances of successful limb salvage and minimize the risks of wound problems and deep infection1-5.
Limb salvage surgery for skeletal and extraskeletal neoplasms in the shoulder region often results in large complex soft-tissue defects. Extensive dissection, exposure of large bone surfaces and neurovascular structures, and the use of massive prosthetic and/or allograft skeletal reconstructions substantially increase the risk of wound dehiscence and septic failure. Primary closure of smaller defects is occasionally possible using local tissue undermining and flap advancement; however, suboptimal soft-tissue coverage of larger defects increases the risk of wound breakdown and secondary deep infection and may also lead to pain, stiffness, and unsatisfactory function, even when healing occurs, due to excessive tension and contracture.
In our experience, the pedicled latissimus dorsi flap is an excellent option for soft-tissue reconstruction following excision of a musculoskeletal neoplasm in the shoulder. Although the procedure is usually performed by a plastic surgeon following tumor excision, it is important for the tumor surgeon to be familiar with it. In fact, understanding the rationale, principles, and anatomic basis of the operation is critical for preoperative planning of the surgical margin and soft-tissue coverage. We describe 2 main variants of the flap technique currently in use in our practice. Selection of the specific technique is based on the location of the defect and the consequent rotation of the flap. One technique involves posterior clockwise rotation of the flap toward the scapular region, which we used to repair a posterior and superior shoulder defect in Case 1 (see Case Examples below), and the other involves anterior counterclockwise flap rotation, which we used to address a more anterior defect in Case 2 (see Case Examples below). The rationale for surgery, the general preoperative evaluation, and the principles of flap elevation and inset are the same with both techniques. However, optimizing flap rotation is critical to maximize transfer length and avoid twisting or stretching of the vascular pedicle.
Indications & Contraindications
Indications
Large or complex soft-tissue defect around the shoulder after oncologic resection.
Combined soft-tissue and bone defects that leave extensive bone surfaces and/or neurovascular structures exposed and require the use of massive prosthetic and/or allograft skeletal reconstructions, due to an increased risk of wound dehiscence and septic failure.
Suboptimal soft-tissue coverage, as this increases the risk of wound breakdown, infection, and contracture.
Contraindications
Tumor or resection directly involving the thoracodorsal vessels or compromising pedicle inflow or outflow.
Previous surgical resection or transection of the latissimus muscle (e.g., posterolateral thoracotomy), as this often divides the latissimus dorsi.
Previous axillary dissection or irradiation, as commonly used for breast or other cancers, as such treatments may limit the use of this flap.
Case Examples
Case 1: Posterior Clockwise Rotation Technique
The following is an illustrative case in which we used the posterior clockwise rotation technique described below.
A 76-year-old man presented with a 3-month history of an essentially painless but progressively enlarging right shoulder mass. Imaging demonstrated a large soft-tissue lesion of the deltoid region, extending to the subacromial space and eroding into the acromion and acromioclavicular joint (Fig. 1).
Fig. 1.
Case 1. Standard anteroposterior radiograph (Fig. 1-A) and fat-saturated T2-weighted magnetic resonance images (Figs. 1-B, 1-C, and 1-D) of a 76-year-old man presenting with a massive soft-tissue tumor involving the deltoid region and subacromial space, with erosion of the acromion and acromioclavicular joint. A histologic diagnosis of extraskeletal myxoid chondrosarcoma was obtained following core-needle biopsy.
The histologic findings in a core-needle-biopsy specimen were consistent with extraskeletal myxoid chondrosarcoma. Staging studies included a technetium-99 methylene diphosphonate whole-body bone scan and chest computed tomography scan, which showed no evidence of distant disease.
Surgical management was planned to consist of a wide en bloc excision of a large midportion of the deltoid and the axillary nerve, the acromion, the spine of the scapula, the acromioclavicular joint (with the lateral third of the clavicle), and the entire subacromial space (with most of the rotator cuff).
