1) The latissimus dorsi myocutaneous flap is one of the largest soft tissue flaps that can be harvested. It receives its blood supply from the thoracodorsal artery and vein. 2) It has several advantages including a long vascular pedicle and arc of rotation, minimal donor site morbidity, and skin paddle color and texture match for head and neck reconstruction. 3) Disadvantages include the inability to perform simultaneous ablative and reconstructive surgery, risk of vascular pedicle compression, and increased risk of minor complications like seroma formation.

1. Latissimus Dorsi Myocutaneous
pedicled flap
Jameel kifayatullah

2. Latissimus Dorsi Myocutaneous
pedicled flap
• Artery: Thoracodorsal artery

3. Advantages
• Largest soft tissue flap that can be harvested in
the body.
• Versatility in soft tissue design.
• Donor site skin is hairless, with comparable color
match to that in the head and neck region.
• Donor scar is less noticeable.
• Longer arc of rotation.
• Breast or chest wall alteration is minimal.

4. Disadvantages
• Inability to perform ablative and reconstructive surgery
simultaneously (except in cases when recipient site is
located in posterior neck or scalp).
• Requires position change for flap harvesting.
• Long vascular pedicle coursing through the axilla and
neck may be more vulnerable to neck infection and
positional change.
• Risk of injury to brachial plexus
• Increased rate of minor complications (prolonged
wound drainage and seroma formation

5. Contraindications in PLDMF harvesting
• Patients who have had previous trauma or
axillary surgery (history of breast cancer) are
poor candidates for the PLDMF
• relatively contraindicated for patients in
whom significant upper-arm strength is
obligated for employment, sports (skiing), and
daily activities (paraplegic)

6. REGIONAL ANATOMY
• The latissimus dorsi is a fanlike
muscle with an origin located
in the spinous processes of the
lower 6 thoracic vertebrae,
lumbar vertebrae, sacral
vertebrae, and dorsal iliac
crest, via thora- columbar
fascia and the external oblique
muscle. The muscle fibers pass
laterally and are cephalized;
then, they insert between the
teres major and pectoralis
muscles at the humerus.
Together with the teres major,
it forms the posterior axillary
fold

7. REGIONAL ANATOMY
• The primary function of
the latissimus dorsi is
to adduct, extend, and
internally rotate the
arm (“posterior push”
motion)

8. REGIONAL ANATOMY
NEUROVASCULAR ANATOMY
• The latissimus dorsi muscle is a class V muscle
with a dominant pedicle (thoracodorsal artery
and vein) and secondary blood supply
(posterior inter- costal perforators).

9. NEUROVASCULAR ANATOMY

10. SURGICAL DEVELOPMENT OF THE PEDICLED
LATISSIMUS DORSI MYOCUTANEOUS FLAP
• Patient Positioning
lateral decubitus position

11. Flap Design
• the identification of the
surgical landmarks.
Important surface land-
marks include the
following
• Anterior border of
the latissimus dorsi
• Scapular tip
• Mid axillary fold
• Posterior superior
iliac spine

12. Surface landmark indicated for flap design
An imaginary line was draw
from mid axillary fold to
pos- terior superior iliac
spine, this is reliable in
predicting the location of
anterior rim of latissimus
dorsi muscle. Skin paddle
shall not be designed too
far anteriorly beyond the
latissimus dorsi muscle,
anterior extension shall be
limited to a maximum of 2
cm. Skin paddle shall not be
designed above the scapula
tip

13. MARKING
• The anterior rim of the latissimus dorsi muscle
can be located by pinch palpation, and then
marked.
• pinch palpation can be difficult in obese subjects
• Alternatively, the anterior border of the muscle
can be predicted over an imaginary line from the
mid axillary groove to the posterior superior iliac
spine. It is approximately 8 cm below the
midpoint of the axilla, along this imaginary line,
where the vascular pedicle enters the
undersurface of the latissimus dorsi

14. SKIN PADDLE DESIGN
• A fusiform-shaped skin paddle is usually
designed along the imaginary line. Ideally, the
skin paddle should be located over the
proximal two-thirds of the latissimus dorsi
muscle (primary angiosome); however, the
exact location of this skin paddle is dictated by
the size of the defect and the arc of rotation.

15. Arc of rotation of the flap
• The PLDMF has a long vascular pedicle that can
reach as far as the skull vertex. Common
reconstructive defects include the oral cavity,
pharynx, facial skin, and scalp
The arc of rotation for the PLDMF is limited by
several factors:
• Proximal vessel dissection
• Tunneling methods: subcutaneous tunnel versus
interpectoral tunnel
• Location of skin paddle

16. SURGICAL PROCEDURE
The sequence of dissection can be easily broken
down into the following steps:
• Initial incision
• Vascular pedicle identification
• Skin paddle development
• Muscular incision
• Axillary dissection
• Mobilization
• Flap tunneling

17. Initial Incision
• Flap raising begins with an initial skin incision
down to the muscle fibers, following the
imaginary line and along the anterior border
of the skin paddle.
• The anterior border of the muscle rim can be
clearly exposed and separated from the
underlying fatty tissue in the lateral to medial
direction. This dissection plane is relatively
bloodless.

18. Pedicle Identification
• Along this anterior incision, a branch of thoraco-
dorsal artery running anteriorly and supplying the
serratus anterior muscle can be appreciated.
Dissection along this serratus branch proximally
can help to identify the thoracodorsal artery
(3–4 cm distal to the serratus branch). Alterna-
tively, the thoracodorsal artery also can be readily
located by palpating for its pulse underneath the
proximal muscle rim (2 cm medial to the anterior
rim of the latissimus dorsi)

19. Pedicle Identification
PLDMF was raised; the green
arrow indicates TDA
(thoracodorsal artery with
concomitant veins) running
parallel to flap longitudinal axis
before entering hilum. The blue
arrow indicates ante- rior serratus
distal branches before entering
the anterior serratus muscle.
Dissection of pedicle/TDA
proceeded proxi- mally into axilla
space, anterior serratus branches
(double asterisk) and scapular
angle branch (asterisk) were
ligated to increase the arc of
rotation of the PLDMF.

