A case report

1. LATISSIMUS DORSI FLAP
Dr. Shahid Mahmood
Dr. Javed Akhtar Rana
PGR,OMFS Department, PIMS,ISLAMABAD

2. INTRODUCTION
• The latissimus dorsi myocutaneous flap (LDMF) is
one of the most reliable and versatile flaps used in
reconstructive surgery. It is known for its use in
chest wall and postmastectomy reconstruction and
has also been used effectively for coverage of large
soft tissue defects in the head and neck, either as a
pedicled flap or as a microvascular free flap

3. HISTORY:
• First Described by Tansini in 1896
for chest wall reconstruction.
• Developed for use in the head and
neck by Quillen et al in 1978

4. ANATOMY:
• Innervation: The thoracodorsal nerve.
• Blood supply: Thoracodorsal artery via the
subscapular artery.
• Artery: Can be up to 2 or 5 mm if harvested up
to the subscapular artery.
• Vein(s): Comparable to the artery. A single
venae commitans.
• Pedicle length: Up to 15 centimeters.

5. SURFACE ANATOMY

6. Muscle Attachments
The muscle originates from the posterior iliac
crest and from the spinous processes of the
lower 6 thoracic vertebrae, the lumbar and
sacral vertebrae, and the thoracolumbar
fascia arising from the dorsal iliac crest.

7. insertion
• . The latissimus inserts anteriorly into the
lesser tubercle and intertubercular groove
of the humerus between the teres major
and pectoralis major muscles

8. VASCULARITY

9. INNERVATION

10. Thoracodorsal Artery

11. LOCATION

12. SURFACE MARKING

13. PATIENT PREPARATION

14. PREP
• Standard prep, 10% providone iodine
• Prep the head and neck separately from free flap
operative site.
• A surgical assistant will be lifting the ipsilateral
arm during the axillary dissection; therefore, the
entire arm needs to be sterile.
• 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.
• Prep ipsilateral thigh for possible skin graft.
• 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.

15. DRAPE
• Head drape
• 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.
• Towels to square off operative site including
ipsilateral arm, chest, abdomen, and back to midline
(also include ipsilateral thigh for possible skin graft)
• Patient will be in a lateral decubitus position with
contralateral axillary roll during flap harvest.
• Impervious drape underneath patient as far as
possible so back stays sterile while patient is supine
• Split sheet

16. PROCEDURE

17. FLAP HARVESTING

18. TUNNELING (Pedicled Flap)

19. INDICATIONS
Reconstruction of
A. Lateral neck defects
B . Parotid defects
C. Temporal bone defects

20. COMPOSITE FLAP
Combined muscle flap with musculus
latissimus dorsi and musculus serratus

21. ADVANTAGES
• The possibility of independent skin
paddles being able to address complex
defects (eg, through-and-through oral
cavity defects)
• Rib or scapula bone is available.
• Minimal donor site morbidity occurs.
• It can be combined with other subscapular
flaps, when indicated.

22. ADVANTAGES
• Large volume of tissue is available for
reconstruction.
• Long vascular pedicle offers excellent
range for pedicled flaps.
• High caliber pedicle makes free flap
vascular anastomoses technically more
feasible, even in patients with significant
atherosclerotic disease.

23. DISADVANTAGES
• Requires lateral decubitus position
• Palpable abnormal lump arising in the latissimus dorsi
(LD) donor site scar.

24. CONTRAINDICATIONS
• 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).

25. POST OP CARE
• We allow the patient to use the ipsilateral
arm postoperatively and no special
dressings are required. The donor area
should be inspected daily for hematoma
formation. This donor area often forms a
seroma, necessitating the use of drains for
often more than a week. We often leave
them in for 2 weeks or longer until the
output is diminished. Seromas should be
aspirated.

26. POST OP CARE
• 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.
• A physical therapy consult will facilitate
rehabilitation of arm movement.
• If a pedicled latissimus flap has been
used, the ipsilateral arm should be
supported on pillows to abduct the
humerus.

27. CASE REPORT

43. •THANK YOU