The latissimus dorsi is a type 5 muscle (major pedicle and multiple segmental vessels).
The dominant pedicle is the thoracodorsal artery and venae comitantes, which originate from the subscapular artery and vein. Secondary pedicles are two rows (lateral and medial) of four to six perforating arterial branches and venae comitantes taking origin from the posterior intercostal and lumbar arteries and veins. The length of the major pedicle can be as long as 8 cm and the arterial diameter up to 2.5 mm. The artery enters the deep surface of the muscle in the posterior axilla, 10 cm inferior to the latissimus muscle insertion into the humerus.35
The motor nerve supply is the thoracodorsal nerve (C6-8) and the sensory innervation of the skin is supplied by multiple cutaneous branches of the intercostal nerves. Generally, this is not used as a sensate flap.
The latissimus dorsi is the largest transfer available, with a muscle surface area of 25 x 35 cm2 and skin territory of 30 x 40 cm2.36
The latissimus dorsi is an expandable muscle since function is preserved by the remaining synergistic shoulder girdle muscles (Fig. 8.7).
Patient position: mid lateral, arm elevated 90°. The dissection begins with an incision along the muscle border. First identify muscle border and its relationship to the serratus muscle. Next identify the pedicle and follow the pedicle to origin in the axilla. Free anterior border of the muscle and raise the flap from a ventral in dorsal direction to the spine. Take care to coagulate or ligate the perforating vessels. Next divide the muscle distally as required. Raise muscle in the cranial direction. Next ligate the serratus branch.
For extensive wounds the latissimus can be transplanted simultaneously with the serratus muscle, on a single vascular pedicle.37 The latissimus is commonly used in reconstruction in lower extremities for large defects.3839 Description of a combined flap including the ninth and tenth ribs as vascularized bone transplanted for simultaneous coverage and tibial bone reconstruction is possible but not commonly used.40
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