20. Skin Paddle Development
• Once the vascular hilum can be observed on
the undersurface of the muscle, an incision is
made circumferentially around the
posteromedial portion of the skin paddle. This
incision is made to the level of the fascia
overlying the muscle
• Before the muscle incision, anchorage sutures
are used to secure the skin paddle to the
muscle

21. Muscular Incision
• Working from the inferior to superior
direction, muscle fibers are transected along
the inferior pole and medial aspect of the flap.
It is prudent to constantly look after the
safety of the vascular pedicle running on the
undersurface of the flap. This part of the
dissection can be facilitated with the use of
ultrasonic scissors

22. Muscular Incision
• As the dissection proceeds proximally,
branches of thoracodorsal artery (transverse
branch to the latissimus dorsi muscle and to
the serratus and teres major muscles, angular
branch to the scapular tip) must be ligated to
fully mobilize the flap

23. Axillary Dissection
• Following the thoracodorsal artery to the
axilla, care should be taken to identify the
circumflex scapular and subscapular vessels
• This part of the dissection can be facilitated
with an assistant abducting and retracting the
arm.
• Care must be taken not to hyperabduct the
arm so as to avoid brachial plexus injury

24. Axillary Dissection
• During pedicle dissection, a thin cuff of tissue around
the pedicles should be preserved
• Fatty loose tissue around the pedicle provides a
cushion effect and helps to identify twisting of the
pedicle
• For most defects in the lower face and the neck,a
PLDMF can reach without sacrificing the circumflex
scapular vessel.
• The preservation of this vessel helps prevent twisting,
kinking, or torsion of these long pedicles during
delivery; however, if the defect is located midface or
superiorly, trans- action of the circumflex scapular
vessels is required to improve the arc of rotation

25. Axillary Dissection
• Careful inspection over the thoracodorsal
pedicle is a prerequisite, the thoracodorsal
nerve is transected if there is a potential of
nerve compression over the vascular pedicle.
However, the long thoracic nerve to the
serratus anterior muscle should be not be
intruded and must be preserved

26. Mobilization
• For the flap to be fully mobilized, the humeral
tendon of the latissimus dorsi muscle should
be skeletonized.

27. Tunneling
The last step of the procedure is to create a
tunnel for flap delivery
There are 2 methods for creating a tunnel: (1)
interpectoral tunnel and (2) subcutaneous
tunnel.

28. Interpectoral tunnel
• The tunnel is formed by blunt dissection (from lateral extending
medially) from the anterior axilla to the neck between the
pectoralis major and minor muscles.
• The latissimus dorsi myocutaneous flap will be entering the tunnel
and running medially to the thoracoacromial pedicle, reaching the
clavipectoral fascia underneath the pectoralis major muscle.
• A skin incision parallel and inferior to the clavicle is required. The
clavicle head portion of the pectoralis major muscle is transected to
create an exit pathway for the pedicled flap. This path should be
wide enough to accommodate the operator’s hand freely between
the axilla and neck. When tension is appreciated, several
maneuvers can be done:
• Separate the pectoralis minor from its insertion to the coronoid
process.
• Acromial branch of the thoracoacromial vessel can be ligated and
transected to avoid interference.
• Trimming of the proximal latissimus muscle.

29. Interpectoral tunnel
• Before flap delivery, meticulous hemostasis is
required to avoid a postoperative hematoma
that may, inadvertently, compromise the
vascular pedicle. After delivery, the
vasculature of the pedicle should be checked
to ensure that it is free of tension.

30. TUNNELING
• Blue indicates the area of
subpectoralis major muscle
undermining in preparing an
interpectoral tunnel; this
undermining procedure was
performed between the
enveloping fascia of pectoralis
muscles, which is almost a
bloodless field if the
thoracoacro-mial blood vessels
remain intact. Yellow indicates
area of subcutaneous
undermining in preparing a
subcutaneous tunnel.
•

31. Subcutaneous tunnel
• The dissection of the subcutaneous tunnel is
straightforward at the subcutaneous tissue
layer, especially if pectoralis flap has been
used. The PLDMF is rotated 180○ and passed
through the tunnel, reaching the defect region

32. Tunneling techniques comparison
SUBCUTANEOUS
ADVANTAGES
• Ease of dissection
• Limited compression
within the Tunnel
DISADVANTAGES
Shorter arc of rotation
INTERPECTORAL
ADVANTAGES
• Increase arc of rotation
DISADVANTAGES
• Difficult dissection
• Compression from the
pectoralis muscle
• Possible trauma to the
thoracoacromial artery

33. Post operative management
• The donor site defect can be closed primarily
with generous undermining in the
surrounding tissue. Usually, a skin paddle of
less than 8 cm in width can be closed without
the need for skin grafting.
• negative pressure drains placement

34. COMPLICATIONS
• Intraoperative
Complications
(1) unnecessary injury to
the serratus anterior or
long thoracic nerve
during dissection, or
(2) brachial plexus injury
from inadequate cushion
support during patient
positioning
• Postoperative
Complications
1) Donor site
• Seroma formation
• Functional deficits of the
shoulder and arm from
the loss of the latissimus
dorsi muscle are esti-
mated to average 7% in
most patients