Combined bipedicled latissimus dorsi and groin flap for anterior chest wall reconstruction

Abstract

We provide a case report of reconstruction of a massive chest wall defect after recurrent phyllodes tumour resections. The reconstruction used a bipedicled groin and latissimus dorsi flap, with composite rib autologous reconstruction. The patient successfully recovered from the operation. Our case illustrates the applicability of this flap in the armamentarium of anterior chest wall reconstructive options.

Background

The combined latissimus dorsi (LD) myocutaneous flap and groin flap have been reported in the literature as a free flap^{1 2} and as a pedicled flap.³ Because of the two axial vascular supplies, the flap is robust and can be used to cover large defects. In addition, vascularised ribs can be included as part of the flap for reconstruction of the chest wall defect. This combined chimeric flap can cover a large anterior chest wall defect with no microvascular anastomosis and has a low rate of donor site morbidity.

Case presentation

A 43-year-old woman presented for chest wall reconstruction after recurrent phyllodes tumour resections. She first presented to our institution 2 years earlier with a small breast mass that was found to be a benign phyllodes tumour on lumpectomy. At the present visit, she had a large malignant phyllodes tumour with active bleeding and involvement of the fourth, fifth and sixth ribs (figures 1 and 2). No sign of metastatic disease was observed on workup.

Figure 1.

Preoperative presentation of the massive phyllodes tumour.

Figure 2.

Preoperative CT scan showing involvement of the ribs.

Treatment

The general and thoracic surgery teams conducted a wide local resection of the tumour and fourth through sixth ribs (the specimen measured 38×28×35 cm and weighed 5.6 kg). The patient had a 6×8 cm pleural defect with exposed lungs, requiring rib reconstruction for stabilisation and coverage with skin flap and muscle (figure 3).

Figure 3.

Intraoperative views of reconstruction field and findings. (A) Findings of chest wall defect and bipedicle flap. (B) Findings of chest wall specimen and tumour. (C) and (D) Marking of the surgical plans.

The latissimus flap is a musculocutaneous flap based on the thoracodorsal artery. Skin paddle could be included with the LD. The classic groin flap was first described by McGregor and Jackson,⁴ is based off the superficial circumflex iliac artery, and has been used for various applications in the upper extremity.⁵

The combination of latissimus flap and groin flap was bipedicled on the basis of these two sources of blood supply—the thoracodorsal artery and the superficial circumflex iliac artery. A longitudinal skin paddle of 10–15 cm was marked for connection of the origin of these two flaps.

The superficial circumflex artery was identified with palpation of the inguinal ligament and the anterosuperior iliac spine. Dissection was carried out toward the midline, where the sartorius origin was identified. The artery pierced the fascia of the sartorius at the medial edge. The dissection stopped before reaching the medial fascia of the sartorius, thereby decreasing the risk of pedicle damage. The patient was then repositioned in the right decubitus position, and attention was directed toward the LD flap.

The patient’s anterior border of the flap on the chest was the posterior-lateral margin of tumour resection. The dissection was performed in a subcutaneous manner posteriorly until the LD was reached, at which point the entire LD was separated from its inferior iliac crest and lumbar fibrous attachment, with the surgeons dissecting from distal to proximal. The thoracodorsal artery was traced to the origin and released to increase the arc of rotation, with care taken to preserve the branch to the serratus and leave the superior segment of serratus anterior in place to prevent scapular winging.

The perforator supplying the ninth rib was identified. The flap was dissected to incorporate the ninth rib and the lower two digitations of the left serratus anterior muscle, with care taken not to damage the pleura.

Next, the bipedicle flap was mobilised anteriorly. The ninth rib was mobilised in an anterosuperior direction and fixed with wires to the rib defect. LD muscle was sutured to the edge of the pleura. The posterior and abdominal donor sites were grafted with meshed split-thickness skin graft from the left thigh.

Outcome and follow-up

Most skin grafts took hold well (figure 4). One spot did not heal and underwent a skin graft on subsequent follow-up. The bipedicled flap itself healed well without areas of necrosis, and the patient has no postoperative issues with breathing (figure 5).

Figure 4.

At 3 months after the operation, when flap had healed well and skin graft had taken hold.

Figure 5.

Chest radiographic findings of the autologous rib reconstruction.

Discussion

Phyllodes tumours are rare, are benign or malignant tumours, and can grow large quickly, causing destruction of local structures.⁶ Surgery is the main modality of treatment and usually involves wide local excision, sometimes necessitating mastectomy and resection of related structures and requiring either delayed or immediate reconstruction. Several recent reports have noted that it is locally destructive but patients have a good prognosis if a wide local excision is performed, because nodal and distant metastasis is rare.^6–9 For our patient, the phyllodes tumour resection necessitated reconstruction of the anterior chest wall.

Many options exist for reconstruction of the anterior chest wall defect.^10–13 With a large defect such as in the present case, a muscle flap is preferable for the reconstruction. Given that the large bony defect exceeded three ribs, a stable structural support was needed with either autologous rib or synthetic material such as a mesh product (eg, polytetrafluoroethylene, acellular dermal matrix).5 10 14–16

The local muscle flap options included pectoralis major, LD, serratus anterior and rectus abdominis.^{12 17} For our patient, most of the pectoralis major was resected, making it a poor option. The contralateral pectoralis major would not reach the entire defect. The ipsilateral latissimus muscle alone is not bulky enough for such a resection. In addition, the most crucial part of the defect would be covered by the tip of the traditional LD flap, making it prone to ischaemia and breakdown. The rectus abdominis muscle or local perforator flaps were considered because this have been reported in the literature recently.^{12 18} However, it also was deficient in volume for this patient, and the pedicle was unreliable because the extensive resection included the internal mammary artery and the eighth intercostal perforator.¹⁹ In addition, the omentum flap would not provide a stable construct.

Since Harii et al ¹ and later Katsaros et al ³ introduced the combined LD musculocutaneous and groin flap, this combination has rarely been reported in the literature,⁵ likely because of the limited situation in which it is suitable. More esoteric flaps have been described, including a case report of bilateral free traverse rectus abdominis flaps²⁰ and a free LD-groin flap transfer.² However, these procedures require prolonged operative time and microvascular anastomosis and its associated risks. Composite rib reconstructions have been described, including thoracodorsal artery perforator flap^{18 21} and LD with rib pedicled flap.²²

For the present case with the large anterior chest wall defect requiring rib reconstruction, this bipedicled flap in combination with the pedicled autologous rib provided an ideal solution. It required minimal surgical time and no microvascular anastomosis and its associated risks. Furthermore, this flap allows flexibility for the surgeons to divide the groin flap and do a microvascular anastomosis if the bipedicled method would not adequately cover the entire defect.

Patient’s perspective.

I am very happy with this reconstruction option because there was no risk of a flap failure. I had no other donor site complications except in the local areas of the skin graft and the graft donor site, where I had some pain.

The short recovery time was helpful.

Learning points.

• A combination flap for large reconstruction can prevent complications.

• Even with microsurgical expertise, a free flap might not be necessary or the best reconstructive option for cases where combination flaps will suffice.

• Pedicled latissimus dorsi and groin flap can provide a useful reconstructive option.