As adequate stability could be maintained by preserving the glenohumeral joint and residual musculature of the shoulder girdle, formal bone reconstruction was deemed to be unnecessary. However, a large soft-tissue defect not amenable to primary closure was anticipated. After thorough review of the case and evaluation for plastic surgery, we elected to address the soft-tissue defect by using pedicled latissimus dorsi flap rotation. Because of an anticipated superior shoulder defect, we selected a flap rotation with a posterior-based arc of rotation.
Case 2: Anterior Counterclockwise Rotation Technique
The following is an illustrative case in which we used the anterior counterclockwise rotation technique described below.
A 45-year-old man presented with painful chronic anterosuperior dislocation of a right proximal humeral endoprosthetic replacement 3 years after primary excision of a low-grade chondrosarcoma followed by reconstruction (Fig. 2). Physical examination confirmed complete, irreducible shoulder dislocation and insufficient anterior soft-tissue coverage, as the implant was palpable underneath the skin. Review of radiographs of the right shoulder and arm suggested insufficient retroversion of the humeral prosthesis as an important causative factor, along with an inadequate soft-tissue envelope. The preoperative plan for revision surgery included shoulder reduction by disassembling and reorienting the prosthetic modular components, with soft-tissue augmentation by capsular-deltoid reinforcement and anterior pedicled latissimus dorsi transfer. Because of the anterior location of the soft-tissue deficiency, an anterior counterclockwise flap rotation toward the axilla was planned.
Fig. 2.
Case 2. Obvious anterosuperior dislocation of the shoulder in a 45-year-old man 3 years after primary tumor excision and prosthetic reconstruction for a low-grade chondrosarcoma.
Step 1 (Posterior Clockwise Rotation Technique): Preoperative Evaluation, Positioning, and Preparation
Verify the adequacy of the latissimus dorsi, confirm the feasibility of the flap in relation to the extent of the defect, and use a laparotomy pad to simulate the arc of flap rotation.
During the preoperative office visit, establish the anticipated extent of the defect after tumor excision. Verify the presence and adequacy of the ipsilateral latissimus dorsi by palpation of its anterior and posterior edges, while the patient’s hand is resting on the hip (Fig. 3).
Confirm the feasibility of a pedicled latissimus dorsi flap in relation to the approximate extent of the defect. Detailed knowledge of the regional anatomy, including the local blood supply and the vascular pedicle of the flap, is essential to understand the rationale for and the technical principles of the procedure (Fig. 4).
Place the patient in the lateral decubitus position, as you will during the surgery. Next, use a laparotomy gauze pad to simulate the arc of rotation of the flap, based on its vascular pedicle, from the latissimus dorsi insertion to the anticipated shoulder defect (Fig. 5).
Computed tomography and magnetic resonance imaging angiography are not routinely part of the preoperative imaging, as the thoracodorsal pedicle is constant and reliable. If a patient underwent prior regional surgery, such as axillary dissection for breast cancer, the role of additional dedicated imaging needs to be carefully evaluated.
At the time of surgery, place the patient in a loose lateral decubitus position so that the torso may rotate 30° anteriorly or posteriorly to facilitate the surgery. This position can be obtained, after standard lateral positioning of the head and neck region, by using a beanbag positioner from the chest to the entire pelvis and hip region. Stability is usually achieved with 2 well-padded belts placed around the table and across the waist and lower extremities.
Prepare and drape out the entire hemithorax and include the entire upper extremity in the field. Posteriorly, the preparation must include the posterior iliac crest and extend past the midline spine.
When approaching the axillary region during flap elevation, manipulate the arm, if needed, to improve visualization of the vascular pedicle.
Fig. 3.
Before surgery, the presence and adequacy of the latissimus dorsi should be verified by pinching the lateral border of the muscle.
Fig. 4.
Planned posterior arc of flap rotation into the shoulder defect. Successful rotation of the latissimus dorsi flap requires preservation of its vascular pedicle—i.e., the thoracodorsal vessels. These emerge from the subscapular trunk approximately 4 cm from its origin at the axillary artery, immediately after the scapular circumflex artery. The thoracodorsal vessels give origin to the serratus branches. The dotted area represents the skin paddle of the mobilized myocutaneous flap. The skin paddle with the muscle perforators stays attached to the muscle portion of the flap, which is rotated into the shoulder defect. (Reproduced with permission of Memorial Sloan Kettering Cancer Center [MSKCC].)
