10.1245/s10434-006-9292-5
Annals of Surgical Oncology 14:1591-1595 (2007)
© 2007 Society of Surgical Oncology
The Pedicled Latissimus Dorsi Flap for Shoulder Reconstruction After Sarcoma Resection
Amir Babak Behnam, MD1,
Constance M. Chen, MD, MPH1,
Andrea L. Pusic, MD, MHS1,
Babak J. Mehrara, MD1,
Joseph J. Disa, MD, FACS1,
Edward A. Athanasian, MD2 and
Peter G. Cordeiro, MD, FACS1
1 Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
2 Orthopedic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Correspondence: Address correspondence and reprint requests to: Peter G. Cordeiro, MD, FACS; E-mail: cordeirp{at}mskcc.org
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ABSTRACT
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Background: Tumor extirpation around the shoulder can result in large defects requiring coverage of allograft-alloprosthetic constructs and vital neurovascular structures. This study examined a single institution’s experience with the pedicled latissimus dorsi flap in reconstructing large shoulder defects after oncologic resection.
Methods: Using a prospectively maintained database, 33 consecutive patients were reviewed who had undergone a pedicled latissimus dorsi flap to reconstruct oncologic shoulder defects between 1994 and 2004. Wide excision or radical en-bloc resection of shoulder tissues was performed with defects often extending intra-articularly and to the level of the mid-arm. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were evaluated. Outcome variables included major and minor complications, patient survival, and limb viability.
Results: Adjuvant therapy included chemotherapy in 18 patients, radiation therapy in 12 patients, and brachytherapy in 2 patients. Defects averaged 280.1 cm2 (range 18–1,225 cm2). Mean skin paddle surface area was 118.9 cm2 (range 21–350 cm2). There were 28 myocutaneous flaps and 5 muscle flaps. Materials for bony reconstruction included 13 allograft and alloprosthetic composites, 6 metallic prostheses, and 3 reconstructions using allograft alone. Two patients experienced partial skin flap necrosis. One patient developed local recurrence. Two patients required combined flaps.
Conclusions: Use of the pedicled latissimus dorsi flap in complex shoulder reconstructions provided ample well-vascularized soft tissue, minimized risk of infection, and maximized limb salvage. In our experience, the pedicled latissimus dorsi flap is an excellent choice for reconstruction of defects around the shoulder after tumor extirpation.
Key Words: Pedicled Flap • Latissimus Dorsi • Shoulder • Reconstruction • Sarcoma • Resection
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INTRODUCTION
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The shoulder is anatomically defined as the junction between the trunk and the arm, including the scapular complex.1 Oncologic resection around the shoulder often results in large complex tissue defects. Vital soft tissue or skeletal structures may be left exposed. When compared to autologous reconstructions, bony reconstructions involving allograft and/or alloprostheses introduce foreign material that can increase the risk of infection. Furthermore, inadequate amounts of soft tissue can lead to contracture during healing, restricting shoulder movement and compromising overall function of the upper extremity. A key reason for reconstructing the shoulder is to preserve function. Thus, when oncologic resection around the shoulder presents a reconstructive challenge, stable and durable soft tissue coverage is critical.
Depending on the extent of the shoulder defect and involvement of adjacent structures, a variety of options may be considered for closure. For small wounds that can be closed without tension, it may be possible to bring wound edges together for primary closure. This is particularly true when resection is superficial and no vital structures are exposed. Once a large area of tissue has been resected, however, primary closure becomes more difficult. When underlying nerve, vessels, tendon, ligament, or even bone has been removed, primary closure is not advisable. Not only may it be impossible to advance flaps far enough to achieve closure, but even if the adjacent tissue could be undermined to allow wound edges to meet, the lack of elasticity in the resulting scar tissue is at high risk of causing problems that can restrict range of motion.
