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Latissimus Free Flap and Pedicled Flap

last modified on: Tue, 02/20/2024 - 08:25

return to: Microvascular Surgery Protocols

Note: last updated before 2013

GENERAL CONSIDERATIONS

  1. Indications
    1. The flap may be used either as a free or pedicled flap. Initially, the procedure for harvesting the flap is the same. If the flap is used as a free flap, the vascular pedicle is traced proximally and divided. If the flap is used in a pedicled fashion, the humeral insertion of the pectoralis is partially divided to create a subcutaneous tunnel into the neck. Venous congestion can be a significant problem if the flap is used in a pedicled fashion, and we prefer to use the flap as a free tissue transfer if recipient vessels are available.
    2. This flap is particularly well suited for lateral facial, temporal area, and craniofacial reconstruction in which a large surface area needs to be covered.
    3. Due to the flap's large size, through-and-through defects that require internal and external lining are often an indication for this flap, which can be folded 180°.
    4. The flap also serves as an excellent means of reconstructing total glossectomy defects. In these cases, the motor innervation of the flap is maintained through anastomosis of the thoracodorsal nerve to the stump of the hypoglossal nerve. This innervation does not allow purposeful movement, but does result in maintenance of muscular bulk.
  2. Contraindications
    1. See General microvascular protocol. Flap-specific contraindications include prior axillary surgery and prior surgery to the upper lateral back that may have disrupted the muscle or its blood supply.
    2. If possible, the flap should be harvested from the side of the nondominant hand. Relative contraindications would include patients who require significant upper-arm strength for employment or sports activities (competitive tennis players and swimmers).
  3. Pertinent Anatomy
    1. The latissimus dorsi is a fan-shaped muscle with its insertion in the intertubercular groove on the medial aspect of the proximal humerus. It takes origin from the iliac crest and external oblique fascia inferiorly and the thoracolumbar fascia and lower six vertebrae inferomedially.
    2. The latissimus is a component of the subscapular system of flaps. Blood supply is derived from the thoracodorsal artery that is a distal continuation of the subscapular artery following the branching of the circumflex scapular. Occasionally, the circumflex scapular and thoracodorsal will both branch directly off the axillary artery.
    3. The artery enters the muscle on its lateral deep surface approximately 10 cm from the insertion in the humerus. The thoracodorsal artery frequently divides shortly after entering the muscle to give an anterior branch supplying the lateral muscle and a posterior branch supplying the medial muscle and overlying skin. The vascular pedicle is accompanied by the thoracodorsal nerve. A second blood supply is derived from four to six segmental paraspinous perforators medially. These segmental vessels are routinely divided when the flap is transferred based on the dominant thoracodorsal vessels.
    4. The flap is generally used as a musculocutaneous flap, with the overlying skin nourished by musculocutaneous perforators that enter the dorsal thoracic fascia.

PREOPERATIVE PREPARATION

  1. Evaluation
    1. Thorough history and physical exam exclude prior traumatic or surgical disruption of axilla or upper lateral back.
    2. Mark out lateral border of latissimus muscle with patient sitting with hands on hips. (This is not useful in the elderly patient with redundant skin or in the obese patient.)
  2. Potential Complications
    1. See General microvascular protocol. Flap-specific complications include injury to the long thoracic nerve with resultant "winged scapula," upper-arm stiffness, seroma, and wound separation at the harvest site. If a large skin paddle is planned, the patient should be told that a skin graft may be required to close the donor defect.
    2. Venous congestion is a serious consideration if the flap is used in a pedicled fashion. For this reason, the free transfer is preferred if recipient vessels are available.

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
      1. Vacuum bean bag mattress on bed for positioning patient on side
      2. Mayfield headrest
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Microsurgery Instrument Tray, Otolaryngology
      4. Bipolar Forceps Trays
    2. Special
      1. Retractor Tray, Large
      2. Dermatome set-up (available only)
  3. Medications (specific to nursing)
    1. Antibiotic ointment
    2. 1% lidocaine HCL injection with 1:100,000 epinephrine
    3. Heavy sterile topical (liquid petroleum), 10 ml (for skin graft)
    4. Heparin sodium injection, 1,000 units per ml, 10 ml vial
    5. Papaverine injection, 60 mg per 2 ml, 2 ml ampule x 2
    6. PhysioSol irrigation solution, 500 ml (be sure the PhysioSol is in the warmer in sufficient time to be warm when the surgeon requests it)
  4. Prep and Drape (see photos for: Prep and Drape for Latissimus Dorsi Free and Pedicled Flap)
    1. Standard prep, 10% providone iodine
      1. Prep the head and neck separately from free flap operative site.
      2. A surgical assistant will be lifting the ipsilateral arm during the axillary dissection; therefore, the entire arm needs to be sterile.
      3. Prep back from hairline to level of iliac crest 3 cm past midline and staple a waterproof barrier and drape up the midline from the bottom to the top of the back prep.
      4. Prep ipsilateral thigh for possible skin graft.
      5. The entire prep of the back is done prior to starting the head and neck procedure so that all that needs to be done to harvest the flap is to roll the patient and deflate the bean bag.
    2. Drape
      1. Head drape
      2. Patient will need to be in the lateral position at times during the procedure, so place towels and drapes so the entire face (from below eyes to both mastoid tips), both sides of neck, chest, shoulder over deltoid including ipsilateral arm, axilla, and back to midline on down to ilium are included in the operative site.
      3. Towels to square off operative site including ipsilateral arm, chest, abdomen, and back to midline (also include ipsilateral thigh for possible skin graft)
      4. Patient will be in a lateral decubitus position with contralateral axillary roll during flap harvest.
      5. Impervious drape underneath patient as far as possible so back stays sterile while patient is supine
      6. Split sheet
  5. Drains and Dressings
    1. Varidyne vacuum suction drains: 7 mm or 10 mm
    2. Antibiotic ointment to suture lines
    3. Fluffs
    4. Elastoplast tape
  6. Special Considerations
    1. Skin graft may be necessary
    2. Heparin sodium injection 5000 units in sodium chloride 0.9% 500 ml in syringe, Luer tip 5 cc syringe with 24-gauge IV cannula is used to irrigate vessels.
    3. Papaverine 60 mg in 500 cc sodium chloride 0.9% in a Luer tip 10 cc syringe with 18-gauge IV cannula will be used topically to irrigate for vasospasm.
    4. Use all measures to keep body temperature at least 37.6°C (warming blanket, room temperature).
    5. See Skin graft protocol if necessary for procedure.
    6. See General microvascular protocol.
    7. If a pedicled flap is to be used, the operating surgeon needs a headlight during creation of the subcutaneous tunnel into neck.