Fig. 5.
Fig. 5-A A laparotomy gauze pad is used to simulate the arc of rotation of the flap based on the pedicle. The examiner’s left hand corresponds to the latissimus dorsi medial paraspinal and lumbar fascia insertion, which needs to be released to mobilize the flap. The examiner’s right hand represents the flap pedicle (the thoracodorsal vessels). Fig. 5-B Once released medially, the flap can pivot on the pedicle and rotate over the shoulder to fill the anticipated soft-tissue defect.
Step 2 (Posterior Clockwise Rotation Technique): Flap Design and Marking in Relation to Anatomic Landmarks
At the time of surgery, proper flap design and markings are critical for successful tumor excision and flap rotation.
Outline the anticipated extent of the defect after tumor excision in a detailed fashion with respect to anatomic landmarks, such as the clavicle, acromion, spine of the scapula, and deltoid muscle (Fig. 6).
Outline the shape and extension of the latissimus dorsi muscle. Mark the anterior border of the latissimus muscle along the posterior axillary fold to the distal thoracic rib cage. Mark the tip of the scapula and the spine (Fig. 7).
Proximally, define the superior aspect of the latissimus dorsi muscle by drawing a line from just above the tip of the scapula across to the chest. Distally, outline the muscle origin from the iliac crest and thoracolumbar fascia. Proximally, identify the trapezius where it overlaps the superomedial portion of the latissimus dorsi. The humeral insertion of the muscle is just medial to the bicipital groove.
The thoracodorsal artery and nerve originate from the subscapular artery, the largest branch of the axillary artery, right after the scapular circumflex artery and course along the undersurface of the latissimus dorsi, extending inferiorly to supply the entire muscle flap. Abduct the arm and palpate the axillary artery in the axilla. The hilum for the thoracodorsal vessels enters the muscle approximately 10 cm distal to this point.
The flap can be elevated with muscle alone (myofascial flap) or with the inclusion of a skin island (myocutaneous flap). A variety of configurations can be used for the skin paddle, the size and shape of which is dicated by the location and extent of the defect along with the anticipated rotation of the flap. In general, the skin paddle should completely lie on muscle, ideally as centrally as possible on the muscle belly. Design a skin paddle over the latissimus dorsi muscle, incorporating cutaneous perforators to supply the skin and keeping in mind the size and shape of the skin defect. A Doppler probe can be used to help confirm skin perforators in the skin island design. Pinch the designed skin paddle together to ensure that the donor site can be closed primarily without undue tension.
After marking the latissimus dorsi muscle, simulate the arc of rotation of the flap into the defect using the laparotomy pad technique as a useful guiding tool (Fig. 5).
Fig. 6.
At the time of surgery, a detailed outline of the anticipated soft-tissue defect in relation to nearby bone structures is crucial to obtain a negative margin and precisely plan the latissimus dorsi rotation. The resection borders delimit an ellipse-shaped specimen, including an area of skin over the deltoid that contains the needle biopsy track.
Fig. 7.
Marking of the pedicled latissimus dorsi flap. With the patient in the lateral decubitus position, which is optimal for raising and insetting the flap, anatomic landmarks and the borders of the latissimus dorsi are marked. The yellow oval represents a common skin paddle associated with the flap.
Step 3 (Posterior Clockwise Rotation Technique): Tumor Excision and Flap Elevation
Confirm adequate tumor removal, prepare the recipient site for the flap, ensure the proper size and shape of the skin island, deepen the dissection circumferentially around the skin paddle, divide the latissimus from the thoracolumbar fascia, develop the natural plane of the flap, divide the branch for the serratus to increase rotation if necessary, and release the humeral insertion to further increase rotation if necessary.
The goal of surgery for musculoskeletal malignant tumors is to obtain a negative margin. Therefore, in Case 1 (see Case Examples above) the surgical goal was an en bloc excision of the tumor completely surrounded by noninvolved normal tissue, including the midportion of the deltoid and the axillary nerve, the acromion-clavicle arch, the subacromial space, and most of the rotator cuff (Fig. 8).