Moving up the reconstructive ladder, if a shoulder defect is too wide for primary closure, a tissue transfer is necessary. Due to the rich vascular network that exists around the shoulder, there are multiple local flaps that are possible. Fasciocutaneous flaps may be raised based on septal and fascial perforators of the axillary subscapular and thoracoacromial trunks. These flaps provide thin, pliable, and durable tissue, and provide missing soft tissue for moderate size wounds. Their proximity to the shoulder also makes them convenient to elevate. In an oncologic setting, however, their adjacency to the surgical field can make them risky choices. If involved in disease, extirpation would be necessary, which would negate their use. Furthermore, for large defects around the shoulder, a thin fasciocutaneous flap may not provide sufficient volume.
For large, complex shoulder defects, regional muscle flaps such as the latissimus dorsi and pectoralis major are necessary to obtain adequate tissue for durable and stable coverage of the shoulder. As pedicled flaps, these flaps have a reliable blood supply, which eliminates the small, but not negligible, risk associated with microsurgical free tissue transfer. As muscle flaps, they also have enough bulk to fill in a large complex shoulder defect.
As reconstructive solutions for complex shoulder defects, the latissimus dorsi and pectoralis major muscle flaps are not equal. Both the latissimus dorsi and the pectoralis major have humeral insertions that can be released to allow for maximum mobilization. Yet the thoracodorsal vessels of the subscapular system of the latissimus flap allow for much greater mobilization of the pedicle than the thoracoacromial trunk of the pectoralis flap. The latissimus also has a larger surface area and volume than the pectoralis, making it more appropriate for large defects around the shoulder. In our experience, these differences are significant enough to make the latissimus dorsi the preferred flap for shoulder reconstruction. The purpose of this study is to review our experience with the pedicled latissimus dorsi flap and examine its benefits in reconstructing large defects of the shoulder after oncologic resection.
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METHODS
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A retrospective review was performed of 33 consecutive pedicled latissimus dorsi flaps for complex shoulder defects secondary to oncologic resection at Memorial Sloan-Kettering Cancer Center (MSKCC) from 1994 to 2004. Patients were identified using a prospectively maintained database; subsequently, chart review and patient examinations were performed. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were recorded. Outcome variables included major and minor complications, limb viability, and patient survival.
All experimental protocols were approved by the MSKCC Institutional Review Board and meet the guidelines of the responsible governmental agency.
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OPERATIVE TECHNIQUE
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Following oncologic resection, the extent of the soft tissue wound should be assessed. If bony reconstruction is needed, allograft and/or a prosthesis is placed by the orthopedic surgeon (Fig. 1
). A significant shoulder defect that requires a musculocutaneous flap may be covered with the latissimus dorsi muscle. The skin paddle is designed in an oblique fashion over the latissimus dorsi muscle.
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FIG. 1. Following oncologic extirpation of the shoulder, the extent of soft tissue resection should be assessed. If needed bony reconstruction is needed, allograft and/or a prosthesis is placed by the orthopedic surgeon. Six patients received a metallic prosthesis, as shown here.
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After incisions are made through the skin and subcutaneous tissues of the back, dissection is carried down to the muscle. As the dissection continues towards the humeral insertion, the serratus anterior muscle and its vascular pedicle, a branch of the thoracodorsal artery, should be identified.2 The thoracodorsal nerve accompanies the vascular pedicle and is often included to minimize atrophy. Unless the muscle slips of the serratus anterior are to be carried with the latissimus dorsi, the pedicle to the serratus muscle is divided in order to obtain the longest vascular leash. Once the flap has been completely elevated and the pedicle identified, the humeral insertion may be divided if extra reach is needed.
A subcutaneous tunnel may then be developed along the axis of the shoulder and arm to facilitate passage of the flap without additional incisions. The flap should completely cover all vital soft tissue structures and bony reconstructions (Fig. 2). The skin paddle is tailored and deepithelialized. Split-thickness skin grafts may also be used as necessary. The upper extremity must be well padded and immobilized, particularly over bony prominences.
