Pedicled Latissimus Dorsi Flap for Shoulder Soft-Tissue Reconstruction After Excision of a Musculoskeletal Neoplasm.

INTRODUCTION

The use of a pedicled latissimus dorsi flap for reconstruction of large soft-tissue defects following musculoskeletal tumor excision around the shoulder provides adequate well-vascularized and healthy tissue to maximize the chances of successful limb salvage and minimize the risks of wound problems and deep infection.

INDICATIONS & CONTRAINDICATIONS:

STEP 1: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): PREOPERATIVE EVALUATION, POSITIONING, AND PREPARATION: Verify the adequacy of the latissimus dorsi, confirm the feasibility of the flap in relation to the extent of the defect, and use a laparotomy pad to simulate the arc of flap rotation.

STEP 2: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): FLAP DESIGN AND MARKING IN RELATION TO ANATOMIC LANDMARKS: At the time of surgery, proper flap design and markings are critical for successful tumor excision and flap rotation.

STEP 3: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): TUMOR EXCISION AND FLAP ELEVATION: Confirm adequate tumor removal, prepare the recipient site for the flap, ensure the proper size and shape of the skin island, deepen the dissection circumferentially around the skin paddle, divide the latissimus from the thoracolumbar fascia, develop the natural plane of the flap, divide the branch for the serratus to increase rotation if necessary, and release the humeral insertion to further increase rotation if necessary.

STEP 4: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): POSTERIOR FLAP TRANSPOSITION AND INSET INTO THE DEFECT: Be sure to create an adequately sized tunnel and, when passing the flap through the tunnel, to avoid tension on the vascular pedicle and the skin island.

STEP 5: POSTOPERATIVE CARE: Proper postoperative care includes monitoring the flap blood supply and output of drains, removing sutures, and ensuring satisfactory healing overall.

STEP 1: (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): PREOPERATIVE EVALUATION, POSITIONING, AND PREPARATION: The preoperative evaluation, positioning, and preparation are identical to those for the posterior clockwise rotation technique described above.

STEP 2: (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): FLAP DESIGN AND MARKING IN RELATION TO ANATOMIC LANDMARKS: Make sure you understand the regional anatomy, ensure appropriate anterior flap rotation, and use the laparotomy pad technique to the simulate arc of rotation.

STEP 3: FLAP ELEVATION (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): The surgical principles of flap elevation and transfer are the same regardless of the location of the recipient site (see Step 3 for the posterior technique above).

STEP 4: (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): ANTERIOR FLAP TRANSPOSITION AND INSET INTO THE DEFECT: Elevate the flap, create a large subcutaneous tunnel for anterior transfer, and ensure optimal flap inset into the shoulder defect.

STEP 5: POSTOPERATIVE CARE (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): Perform as for the posterior technique.

RESULTS

In 2007, we reported on a series of 33 consecutive patients treated from 1994 to 2004 with a pedicled latissimus dorsi flap following sarcoma excision in the shoulder region.

PITFALLS & CHALLENGES: