Ann Thorac Surg 2009;87:1930-1933. doi:10.1016/j.athoracsur.2008.10.064
© 2009 The Society of Thoracic Surgeons
Case Reports
Combination of Two Long-Pedicled Myocutaneous Flaps for Closure of a Complex Contralateral Dorsal Defect
Giacomo Datta, MD,
Filippo Boriani, MD*,
Kiran Degano, MD,
Salvatore Carlucci, MD,
Pietro Maria Ferrando, MD,
Giovanni Verna, MD
Department of Plastic and Reconstructive Surgery, University of Turin, Turin, Italy
Accepted for publication October 21, 2008.
* Address correspondence to Dr Boriani, Istituto di Chirurgia Plastica, Università di Torino, Ospedale San Lazzaro, Via Cherasco, 23, Torino, 10100, Italy (Email: filippo.boriani{at}fastwebnet.it).
 |
Abstract
|
|---|
A large and deep oncological defect has been filled up using a very long-pedicled latissimus dorsi myocutaneous flap, together with a trapezius myocutaneous flap, both harvested contralaterally to the lesion. Despite the distance of the defect from the area from which the flaps have been harvested, use of long-pedicled flaps warranted a better flap rotation with less tension and greater availability of bulky tissues. Both flaps were viable, and the recipient site healed uneventfully. The two donor sites were closed directly and healed rapidly. Therefore, a challenging complex thoracic defect was covered immediately after oncological resection through a combination of two myocutaneous flaps contralaterally harvested, which seemed safe and reliable.
|
Introduction
|
|---|
Reconstruction of a superior thoracic defect proves to be often problematic, especially in case of defects greater than 10 cm diameter. Commonly, myocutaneous flaps such as trapezius muscle or less frequently, the latissimus dorsi are used [1, 2]. The use of paraspinal muscle flaps for reconstruction of midline dorsal defects has also been described [3]. Frequently, for large and deep defects, a double layer reconstruction is necessary [1]. Nevertheless, both trapezius and paraspinal muscles can not be used if tissues of the mid-dorsum are damaged. As free flaps are often not feasible, a good option in these cases is represented by a latissimus dorsi myocutaneous flap. In the case of defects as big as those requiring a reconstructing skin paddle that can not be closed primarily, the combination of two flaps can be considered. We report a peculiar and seldom described simultaneous association of two long-pedicled myocutaneous thoracic flaps, in which the skin paddle is distally located, for covering an upper contralateral hemi-dorsum defect.
A 62-year-old patient was admitted to our department for a recurrent sarcoma of the upper portion of the right hemi-dorsum (Fig 1). Neoplasm involved the deep muscular planes, including the latissimus dorsi muscle. The oncologic resection comprised skin, subcutaneous tissue, fascia, and the latissimus dorsi muscle (full thickness). The costal layer and muscles inserted on the scapula were exposed. After excision of the lesion, the residual defect measured approximately 25 x 18 cm. The reconstruction consisted of two myocutaneous flaps from the left hemi-dorsum: a latissumus dorsi (Fig 2) with a 18 x 13-cm skin paddle for the lower portion and a trapezius with a cutaneous component of 13 x 10 cm for the upper portion of the defect.
View larger version (139K):
[in this window]
[in a new window]
|
Fig 2. Reconstruction of the defect with a combination of a long-pedicled latissimus dorsi flap with a trapezius myocutaneous flap from the left hemi-dorsum (not shown in picture).
|
|
The skin paddle of the latissimus dorsi flap was placed in correspondence of the distal part of the muscle, a few centimeters cranially of the iliac insertion. Distal insertions of the muscle were resected. After denervation and dissection of the muscle from the humerus, the myocutaneous flap was rotated on its long muscular axis to easily reach the defect. The trapezius myocutaneous flap was harvested with a distal skin paddle, too, corresponding to the fourth, fifth, and sixth thoracic vertebras. Both flaps healed with no complications (Fig 3).
The latissimus dorsi receives a dominant vascularization through thoracodorsal artery and a supplementary perfusion from the intercostal vessels. The distal, aponeurotic portion is often dominantly supplied by the posterior intercostal vessels rather than by the thoracodorsal system.
The traditional description of this type of flap consists of a skin paddle most frequently placed over the proximal cephalic two thirds [1] for covering a defect that is homolateral to the flap (Fig 4). Seldom times the skin paddle is placed over the distal one third of the muscle and can be used for covering an uppermost or contralateral defect. Many authors have reported marking skin islands anywhere over the latissimus dorsi [4–6].