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RESULTS
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Demographics
From 1994 to –2004, 33 patients (M = 15, F = 18) underwent reconstruction of large complex shoulder defects using a pedicled latissimus dorsi flap. The mean age was 36.5 years (range 6–74 years). Wide excision or radical en-bloc resection of the shoulder tissues were performed in all patients. With regard to adjuvant therapy, 12 patients underwent radiation therapy, 18 patients underwent chemotherapy, and two patients underwent brachytherapy; one patient did not undergo adjuvant therapy. Defects commonly extended intra-articularly or to the level of the mid-arm. Wound size was recorded in 12 cases, and in these patients the mean defect size was 280.1 cm2 (range 18–1,225 cm2).
Outcome
All 33 patients had successful healing of their shoulder reconstructions (Fig. 3). A myocutaneous flap was performed in 28 patients; a muscle flap without a skin paddle was performed in five patients. In patients who underwent a myocutaneous flap transfer, the mean skin paddle dimensions were 5.8 cm in width (range 3–10 cm) and 18.8 cm in length (range 7–35 cm); mean surface area was 118.9 cm2 (range 21–350 cm2). Of these 28 myocutaneous flaps, five required additional split-thickness skin grafting. In the patients who underwent a latissimus muscle flap without a skin paddle, three patients required split-thickness skin grafts. In two patients, the latissimus dorsi flap was combined with another flap, which consisted of a serratus flap in one patient and a deltoid flap in the other patient.
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FIG. 3. Shown is a postoperative view of a successful myocuta-neous flap for shoulder reconstructions with stable and durable coverage of the wound.
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Various techniques were used to maximize the function of the latissimus dorsi flap. Three flaps were disinserted from their humeral insertions to facilitate insetting of the flap around the shoulder. In two flaps, the serratus branch of the thoracodorsal artery was ligated for increased pedicle mobilization. The thoracodorsal nerve was always preserved to minimize atrophy of the muscle. Osseous reconstruction was required in 22 patients. In patients who needed bony reconstruction, 13 patients underwent a composite allograft and alloprosthetic shoulder reconstruction, six patients had a metallic prosthesis, and three patients received allograft alone.
Complications
There were no flap losses. Two flaps exhibited partial skin necrosis, but healed with conservative management. One flap augmented with a secondary serratus flap required debridement and, eventually, a split-thickness skin graft, but the primary latissimus dorsi flap underlying it was completely viable. The single flap augmented with a deltoid flap healed without complications.
Of the 22 patients who underwent bony reconstruction, one patient developed an allograft-prosthetic nonunion at the humerus that required revision with an iliac crest bone graft before achieving union. All other patients who required osseous reconstruction of the shoulder had successful healing of their structural defect.
Thirteen patients expired during the study period. The mean time interval from surgery to death was 29.4 months (range 6–80 months). Cause of death for three patients was not known. Ten patients suffered local recurrence and/or metastases, then succumbed to disease. One patient required amputation due to local recurrence. Another patient demonstrated local recurrence that required further resection and reconstruction; on separate occasions, alternative flaps were used for these reconstructive efforts including the pectoralis major, external oblique and local fasciocutaneous flaps. Twenty patients survived without evidence of local tumor recurrence.
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DISCUSSION
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Tumor extirpation around the shoulder can result in large composite tissue defects. Reconstruction of complex shoulder defects requires durable and stable coverage of allograft and/or alloprosthetic constructs in addition to coverage of vital neurovascular structures. The wide range of motion of the shoulder should be preserved. Reconstructive techniques should also strive to recreate the anatomical contour of the shoulder girdle.
The first known use of the pedicled latissimus dorsi flap was in 1906, when the Italian surgeon Tansini described its utility for reconstructing chest wall defects after radical breast amputation.3 Since the early 1900s, the usefulness of the pedicled latissimus dorsi flap has been expanded to include reconstruction of the forearm, elbow, upper arm and shoulder.4,5 The thoracodorsal artery, which provides the vascular supply for the latissimus muscle, is long and dependable. The length of the thoracodorsal artery makes it possible to mobilize the latissimus dorsi flap as a pedicled flap to the level of the mid-forearm.6 In a cadaveric study, Jutte et al.7 demonstrated that the latissimus dorsi flap could be transposed as far as 8.4 cm (range 2–18 cm) distal to the olecranon. In our series, the underlying length of the thoracodorsal artery was augmented by disinserting the latissimus dorsi from its humeral insertion three times and by dividing the serratus branch twice. By mobilizing the distal thoracodorsal vascular leash, the latissimus dorsi flap was rotated to the shoulder with ease.
