EFFICIENT DESIGN OF A LATISSIMUS DORSIMUSCULOCUTANEOUS FLAP TO REPAIR LARGESKIN DEFECTS OF THE UPPER BACK

SHIMPEI MIYAMOTO, M.D.,1* SHUJI KAYANO, M.D.,1 HIROKI UMEZAWA, M.D.,1 MASAHIDE FUJIKI, M.D.,2 JUNICHI NAKAO, M.D.,2

and MINORU SAKURABA, M.D.2

Closing large skin defects of the upper back is a challenging problem. We have developed an efficient design for a latissimus dorsi muscu-locutaneous flap for reconstruction in this region. The longitudinal axis of the skin island was designed to be perpendicular to the line ofleast skin tension at the recipient site so that primary closure of the flap donor site changed the shape of the recipient site to one that waseasier to close. We used this method for four patients with skin cancers or soft-tissue sarcomas of the upper back in 2011 and 2012. Thesize of skin defects after wide excision ranged from 11 3 10 to 25 3 20 cm2, and all skin defects could be covered by the flaps and allwounds of donor site could be closed without skin grafts. No wound complications occurred in any patient. Functional and aesthetic out-comes were satisfactory in all patients. This flap design is effective for reconstructing large skin defects of the upper back. VVC 2013 WileyPeriodicals, Inc. Microsurgery 34:20–22, 2014.

Closing large skin defects of the upper back is a chal-

lenging problem.1 Transfer of a pedicled latissimus dorsi

musculocutaneous flap is the method of choice for recon-

struction in this region2; however, primary closure of the

donor site can interfere with closure of the recipient site,

which can become enlarged depending on the orientation

of the skin island. A simple solution is combined use of

a skin graft; however, wound healing problems and sig-

nificant contour deformities can develop.3,4

To reconstruct large skin defects of the upper back,

we have developed an efficient design for a latissimus

dorsi musculocutaneous flap that does not require skin

grafts. We describe our surgical technique and report the

outcomes of four cases.

PATIENTS AND METHODS

From March 2011 to September 2012, we used

pedicled latissimus dorsi musculocutaneous flaps to

repair large skin defects of the upper back immediately

after wide excision of malignant tumors in four

consecutive patients, and these patients were included

in this study. Defects with a minor diameter greater

than 10 cm were defined as large defects. Two patients

were men and two were women, and their mean age

was 51.5 years.

SURGICAL TECHNIQUE

Our design concept was based on the principle that

the shape of the skin defect being reconstructed is

changed when primary closure of the adjacent flap donor

site is attempted.5 We took advantage of this principle

and developed a flap with a donor site whose primary

closure changes the shape of the skin defect being recon-

structed from circular to elliptical and, therefore, makes it

easier to reconstruct.

The operative procedure was usually performed with

the patient in either the lateral or the prone position.

After tumor ablation, the line of least skin tension at the

defect was determined with a pinch test. The ipsilateral

latissimus dorsi musculocutaneous flap was designed so

that the longitudinal axis of its skin island was perpendic-

ular to this line (Fig. 1, left). We pinched the flap donor

site to simulate primary closure and confirmed that the

shape of the recipient site will change from circular to

elliptical (Fig. 1, center). Then, the defect was partially

closed at either end or both ends, and the required flap

size was determined by reference to the remaining defect.

Finally, an elliptical skin island was designed on the lat-

issimus dorsi muscle along the axis mentioned above.

The flap was raised in the regular manner and transferred

to the defect through a subcutaneous tunnel. The amount

of the latissimus dorsi muscle included in the flap

depended on the dead space of the defect. After the do-

nor site was closed primarily over two suction drains, the

flap was inset to the remaining defect (Fig. 1, right).

RESULTS

Patient data are summarized in Table 1. All skin

defects could be covered by the flaps and all wounds of

donor site could be closed without skin grafts. Postopera-

tively, all flaps survived completely, and no wound

1Division of Plastic and Reconstructive Surgery, National Cancer Center Hos-pital, Tokyo, Japan2Division of Plastic and Reconstructive Surgery, National Cancer Center Hos-pital East, Kashiwa, Japan

*Correspondence to: Shimpei Miyamoto, MD, Division of Plastic and Recon-structive Surgery, National Cancer Center Hospital, Tokyo 104-0045, Japan.E-mail: shimiyam@ncc.go.jp

Received 18 December 2012; Revised 20 February 2013; Accepted 25February 2013

Published online 9 July 2013 in Wiley Online Library (wileyonlinelibrary.com).DOI 10.1002/micr.22108

VVC 2013 Wiley Periodicals, Inc.

complications occurred in any patient. The mean follow-

up period was 11.5 months (range, 4 to 22 months). The

functional and aesthetic results were satisfactory in all

patients.

CASE REPORT

A 44-year-old woman presented with a malignant fi-

brous histiocytoma of the right scapular region. Wide

resection of the tumor resulted in a 13.5 3 12-cm2 skin

defect, and the medial edge of the scapula was exposed

(Fig. 2A). To reconstruct this defect, a latissimus dorsi

musculocutaneous flap with an 18 3 7-cm2 skin island

was harvested from the right side. The skin island was

designed so that its longitudinal axis was perpendicular

to the line of least skin tension of the recipient site (Fig.

2B). The recipient defect was partially closed primarily

at both ends, and the flap was transferred to the remain-

ing defect through a subcutaneous tunnel. The donor site

was closed primarily (Fig. 2C).

The postoperative course was uneventful. Four

months after the operation, the cosmetic outcome was

satisfactory with minimal contour deformity, and no func-

tional disturbance was observed (Fig. 2D).