View larger version (24K):
[in this window]
[in a new window]
|
Fig 4. Elevation of the latissimus dorsi flap. (Left) Skin paddle is drawn distally on the underlying muscle. (Center) Skin incision and elevation of the anterior border of the muscle. (Right) Flap with its skin paddle and muscular pedicle harvested.
|
|
The lower trapezius island myocutaneous flap receives its vascular supply from the transverse cervical artery as the dominant pedicle and from the dorsal scapular artery and perforator intercostal arteries as secondary pedicles [7].
The skin paddle is outlined by centering it between the spinous process and the medial border of the scapula, over the lowermost fibers of the muscle, as close to the midline as possible; it may extend up to 10 to 15 cm caudal to the tip of the scapula. The average size of the paddle is 150 to 200 cm2.
To elevate the flap, the skin paddle should be incised at the distal and lateral portion. The latissumus dorsi muscle should be identified and dissection should go on medially until the trapezius muscle is found and then, deep to it, continue in a medial and cephalad direction.
The proximal portion of the skin paddle should extend well onto the trapezius to ensure capture musculocutaneous perforators. Complete incision from the cephalad tip of the paddle to the origin of the main pedicle (above the levator scapulae muscle) follows, and subcutaneous tissue of the medial-superior portion of the muscle should then be elevated medially and laterally (subcutaneous tunnelling is also possible) (Fig 5).
View larger version (21K):
[in this window]
[in a new window]
|
Fig 5. Elevation of the trapezius flap. (Left) Skin paddle is drawn distally on the underlying muscle (A) and the vascular pedicle is indicated (B). (Right) Elevation of the flap preserving the descending branch of the transverse cervical artery in its pedicle (C).
|
|
Dissection continues deep to the muscle fascia to elevate it from the latissimus dorsi and rhomboid major.
Muscle insertion to the vertebrae should be transected (attachments to the scapular spine, too, if needed) and intercostal perforators are ligated.
Protection to the uppermost portion of the trapezius should be given, then the flap should be rotated into position and the donor site closed primarily with suction drainage.
|
Comment
|
|---|
Reconstruction of upper dorsal defects can be challenging because the dorsum is a weight-bearing surface (as long as the patient is hospitalized) and because of the natural thickness of the dorsal cutaneous mantle. In the case described, the two wider muscles of the contralateral hemi-dorsum were used for covering a wide and full-thickness defect of dorsal soft tissues with a satisfactory result. Microsurgical options were not feasible, as it often occurs in patients with compromised general health and local poor vascular conditions.
In the surgical planning of the latissimus dorsi myocutaneous island flaps, the skin island is generally designed on the cephalic two thirds of the latissimus dorsi muscle [1]. On the contrary, we placed the skin paddle in correspondence to the distal aponeurotic portion of the muscle, thereby achieving a greater quantity of vital and well vascularized muscular tissue to fill up the dead spaces, as well as a greater arc of rotation and a longer pedicle for a more remote recipient area. The rotation potential was so high that we managed to reach, with no tension, the contralateral upper hemi-dorsum. To fill up deep thoracic midline defects, other authors proposed the use of a two-layer closure. This consists of a turnover flap, either of paraspinal muscles or the trapezius, along with thoracolumbar fascia, and more superficially, the latissimus dorsi muscle designed as an advancement flap, an island flap, or as a distally based "reverse" flap [1]. In our case, a double-flap harvesting was already necessary for closing the extended wound secondary to the large dimension of the defect. Reconstruction of the upper dorsum defects can therefore be successfully and easily performed by means of simultaneous raising of a long-pedicled latissimus dorsi and a trapezius myocutaneous flap. Particularly when other options are contraindicated because of the patient's local or general compromised condition, a distant-positioned skin paddle over these flaps can brilliantly both reach and cover distant homolateral and even contralateral defects.
|
References
|
|---|
- Chun JK, Lynch MJ, Poultsides GA. Distal trapezius musculocutaneous flap for upper thoracic back wounds associated with instrumentation and radiotherapy Ann Plast Surg 2003;51:17-22.[Medline]
- Olivari N. Use of 30 latissimus dorsi flaps Plast Reconstr Surg 1979;64:654-661.[Medline]
- Bostwick J, Nahai F, Wallace JG, Vasconez L. Sixty latissimus dorsi flaps Plast Reconstr Surg 1979;63:31-41.[Medline]
- Stevenson TR, Rohrich RJ, Pollack RA, Dingman RO, Bostwick J. More experience with the reverse latissimus dorsi musculocutaneous flap: precise location of blood supply Plast Reconstr Surg 1984;74:237-243.[Medline]
- Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental studies and clinical applications Br J Plast Surg 1987;40:113-141.[Medline]
- Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E, Smith CJ. Functional evaluation of latissimus dorsi donor site Plast Reconstr Surg 1986;78:336-344.[Medline]
- Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery Plast reconstr Surg 2001;107:285-286.[Medline]
Top
Abstract
Introduction