Following removal of the tumor, prepare the defect site to receive the flap by approximating the remaining soft tissues after thorough irrigation and meticulous hemostasis (Fig. 9).
Before the incision, ensure once again that there is proper matching of skin shape and size between the donor and recipient sites. Next, proceed with the incision around the skin paddle. Using the cautery, bevel away from the skin paddle by a few centimeters through the subcutaneous tissues to broaden the skin paddle’s base and dissect down to the muscle (Video 1).
Circumferentially deepen the dissection around the skin paddle down to the muscle fascia and identify the surface of the latissimus dorsi muscle. Make large skin-subcutaneous tissue elevations above the muscle fascia to expose the muscle boundaries all around (Video 2).
Using the cautery, divide the muscle inferiorly where it merges with the thoracolumbar fascia. Accomplish this by using large retractors to pull the skin and subcutaneous layer above the muscle fascia and then visualizing it directly. Next, begin raising the latissimus dorsi myocutaneous flap in an inferior-to-superior direction by transecting its attachments along natural tissue planes. Always keep in mind the latissimus muscle borders, attachments, surrounding structures, and blood supply when raising the flap. Elevation of the latissimus dorsi muscle proceeds in the direction of the main vascular pedicle, which is visible on the undersurface of the muscle. Careful dissection is required when approaching the vascular pedicle (Video 3).
Tie or clip the intercostal perforators (Video 4).
Continue to raise the flap in an inferior-to-superior direction by developing the natural plane represented by loose areolar tissue, watching for the inferior branches of the pedicle. Do not dissect into or directly on the muscle (Videos 5 and 6).
As the dissection progresses superiorly, identify the tip of the scapula and the inferolateral border of the trapezius muscle. Separate the latissimus dorsi from the trapezius muscle. Move the serratus anterior muscle laterally and note the vascular branch for the serratus taking off from the thoracodorsal artery (Fig. 10).
If required for additional arc of rotation, divide the vascular branch for the serratus muscle; however, this is often unnecessary. Do not confuse the serratus vascular supply or other vessels with the main thoracodorsal pedicle supplying the latissimus flap. To minimize muscle atrophy after transposition, preserve the thoracodorsal nerve.
If additional length or mobility of the flap is needed, divide the humeral insertion once the flap has been completely elevated and the pedicle has been identified; however, this also is rarely necessary. Note that, when the flap is raised following a proximal humeral resection, the humeral insertion is usually already released.
Fig. 8.
Intraoperative view showing a specimen mobilized after dissection of the deltoid and osteotomy of the acromion-clavicle arch. The tumor will be removed shortly after division of the residual trapezium muscle fibers.
Fig. 9.
After tumor excision, the defect extends from the lateral third of the clavicle anteriorly to the base of the scapular spine on the posterior aspect of the shoulder. Interrupted sutures were used to approximate the remaining deltoid.
Fig. 10.
On the undersurface of the elevated latissimus dorsi flap, the vascular pedicle (the thoracodorsal vessels) is identified. The serratus branch, running along the chest wall, can also be seen in this photograph.
Video 1.
Make the incision around the skin paddle.
Video 2.
Circumferentially dissect around the skin island and expose the muscle boundaries.
Video 3.
Divide the muscle inferiorly and begin to raise the latissimus dorsi flap.
Video 4.
Tie or clip the intercostal perforators.
Video 5.
Continue to raise the flap in an inferior-to-superior direction (part 1).
Video 6.
Continue to raise the flap in an inferior-to-superior direction (part 2).
Step 4 (Posterior Clockwise Rotation Technique): Posterior Flap Transposition and Inset into the Defect
Be sure to create an adequately sized tunnel and, when passing the flap through the tunnel, to avoid tension on the vascular pedicle and the skin island.