ANESTHESIA CONSIDERATIONS

  1. General
    1. The patient will need to be rolled into a lateral decubitus or park bench position for prep and following the ablative portion of the procedure during flap harvest.
    2. The patient should be on a beanbag with a contralateral axillary roll. A Mayfield headrest should be used.
    3. The table will be turned 180° from the anesthesiologist.
    4. For lateral temporal area ablative cases, it may be possible to begin the flap harvest during the ablative procedure. Speak to the other surgeons involved regarding this possibility.
  2. Specific
    1. No IV lines, arterial lines, or blood pressure cuffs on ipsilateral upper extremity. Long anesthesia tubing will be needed.
    2. Ensure that axillary roll remains in good position when patient is in lateral decubitus position.

OPERATIVE PROCEDURE

  1. Palpate the lateral border of the latissimus muscle, iliac crest, midline of back, and inferior scapular angle; draw these landmarks.
  2. Draw intended skin paddle location with consideration for pedicle length and size of skin paddle needed. The lateral margin of the skin paddle should be along the lateral border of the muscle. Some of the skin paddle should be located over the upper half of the muscle to capture an adequate number of musculocutaneous perforators (within the first or second angiosome).
  3. Begin with incision along the lateral border of the muscle, identify the lateral border of the muscle, and elevate muscle with fascia from lateral to medial. Be careful superiorly as the vascular pedicle emerges from the lateral border to run up into the axilla.
  4. Working from inferior to superior, identify branches to serratus from the thoracodorsal artery, and follow the thoracodorsal artery into the axilla. Identify the thoracodorsal nerve and circumflex scapular vessels. Once the subscapular artery and vein are identified, the serratus and circumflex vessels may be divided and ligated. Unless needed for an innervated flap, the nerve is also divided. Use care to avoid injury to the long thoracic nerve to the serratus. This nerve is just deep to the vascular branches to the serratus. Several sutures to tack the skin paddle to the underlying muscle during dissection are advisable to prevent shearing injury to perforating vessels.
  5. With the vascular pedicle identified, the muscle and outlined skin paddle are elevated by working medially and posteriorly. The paraspinous perforators will need to be divided. The fibrous attachment of the latissimus to the inferior scapular angle will need to be divided as the flap is elevated.
  6. With the vascular pedicle under direct vision, the humeral attachment of the latissimus is divided as the last step prior to vascular pedicle division.
  7. The flap can be stapled back into its normal anatomic position during completion of the ablative procedure and while the neck vessels are being prepared.
  8. If the flap is to be used as a pedicled flap, a tunnel is created anteriorly and superiorly up into the neck. The tunnel is in the subcutaneous plane. It is not advisable to tunnel the flap under the pectoralis muscle. In most cases, some of the fibers of the pectoralis are divided to create a larger tunnel through which the latissimus may be passed. Once the flap is positioned in the defect, the tension of the subscapular artery should be checked. The tendon of the latissimus should then be sutured to the anterior chest wall tissue to "fix" the position of the proximal pedicle. This will prevent tension on the proximal pedicle during flap inset and postoperatively if the patient turns.
  9. The final step in flap transfer is division of the subscapular vessels. Be aware that infrequently the thoracodorsal takes origin directly from the axillary artery.
  10. The donor defect is closed in two layers with 2-0 or 3-0 vicryl deep sutures and skin staples over two large suction drains.
  11. If the defect will not close easily, it is best to skin graft some of the defect. The skin graft is best positioned inferiorly away from the axilla and scapula (movement will occur in these areas, decreasing the chance of a good skin graft take).

POSTOPERATIVE CARE

  1. See General microvascular protocol
  2. Donor site drains are generally removed in five to seven days. If a seroma develops and the incisions are healed, this can frequently be dealt with by serial aspirations.
  3. A physical therapy consult will facilitate rehabilitation of arm movement.
  4. If a pedicled latissimus flap has been used, the ipsilateral arm should be supported on pillows to abduct the humerus. This will minimize any pressure on the pedicle as it traverses the axilla.

REFERENCES

Haughey BH. Tongue reconstruction: concepts and practice. Laryngoscope. 1993;103:1132-1141.

Haughey BH, Fredrickson JM. The latissimus dorsi donor site. Arch Otolaryngol Head Neck Surg. 1991;117:1129-1134.

Laitung JKG, Peck F. Shoulder function following the loss of the latissimus dorsi muscle. Br J Plast Surg. 1985;38:375-379.

Schwabegger A, Ninkovic M, Brenner E, Anderl. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg. 1997;38:594-597.

Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Recon Surg. 1981;67:637-641