Versatility of the Pedicled Latissimus Dorsi Myocutaneous Flap in Reconstruction of Upper Limb and Trunk Soft Tissue Defects

Abstract

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects. Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience. Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively). Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications. Level of Evidence This is a level IV, therapeutic, retrospective study.

Keywords: pedicled latissimus dorsi myocutaneous flap; trunk reconstruction; upper limb reconstruction.

Fig. 1

Image showing (A) extensive avulsion injury of left upper limb extending from the mid-arm to the distal forearm with lost elbow flexors and gangrenous ring and little fingers, (B) flap design, (C) after inset and skin grafting, and (D) well-settled flap and good elbow flexion.

Fig. 2

Image showing the areas covered by the pedicled LDMF. The colored segments depict the recipient areas of flap in our study. These include anterior arm, elbow, forearm, breast, and sternum. The uncolored segments indicate the areas not covered in our series, but well-known indications of LDMF. They are head and neck, clavicular region, shoulder, and upper lateral abdomen. LDMF, latissimus dorsi myocutaneous flap. (The marked portion of the flap indicates that the distal reach of the LDMF can be extended to middle one-third of the forearm by dissecting the thoracodorsal pedicle to the origin with or without transecting the insertion of the muscle. However, there is a risk of stretching of pedicle and flap tip necrosis.)

Fig. 3

Image showing the areas covered by the pedicled LDMF. The colored segments depict the recipient areas of flap in our study. These include posterior arm, posterior elbow, axilla, scapula, midline dorsum, and lumbosacral region. The lumbosacral region of LDMF is indicated by striped yellow colored region. This flap is based on the lumbar perforators and the thoracodorsal pedicle is divided as depicted. The uncolored segments indicate the areas not covered in our series but well-known indications of LDMF. They are posterior neck and occipital region. LDMF, latissimus dorsi myocutaneous flap.

Fig. 4

Image showing (A) right axillary hidradenitis suppurativa, (B) image showing soft tissue defect following excision of the lesion and the hair bearing skin and LDMF just before inset, (C) well-settled flap in the axilla, and (D) the patient was showing full shoulder abduction.

Fig. 5

Image showing (A) large left mastectomy defect (patient in right lateral position), (B) ipsilateral pedicled LDMF design, (C, D) before and after inset of the flap, (E) well-settled flap, and (F) well-healed donor-site skin graft in the back. LDMF, latissimus dorsi myocutaneous flap.