DISCUSSION

Closing large skin defects of the upper back is a chal-

lenging problem. The high tension on the wound edges

resulting from primary closure might lead to dehiscence

or tension necrosis. However, the tautness of the sur-

rounding skin precludes the use of local flaps. Because

the scapula or vertebrae are often exposed, skin grafts

directly to the defect are not indicated. Furthermore, if

dead space is not adequately obliterated, wound healing

can be delayed because of the mobility of the scapula.

Transfer of a pedicled latissimus dorsi musculocutane-

ous flap is the method of choice for reconstructing the

skin of the upper back.2 Advantages include a large, con-

sistent, and reliable vascular pedicle; a highly flexible

skin island design; ease of flap elevation; and minimal

donor-site morbidity.6 The only problem with this flap is

that closure of the donor site interferes with closure of

the recipient site, which can become enlarged, depending

on the orientation of the skin island.

Our flap design is novel because closure of the flap do-

nor site changes the shape of the recipient site to one that

is easier to close. The longitudinal axis of the skin island

is perpendicular to the line of least skin tension of the re-

cipient site, and primary closure of the flap donor site

Figure 1. Diagram of the surgical technique. (left) The longitudinal axis of the skin island (line B) is perpendicular to the line of least skin

tension at the recipient site (line A). (center) Primary closure of the donor site changes the shape of the recipient defect from circular to el-

liptical. LD: latissimus dorsi muscle. (right) The recipient defect is partially closed at either end or at both ends. The flap is inset to the

remaining defect. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Table 1. Summary of Patients

Patient

no.

Age,

sex Tumor type

Defect

size (cm2)

Flap

size (cm2)

Postoperative

complication

Follow-up

period (months)

1 36 F Epithelioid sarcoma 11 3 10 11 3 7 None 22

2 44 F Malignant fibrous histiocytoma 13.5 3 12 18 3 7 None 14

3 47 M Skin metastasis of nasopharyngeal

squamous cell carcinoma

25 3 20 28 3 8.5 None 6

4 79 M Extraskeletal osteosarcoma 14 3 12 20 3 8.5 None 4

Latissimus Dorsi Flap for Upper-Back Reconstruction 21

Microsurgery DOI 10.1002/micr

changes the shape of recipient site from circular to ellipti-

cal. This change in shape allows partial primary closure of

the recipient site and reduces the required width of the

skin island. The elliptical skin defect can be closed with

the skin island of the flap without undue tension.

Large skin defects of the upper back have traditionally

been reconstructed through transfer of a pedicled latissi-

mus dorsi musculocutaneous flap, combined with skin

grafts to help close the primary defect or the donor site or

both.7 Although this reconstruction method is simple to

perform and widely applicable, skin grafts to the back of-

ten result in delayed wound healing and significant contour

deformity.8 The sliding-shape latissimus dorsi musculocu-

taneous flap is another option8; however, the two skin

islands are extremely difficult to design because the donor

site is adjacent to the defect and because the amount of

available tissue is limited. Free flaps are rarely indicated in

this region because adequate recipient vessels are unavail-

able and because the patient’s surgical position precludes

access to the commonly used donor sites. Several authors

have reported the versatility of pre-expansion or surgical

delay for augmenting the survival area of latissimus dorsi

musculocutaneous flaps9,10; however, the role of such two-

stage procedures is limited in patients with advanced

malignancy because of the lack of time for preparation.

Indications for the thoracodorsal artery perforator flap

have been expanding in several fields of reconstructive

microsurgery.11 Our design can also be applied to the thor-

acodorsal artery perforator flap if a perforator of appropri-

ate size and location can be found. In this series, we used

conventional musculocutaneous flaps and focused on tech-

nical easiness and great freedom in flap design. In addi-

tion, when partial scapulectomy is performed, using the

latissimus dorsi muscle to eliminate dead space around the

scapula is essential. When the defect is not deep, the thora-

codorsal artery perforator flap can be a versatile option for

reconstruction in the upper back.

The main limitation of this study was its small sam-

ple size. From our series of four patients, definitive con-

clusions cannot be drawn. Further experience with this

method is obviously necessary.

In conclusion, our design of a latissimus dorsi muscu-

locutaneous flap is effective for reconstructing large skin

defects in the upper back and obviates the need for a

skin graft.

REFERENCES

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3. Laitung JK, Batchelor AG. Successful preexpansion of a free scapu-lar flap. Ann Plast Surg 1990;25:205–207.

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7. Westreich M, Yeshua R. Scapulectomy with latissimus dorsi muscu-locutaneous flap in the treatment of sarcoma of the upper back. AnnPlast Surg 1989;23:337–340.

8. Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsiflap. Ann Plast Surg 1997;38:41–45.

9. Fujiwara M, Nagata T, Matsushita Y, Fukamizu H. Free hemibackflap with surgical delay for reconstruction of extensive soft tissuedefect: A case report. Microsurgery 2013.;32:152–155.

10. Kulahci Y, Sever C, Uygur F, Oksuz S, Sahin C, Duman H. Pre-expanded pedicled thoracodorsal artery perforator flap for postburnaxillary contracture reconstruction. Microsurgery 2011;31:26–31.

11. Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ, DupinCL. The thoracodorsal artery perforator flap: Clinical experience andanatomic study with emphasis on harvest techniques. Plast ReconstrSurg 2004;114:32–41; discussion 42–43.

Figure 2. (A) The defect resulting from wide resection was 13.5 3

12 cm2 and exposed the medial edge of the scapula. (B) The defect

after being partially closed at the both ends and the flap design. (C) Im-

mediately after flap transfer. (D) After 4 months. [Color figure can be

viewed in the online issue, which is available at wileyonlinelibrary.com.]

22 Miyamoto et al.

Microsurgery DOI 10.1002/micr