Create a large, adequately sized skin-subcutaneous tunnel to connect the donor site with the shoulder defect. When transposing the flap through the skin tunnel, take care to avoid tension on the pedicle or the perforators to the skin island (Fig. 11) as this can lead to vessel injury by avulsion. If needed, make the skin tunnel larger or divide the tunnel. Previous radiation can make this step more difficult but is not in itself a formal contraindication. Moderate doses (up to 30 to 35 Gy) do not present a major technical issue, whereas higher doses and the presence of extensive fibrosis warrant a case-by-case approach, including consideration of a different strategy. However, since the only alternative in these circumstances may be a free flap, which is also a technical challenge in the setting of severe post-radiation changes, a pedicled latissimus dorsi flap may remain the most viable option.
Make sure the flap completely covers the defect, particularly the most critical areas such as bone surfaces and allograft or prosthetic implants if present. Ensure that the flap also lies without tension on the pedicle and the skin paddle (Fig. 12).
Tailor the skin paddle to the defect if needed (e.g., de-epithelialize or resect with care to avoid injury to the vascular pedicle).
Inset the flap and skin paddle into the defect with deep dermal absorbable sutures (e.g., 3-0 Vicryl [polyglactin]) over 1 or 2 suction drains. Close the skin with 3-0 nylon sutures. Close the donor site after placing 1 or 2 suction drains (Fig. 13).
Fig. 11.
Raising the flap. This photograph shows the latissimus dorsi muscle being elevated with the skin paddle. At this point, the muscle has been released from the thoracolumbar fascia and its paraspinal insertions and, anteriorly, from the serratus. To help illustrate the flap orientation and rotation into the defect, the medial pole of the skin paddle is marked by an asterisk. Note that a large subcutaneous tunnel has been created to transpose the flap into the defect.
Fig. 12.
The latissimus dorsi flap transposed into the defect through the subcutaneous tunnel. The medial tip of the ellipse-shaped skin paddle (asterisk) fills the defect anteriorly. The flap should completely cover the defect without tension on the pedicle or the skin paddle.
Fig. 13.
Anterior (Fig. 13-A) and posterior (Fig. 13-B) views of the flap recipient site following deep and superficial closure over a suction drain. To avoid postsurgical seroma and hematoma, it is important to close the donor site in multiple layers over 1 or 2 suction drains. The asterisk indicates the medial tip of the skin paddle.
Step 5: Postoperative Care
Proper postoperative care includes monitoring the flap blood supply and output of drains, removing sutures, and ensuring satisfactory healing overall (Fig. 14).
Close postoperative monitoring of the flap by trained medical and nursing staff is crucial. Check the flap frequently, especially during the first 24 to 48 hours.
Monitor the warmth, color, and capillary refill of the skin paddle. We prefer to monitor the clinical characteristics of the flap rather than measuring O2 saturation with an external monitor as they are a more reliable indicator of flap viability.
Remove the drains at the flap recipient site after 3 to 5 days or when drain output is <30 mL/day.
As seroma is a common complication in this setting, it is important to keep the donor site drains in place until low output (<30 mL/day) is observed.
Leave skin staples or sutures in place for at least 14 days. An additional 7 to 10 days should be considered for patients who have received radiation therapy.
Place the arm in a shoulder sling usually for 3 to 8 weeks, with the precise length of time depending on the extent of the operation, shoulder stability, and the presence of a massive skeletal reconstruction. In Case 2 (see Case Examples), the arm was placed in a sling for approximately 3 weeks; then, gentle passive range-of-motion exercises were started, followed by active mobilization at 6 weeks after surgery (Fig. 15).
Fig. 14.
The site of the operation at the 4-month follow-up visit shows complete wound-healing and viability of the flap, which provides supple and excellent soft-tissue coverage of the shoulder.
Fig. 15.
Fig. 15-A At the postoperative follow-up visit 2.5 weeks after surgery, there is complete wound-healing and viability of the flap, providing supple and completely satisfactory soft-tissue coverage of the shoulder. Note the dressing applied at the drain site following removal of the drain during the office visit. The asterisk locates the medial tip of the skin paddle in its final position. Fig. 15-B Complete healing of the donor site is shown.
