Latissimus Dorsi Island Flap

Flap type: myocutaneous island flap of the axial pattern type (see Figs. 1.3 and 1.4). Flap components: skin, subcutaneous fat, fascia, muscle (latissimus dorsi).

Use: myocutaneous island flap, microvascular anastomosis.

Vascular pedicle: The vascular bundle supplying the muscle consists of the thoracodorsal artery and vein (Fig. 12.2), which are a continuation of the subscapu-lar artery and vein and give off the circumflex scapular artery and vein about 2-4 cm below their origin from the axillary artery and vein (Fig. 12.2). Several millimeters below the origin of the circumflex scapular artery, a vessel springs from the thoracodorsal artery to supply the serratus anterior muscle. The caliber of the vessel increases toward the axillary artery and is approximately 2-4 mm at its origin. The vascular pedicle is approximately 10-15 cm long. The venae comitantes are often paired but have a common termination in the axillary vein. Flap size: The latissimus dorsi flap is the largest my-ocutaneous flap used in plastic reconstructive surgery. It has a maximum useful size of 20 x 35 cm ("tennis racket" flap; Fig. 12.2, 6). Position: lateral decubitus.

Flap elevation: A line is drawn (Fig. 12.2, 5) from the center of the iliac crest to the posterior axillary line. The vascular bundle enters the muscle on that line about 10-12 cm below the axilla, and this point is

Latissimus Dorsi Flap

Fig. 12.2 Myocutaneous latissimus dorsi island flap.

1 Axillary artery

2 Subscapular artery

3 Circumflex scapular artery

4 Thoracodorsal artery

The flap is raised behind aline from the center of the iliac crest to the anterior axillary fold (5). The flap is based on the thoracodorsal artery (4). The initial incision is made over the anterior border of the latissimus dorsi muscle, following the line shown (5). The very large flap has a long arc of rotation (6) that can reach all head and neck defects (see text).

Fig. 12.2 Myocutaneous latissimus dorsi island flap.

1 Axillary artery

2 Subscapular artery

3 Circumflex scapular artery

4 Thoracodorsal artery

The flap is raised behind aline from the center of the iliac crest to the anterior axillary fold (5). The flap is based on the thoracodorsal artery (4). The initial incision is made over the anterior border of the latissimus dorsi muscle, following the line shown (5). The very large flap has a long arc of rotation (6) that can reach all head and neck defects (see text).

marked on the skin. The connecting line runs about 2 cm behind the anterior border of the latissimus dorsi muscle and also represents the rotational axis of the flap. The skin paddle should be designed over the anterior border of the muscle, as this area has the greatest density of perforator vessels. The initial incision is made along the line to the level of the proposed flap, and the anterior border of the latissimus dorsi is exposed. The vascular pedicle is identified medial to the anterior border and traced to the site where it enters the muscle. The vascular pedicle is dissected superiorly to its origin from the maxillary artery. The perimeter of the skin paddle is incised,

12 Mucocutaneous Island Flaps and the latissimus dorsi muscle is bluntly separated from the serratus anterior muscle from the anterior side, using some sharp dissection inferiorly. The skin is sutured to the subcutaneous fat on the muscle to prevent shearing of the perforator vessels. A myocu-taneous island flap is created by rotating the tissue 180° on the myovascular pedicle at the level of the axillary artery (Fig. 12.2, 6). The flap is carefully passed through a prepared subcutaneous tunnel to its destination and sutured into place. If the flap cannot reach the defect, it can be transferred as a microvascular free flap.

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