In this series, all 33 patients obtained stable and reliable coverage of their shoulder defects after oncologic extirpation. With the largest surface area of any extremity-related muscle in the body, the latissimus dorsi flap can cover most large defects of the shoulder.7 In our series, regardless of defect size (mean 280.1 cm2, range 18–1,225 cm2), the latissimus dorsi flap was always able to provide ample tissue for reconstruction. Only two flaps demonstrated partial skin necrosis, neither of which required operative intervention. Of the two flap problems in this series, one occurred in a patient who underwent preoperative radiation without bony reconstruction; the other problem occurred in a patient without radiation therapy who had an allograft for bony reconstruction. The complications were not linearly related to the size of the defect. All 28 myocutaneous flaps and five muscle flaps without a skin paddle ultimately healed successfully.
Coverage of large complex shoulder wounds with a latissimus dorsi flap can also decrease infection rates. Quinn et al.8 reported 38 patients who underwent bulk allograft reconstruction for extremity defects who went on to develop infection. Eleven patients did not undergo allograft reimplantation and were treated only with intravenous antibiotics and antibiotic-impregnated polymethylmethacrylate spacers. Five of these eleven patients went on to amputation for persistent infection. In our series, thirteen patients underwent allograft and alloprosthetic composite shoulder reconstruction. All thirteen patients with bony and/or prosthetic reconstruction of the shoulder went on to heal their constructs without evidence of infection. Only one patient had nonunion of his humeral allograft-prosthetic reconstruction. After revision with an iliac crest bone graft, this patient healed without further complication. Only one patient underwent amputation of the affected extremity, with amputation due to recurrent disease, not infection.
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CONCLUSION
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Use of the pedicled latissimus dorsi flap in complex shoulder reconstructions provides ample well-vascularized soft tissue, minimizes the risk of infection, and maximizes limb salvage. The vascular pedicle is long, which makes mobilization of the latissimus dorsi flap to the shoulder straightforward. The muscle itself is large, so that there is enough volume to fill large shoulder defects. Finally, the flap is effective, as use of the latissimus dorsi flap to cover complex shoulder defects that have undergone allograft and/or prosthetic reconstruction successfully decreases infection rates. All of these factors facilitate limb salvage over limb amputation. For these reasons, the pedicled la-tissimus dorsi flap is our choice for reconstructing defects around the shoulder after tumor extirpation.
Received for publication April 24, 2006.
Accepted for publication August 16, 2006.
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REFERENCES
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- Vasconez HC, Oishi S. Soft-tissue coverage of the shoulder and brachium. Orthop Clin North Am 1993; 24:435.[Medline]
- Strauch B, Yu HL. Atlas of microvascular surgery New York: Thieme Medical Publishers; 1993 p 482.
- Tansini I, Sopra IL. Mio nuovo Processo di Amputazione della mamella. Riforma Med 1906; 12:757.
- Pierce TD, Tomaino MM. Use of the pedicled latissimus muscle flap for upper-extremity reconstruction. J Am Acad Orthop Surg 2000; 8:324.[Abstract/Free Full Text]
- Rogachefsky RA, Aly A, Brearley W. Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction. Orthopedics 2002; 25:403.[Medline]
- Tomaino MM. Scapulohumeral arthrodesis for post-traumatic proximal humeral loss using vascularized fibular transplantation and allograft bone. J Reconstr Microsurg 2000; 16:335.[CrossRef][Medline]
- Jutte DL, Rees R, Nanney L, Bueno R, Lynch JB. Latissimus dorsi flap: a valuable resource in lower arm reconstruction. South Med J 1987; 80:37.[CrossRef][Medline]
- Quinn RH, Mankin HJ, Springfield DS, Gebhardt MC. Management of infected bulk allografts with antibiotic-impregnated polymethylmethacrylate spacers. Orthopedics 2001; 24:971.[Medline]
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ABSTRACT
INTRODUCTION
