British Journal qfPla.h~ Surgery (1986) 39.21&212 0 1986 The Trustees of British Association of Plastic Surgeons

The thinned latissimus dorsi free flap: a case report

A. R. ROWSELL, A. M. GODFREY and M. A. RICHARDS

Department of Plastic Surgery, The Radcliffe Infirmary, Oxford

Summary-The clinical use of a thinned free vascularised latissimus dorsi muscle flap is described. The ability to thin successfully the latissimus dorsi muscle flap at the time of transfer has extended its clinical use to include such recipient sites as the face, anterior tibia1 region and dorsum of the foot.

Case Report

A ?I-year-old male presented with an extensive area of soft tissue and bone loss in the region of the forehead and anterior part of the scalp; this injury had been sustained in a road traffic accident on the day of admission. An initial exploration under general anaesthetic revealed a grossly contaminated soft tissue wound with loss of the underlying outer table of the skull and exposure of the

frontal sinus. Under the same general anaesthetic the wounds were debrided, but because of the nature of the injury no attempt was made to reconstruct the defect at that time.

Seventy-two hours later the patient was returned to the operating theatre for reconstruction of the forehead/ scalp defect which measured 120 x 80 cm (Fig. 1) using a free vascularised thinned latissimus dorsi muscle flap.

With the patient anaesthetised and in the right lateral

Fig. 1 Fig. 2

Figure l-The appearance of the forehead defect after debridement. The exposed area of frontal bone is evident, and the opening into the frontal sinus is indicated by the arrow. Figure 2-An intra-operative view of the forehead defect filled with the latissimus dorsi muscle flap. The flap is in the process of being tangentially thinned.

210

THE THINNED LATISSIMUS DORSI FREE FLAP: A CASE REPORT 211

Figure 3--(A, B and C). The forehead defect at 12 weeks post-reconstruction showing the acceptable contour alignment of the flap with the remaining forehead skin.

212 BRITISH JOURNAL OF PLASTIC SURGERY

position, the left superficial temporal vessels were identi- fied via a preauricular incision. The left latissimus dorsi muscle was raised as a muscle flap via a vertical incision 2cm in front of the lateral border of the muscle and transferred to the forehead as a free vascularised flap.

The latissimus dorsi muscle flap was placed in the fore- head/scalp defect and secured with several catgut holding sutures. The flap was positioned so that the original deep surface of the muscle lay on the exposed frontal bone. The distal end of the muscle, together with the thoraco- dorsal vascular pedicle, lay laterally in close proximity to the left superficial temporal vessels. The left preauricular incision was continued up in the hair line to join the fore- head wound in order to accommodate the flap’s 1Ocm vascular pedicle. End-to-end anastomoses between the thoracodorsal and left superficial temporal vessels were undertaken using IO/O nylon sutures and microsurgical techniques. With the blood supply re-established, the latissimus dorsi muscle was thinned by removing muscle from its superficial surface until the contour of the muscle flap matched that of the surrounding forehead and scalp (Fig. 2). This required the removal of approxi- mately one-third of the thickness of the muscle belly. The flap was then sutured into position with 4/O catgut and covered with a split skin graft harvested from the left thigh.

During the immediate post-operative course the muscle flap became oedematous but the oedema settled rapidly and the patient was discharged home, healed, on the 14th post-operative day. Figures 3A, B and C show the flap at 12 weeks after surgery and demonstrate the acceptable contour match between the flap and the sur- rounding forehead and scalp.

Bailey, B. N. and Godfrey, A. M. (1982). Latissimus dorsi muscle free flaps. British Journal of Plastic Surgery, 35.41.

Bartlett, S. P., May, J. W. and Yaremchuk, M. J. (1981). The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plastic and Reconstructive Surger.v. 67. 631.

Bostwick, J. (1982). Latissimus dorsi flap: current applications. Annals of Plastic Surgery, 9,311.

Rowsell, A. R., Eisenberg, N., Davies, D. M. and Taylor, G. 1. (1986). The anatomy of the thoracodorsal artery within the latissimus dorsi muscle. British Journal of Plastic .Surgu~, 39, 206.

Discussion

Although some atrophy of the latissimus dorsi muscle -can be expected following its surgical transfer (Bailey and Godfrey, 1982), the degree of

The Authors

atrophy is unpredictable. Invariably the distal part A. R. Rowsell, FRCS, FRACS, Senior Registrar in Plastic Sur-

of the muscle belly remains unacceptably bulky, gery. The Radcliffe Infirmary. Oxford.

A. M. Godfrev. FRCS. Consultant Plastic Sureeon. The

The versatility and safety of flaps based on the latissimus dorsi muscle is well established (Bailey and Godfrey, 1982; Bostwick, 1982). However, un- til now the use of these flaps to reconstruct defects of the face, anterior tibia1 region and foot has been limited because of the physical bulk of the latissi- mus dorsi muscle. This case report has shown that in situations where the latissimus dorsi muscle is used as a muscle flap it can be conveniently thinned without jeopardising its blood supply.

In the case presented in this paper a free vascu- larised thinned latissimus dorsi muscle flap was chosen to reconstruct the forehead defect because a local scalp flap would have transferred hair bearing skin to the forehead and other free flaps such as the scapular flap, groin flap, and a non-thinned latissi- mus dorsi muscle flap would have been a poor con- tour match because of their physical bulk.

References

necessitating a secondary thinning procedure. Radcliffe I&mary, Oxford.

Although the possibility of transferring a M. A. Richards, BDS, FRACS, Overseas Fellow in Plastic Sur-

thinned latissimus dorsi muscle flap was first sug- gery, The Radcliffe Infirmary, Oxford.

gested by Bartlett et al. in 1981, it was not until 1985 that the anatomical basis for such a transfer

Requests for reprints to: A. R. Rowsell FRCS. FRACS, De- partment of Plastic Surgery, The Radcliffe Infirmary, Wood-

was described (Rowsell et al., 1986). stock Road, Oxford OX2 6HE.