Step 1 (Anterior Counterclockwise Rotation Technique): Preoperative Evaluation, Positioning, and Preparation
The preoperative evaluation, positioning, and preparation are identical to those for the posterior clockwise rotation technique described above.
Step 2 (Anterior Counterclockwise Rotation Technique): Flap Design and Marking in Relation to Anatomic Landmarks
Make sure you understand the regional anatomy, ensure appropriate anterior flap rotation, and use the laparotomy pad technique to the simulate arc of rotation.
Understanding the regional anatomy and ensuring proper flap design and markings are critical steps of the preoperative plan (Fig. 16).
An anterior location of the soft-tissue deficiency requires anterior, counterclockwise flap rotation toward and across the armpit (Figs. 17, 18, and 19).
The laparotomy pad technique can again be used to simulate the potential flap, skin paddle, and arc of rotation into the defect during the procedure (Fig. 19).
Fig. 16.
The site of the previous operation demonstrates obviously attenuated anterior soft tissues, with the prosthesis palpable underneath the skin.
Fig. 17.
Anterior flap rotation for an anterior shoulder defect. See also Video 7, and compare this drawing with the posterior arc of flap rotation shown in Figs. 4 and 5. (Reproduced with permission of Memorial Sloan Kettering Cancer Center [MSKCC].)
Fig. 18.
Marking of the pedicled latissimus dorsi flap. With the patient in the lateral decubitus position, which is optimal for raising and insetting the flap, anatomic landmarks and the borders of the latissimus dorsi are marked.
Fig. 19.
The laparotomy pad technique is used to simulate the anterior arc of flap rotation based on the pedicle. Fig. 19-A The laparotomy pad outlines the latissimus dorsi muscle while the blue sketch represents the anticipated skin paddle. The flap pedicle is simulated by holding the left superolateral corner of the laparotomy pad in the axilla. Fig. 19-B The flap can pivot on the pedicle and rotate counterclockwise over the shoulder to fill the anticipated soft-tissue defect. The asterisks identify the medial tip of the skin paddle before and after rotation.
Step 3: Flap Elevation (Anterior Counterclockwise Rotation Technique)
The surgical principles of flap elevation and transfer are the same regardless of the location of the recipient site (see Step 3 for the posterior technique above).
Step 4: (Anterior Counterclockwise Rotation Technique): Anterior Flap Transposition and Inset into the Defect
Elevate the flap, create a large subcutaneous tunnel for anterior transfer, and ensure optimal flap inset into the shoulder defect.
Once the flap elevation is complete, perform anterior shoulder transfer by counterclockwise rotation of the flap into the shoulder defect (Video 7). See Fig. 4 to compare this with rotation of a posterior flap over the scapula.
Create a large subcutaneous tunnel to transfer the flap into the defect. Transpose the flap through the tunnel into the shoulder defect (Video 8).
Inset the flap into the shoulder defect. To avoid a postsurgical seroma, close the back donor site in multiple layers over 1 or 2 suction drains (Video 9).
Video 7.
Anterior rotation of the flap into the shoulder defect.
Video 8.
Transpose the flap through the subcutaneous tunnel into the anterior shoulder defect.
Video 9.
Inset the flap into the anterior shoulder defect.
Step 5: Postoperative Care (Anterior Counterclockwise Rotation Technique)
Perform as for the posterior technique.
Results
In 2007, we reported on a series of 33 consecutive patients treated from 1994 to 2004 with a pedicled latissimus dorsi flap following sarcoma excision in the shoulder region1. A myocutaneous flap transfer was used in 28 patients (85%), and a myofascial flap that did not include a skin paddle was used in the remaining 5 (15%). The arc of rotation of the flap was posterior in 31 cases (94%) and anterior in 2 (6%). Of the 28 patients who underwent myocutaneous flap transfer, 5 required additional split-thickness skin grafts at the time of the primary surgery, whereas 3 of the 5 patients who underwent a myofascial flap without a skin paddle required split-thickness skin grafts. The thoracodorsal nerve was always preserved to minimize atrophy of the muscle. Three flaps (9%) had skin-related delayed healing, 2 flaps (6%) exhibited partial skin necrosis but healed with conservative management, and 1 flap (3%) required debridement and a split-thickness skin graft although the underlying primary latissimus dorsi flap remained completely viable. All 33 patients ultimately had successful healing of the shoulder reconstruction, and there were no flap losses.
