Latissimus Dorsi Flap

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The latissimus dorsi (LD) muscle originates from the six caudal thoracic spines and fascia, the lumbar spines and fascia, and the posterior iliac crest. It inserts into the humerus. Its blood supply is from the thoracodorsal artery, accompanied by the thora-codorsal vein and nerve. The neurovascular pedicle enters the undersurface of the muscle 6 to 11.5 cm distal to the origin of the subscapular artery and 1.0 to 4.0 cm medial to the anterior border of the muscle. The thoracodorsal artery divides into a medial and lateral branch. The medial branch parallels the upper border and the lateral runs 2.5 cm from the lateral edge of the LD. Secondary smaller branches come from the dorsal branch of the ninth, tenth, and eleventh intercostal arteries and the four lumbar arteries. The overlying skin is supplied in the upper portion by large myocutaneous perforators and in the middle by smaller perforators and by lateral dorsal branches of the intercostal and lumbar vessels entering 8 cm from the midline. One or more skin islands with different orientation may be outlined over the muscle (Figure 18-19). A maximum size of 12 x 35 cm allows direct closure. For head and neck reconstruction, it is advisable to design the skin island distally over the lateral border of the muscle in order to reach the defect.45 The flap is transferred to the head and neck through a tunnel either subcutaneously or beneath the pectoralis muscle.46-48 As a pedicled flap it is a useful option for neck and cheek defects that do not extend beyond the buccomandibular subunit (Figure 18-20). The donor site is usually closed primarily. The main shortcoming of the LD flap is that simultaneous resection/reconstruction of the head and neck region is not feasible, due to the need for patient repositioning in order to harvest the flap and close the donor site. Due to a limited arc of rotation,

Figure 18-18. A, Squamous cell carcinoma of anterior floor of mouth. B, Intraoperative appearance after tumor resection, marginal mandibulectomy and neck dissection. C, Design of pectoralis major flap. D, Late appearance of flap healed in anterior floor of mouth.

Figure 18-19. A, Design of latissimus dorsi flap with skin island. B, Flap elevated with skin island.

Figure 18-19. A, Design of latissimus dorsi flap with skin island. B, Flap elevated with skin island.

this flap is often transferred as free tissue. Its large diameter vessels (2.0 to 3.0 mm) and length (8.0 to 12.0 cm) allow the performance of anastomoses with neck vessels safely (see below). It is not as bulky as the rectus abdominis myocutaneous flap and therefore can be folded more easily.

Trapezius Flap

The trapezius muscle originates from the occipital bone and the lateral processes of the seventh cervical and all thoracic vertebrae. It inserts into the scapular spine, acromion, and lateral third of the clavicle. The trapezius myocutaneous flap may be transferred as a horizontal, lateral or vertical flap.

The horizontal myocutaneous trapezius flap (7 x 30 cm) receives its blood supply from a branch of the occipital artery in the uppermost part, and by a direct cutaneous descending branch, lying on the semi-spinalis between the sternocleidomastoideus and the trapezius.49 This flap has a large arc of rotation and has been used for reconstruction of the floor of mouth, cheek, temporal fossa and occiput (Figure 18-21).49-51 Closure of the donor site requires a skin graft. The lateral trapezius flap is based on the transverse cervical artery, arising from the subclavian artery. The skin island is centered over the acromioclavicular joint, and the muscle may carry the scapular spine. This flap has been used for reconstruction of floor of mouth, midfacial and mandibular defects with poor results.50

Figure 18-21. Arc of rotation of the trapezius

The vertical trapezius flap has a wider range of transfer in the head and neck area than other flaps (see Figure18-21). Its blood supply comes from the dorsal scapular artery, originating from the descending branch of the transverse cervical artery, near the cranial border of the scapula or emerging directly from the subclavian artery. It descends vertically midway between the vertebral column and the medial border of the scapula, where the skin island of the flap usually is centered. Its caudal end may extend beyond the muscle and has a random blood supply. The skin island may be as large as 9 x 20 cm. The donor site may be closed primarily if it is less than 9.0 cm wide; however donor site healing in this area is frequently associated with seroma formation and a very noticeable scar. This flap has been used for reconstruction of defects centered around the orbit and upward to the skull, across the midline, or for intracranial reconstruction. Although color match and texture of the trapezius flap is good for use in the neck, it is not ideal when used for the face. Similar to the latissimus dorsi flap, intraoperative repositioning of the patient is usually required. Additionally, this flap is not an option in the setting of an ipsilateral

radical neck dissection, due to sacrifice of the transverse cervical vessels.

FASCIOCUTANEOUS FLAPS

Fasciocutaneous flaps were described after recognition of certain patterns of cutaneous blood supply. The blood supply of the deep fascia appears to consist of both a deep and a superficial fascial plexus.52 These fascial vessels connect both: to perforating vessels from the underlying muscles, and to the subcutaneous tissue vessels above them. In some areas, fascia supplies overlying subcutaneous tissue and skin in a more direct fashion. Direct branches from major vessels course through intermuscular septa to reach the deep fascia. These septocutaneous perforators supply the overlying skin and subcutaneous tissue. At least three types of fasciocutaneous flaps exist according to their blood supply configuration.53 Type A flaps are those fed by multiple small, longitudinal vessels that course with the deep fascia. This type of flap must be raised with a base of a certain width to ensure its vascular supply and therefore cannot be raised as an island. The majority of type A fasciocutaneous flaps have been described on the lower leg. Type B flaps are those fed by a single major vessel within the fascia (scapular or lateral arm flap). Type C flaps are those supplied by multiple perforating segments from a major vessel that courses through intermuscular septa (eg, radial forearm flap) (Figure 18-22). Both type B and C flaps can be raised as island flaps or can be transferred as free tissue. All fasciocutaneous flaps described for head and neck reconstruction can only be transferred as free flaps.

FREE FLAPS

Perhaps the most significant contribution to the management of head and neck cancer patients in the past 3 decades is the development of microsurgical free tissue transfer.54,55 Different specialized tissues receiving blood supply from specific vessels are totally detached from the donor site and the artery and vein are reconnected at the recipient site by performing vascular anastomoses with the aid of magnification systems. Success rates using microvascular reconstruction techniques have been reported to be > 95 percent in most major medical centers.6,56,57 Although many free flaps have been described for head and neck reconstruction, a review of 716 free flaps performed in our institution revealed that only four free flaps are required for reconstructing 95 percent of head and neck defects in the oncologic patient.6 These include radial forearm flap, rectus abdominis, fibula and jejunum. Some of the other free flaps occasionally used for head and neck

Latissimus Flap Reconstruction
Figure 18-22. Types A,B,C fasciocutaneous flaps.

reconstruction are the scapula, latissimus dorsi, lateral arm, iliac crest and anterolateral thigh flaps. The versatility of some of these free flaps is reflected in their ability to include different tissues from the same donor site based on one single pedicle, and therefore to harvest composite tissue which can then be used for reconstruction of complex defects, as described below.

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