Use of the pedicled latissimus dorsi flap in complex shoulder reconstructions provides ample well-vascularized soft tissue, minimizes the risk of infection, and maximizes successful limb salvage. The vascular pedicle is long, making mobilization of the latissimus dorsi flap around the shoulder relatively straightforward. The muscle itself is fan-shaped and rather bulky. Thus, it usually provides enough volume to fill large shoulder defects and even address complex bone and soft-tissue deficiencies requiring massive skeletal reconstruction (often necessary in musculoskeletal oncology), thereby decreasing the risk of wound slough and infection. For the same anatomic reasons of easy elevation and rotation, the pedicled latissimus dorsi flap also has been used successfully in extensive posttraumatic bone and soft-tissue defects6,7. Whereas relatively limited defects of the anterior shoulder region can be successfully managed with alternative pedicled flaps, such as pectoralis major and pectoralis minor flaps8,9, the latissimus dorsi flap can be used to address larger defects involving the superior and posterior regions as well. Occasionally, the pedicled latissimus dorsi flap is not available, as when the pedicle has been frankly divided, excised with the tumor, or otherwise compromised during the current or prior surgical dissection or in cases of previous rotation. In these circumstances, a free flap may be the only available option for soft-tissue reconstruction10,11. In most patients, however, the pedicled latissimus dorsi flap is our choice for reconstructing defects around the shoulder after tumor excision.
Pitfalls & Challenges
Anticipating the location and extent of the defect is essential for optimal planning of tissue transfer.
Improper alignment of the skin paddle over the muscle, failure to include skin perforators, and/or tension on the skin paddle or flap may lead to necrosis or flap failure.
Templates and markings should ensure proper flap and skin paddle orientation, along with an estimated arc of rotation, before the flap is raised.
The arc of rotation of the flap is limited by the location of the vascular pedicle and the length of the flap. Obesity reduces the arc of rotation and makes flap transposition more difficult.
Proper pedicle identification should be ensured (e.g., the main thoracodorsal pedicle should not be confused with the serratus branch).
Color and dermal bleeding at the edges of the skin paddle should be checked during elevation and after transposition.
No tension or compression should be applied to the vascular pedicle at any time.
Damage to the serratus anterior muscle should be avoided, as it may cause scapular winging.
Donor site seroma is a common complication; it is important to keep drains in place until output is low.
Flap failure is a rare but catastrophic complication for which there is no standard approach. Important decision-making factors are timing, location, extent of the defect, partial versus complete flap loss, and prior surgery and/or radiation. With the scarcity of local options, the salvage strategy often entails a free tissue transfer.
Evaluation of long-term functional outcomes following latissimus dorsi transfer has demonstrated a mild, nonrestrictive deficit of shoulder extension and adduction12,13.
Clinical Comments
What measures have you found to be effective in reducing complications such as flap loss or dehiscence?
Accurate preoperative planning and meticulous surgical technique—including accurate identification of anatomic landmarks, use of templates, and simulation of the flap rotation—help reduce technical difficulties such as tension or torsion, which can ultimately lead to flap dehiscence or loss. Careful dissection reduces the chance of pedicle injury during flap mobilization. Avoiding any tension on the pedicle lessens the chance of avulsion injury during flap elevation, transposition, and inset. Also, frequent checking of the flap skin edges for bleeding during the operation is helpful for detecting a reduction or interruption of the flap’s blood perfusion. Close postoperative monitoring of the flap by trained staff is required, as is ensuring that there is no compression of the flap recipient area or subcutaneous tunnel.
Footnotes
Published outcomes of this procedure can be found at: Ann Surg Oncol. 2007;14(5):1591-5.
Disclosure: Work at Memorial Sloan Kettering Cancer Center is supported in part by a grant from the National Institutes of Health/National Cancer Institute (Grant P30CA008748). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article.
References
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