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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 31-36

Limitations and complications of latissimus dorsi flap: A hospital-based study


1 Department of Surgery, Subharti Medical College, Meerut, Uttar Pradesh, India
2 Department of Physiology, Subharti Medical College, Meerut, Uttar Pradesh, India
3 Department of Obstetrics and Gynaecology, Subharti Medical College, Meerut, Uttar Pradesh, India

Date of Web Publication29-May-2013

Correspondence Address:
Shashank Mishra
Department of Surgery, Subharti Medical College, Delhi-Haridwar Bypass Road, NH-58, Meerut - 250 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.112628

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  Abstract 

Objectives : The latissimus dorsi muscle is a large, flat muscle that covers the inferior half of the posterior trunk. It is a very useful natural cover that can be utilized to cover even a wide defect. This study is an attempt to study the limitations of the flap and to describe the complications associated with the latissimus dorsi flap at the donor and recipient sites. This was a retrospective analysis of a prospective study conducted during August 2008 to July 2011 (3 years) with permission from the institutional ethical committee. This study included 23 patients (n = 23) with their or their attendants' informed consent. Materials and Methods : The patients were admitted through plastic surgery outpatient department or referred from orthopaedics department. Flap selection was done regarding size, site, shape of defect, status of surrounding tissue, presence of external fixator, mobility of different joints, and patient comfort. Limitations and complications of this flap were recorded and managed accordingly. The data collection and storage was done on pre-formed working Performa sheets. Results were analyzed using statistical analysis including determining average mean (χ) = ∑x 1 + x 2 +…….x n /n and comparison with previous studies. Results: When used as free-flap or pedicle-flap, latissimus dorsi can cover extensive and distant defects without obvious donor site loss of function. The latissimus dorsi muscle and myocutaneous flap in pedicle-flap or free-flap form has provided a consistently reliable method of reconstruction of head and neck, upper limb, lower limb, chest, abdomen, breast, and myelomeningocele. Conclusions: Vulnerability of the vascular pedicle to kink and bulkiness of the flap precluding its use in small defects were few of the limitations seen in this study.

Keywords: Free flap, latissimus dorsi, myocutaneous flap, pedicle flap, vascular pedicle


How to cite this article:
Mishra S, Bhatnagar A, Tyagi R, Bhatnagar K, Garg D, Prakash A. Limitations and complications of latissimus dorsi flap: A hospital-based study. Saudi J Health Sci 2013;2:31-6

How to cite this URL:
Mishra S, Bhatnagar A, Tyagi R, Bhatnagar K, Garg D, Prakash A. Limitations and complications of latissimus dorsi flap: A hospital-based study. Saudi J Health Sci [serial online] 2013 [cited 2022 May 23];2:31-6. Available from: https://www.saudijhealthsci.org/text.asp?2013/2/1/31/112628


  Introduction Top


The latissimus dorsi (plural: latissimi dorsi), meaning "broadest muscle of the back" (Latin latus meaning "broad," Latissimus meaning "broadest" and dorsum meaning the back), is the larger, flat, dorso-lateral muscle on the trunk, posterior to the arm, and partly covered by the trapezius on its median dorsal region. The latissimus dorsi is responsible for extension, adduction, horizontal abduction, flexion from an extended position, and internal rotation of the shoulder joint. [1],[2],[3],[4],[5] It also has a synergistic role in extension and lateral flexion of the lumbar spine. It is a very useful natural cover that can be utilized to cover even a wide defect. Until now, there have been very few studies on the role, limitations, and complications of latissimus dorsi muscle flap as a reliable method of reconstruction. [3],[4],[5] This study is an attempt to find out the role of latissimus dorsi muscle flap as a reliable method of reconstruction of head and neck, upper limb, lower limb, chest, abdomen, breast, and myelomeningocele and to define the limitations of the flap and to describe the complications associated with the latissimus dorsi flap at donor and recipient sites.


  Materials and Methods Top


This is a retrospective analysis of a prospective study conducted during August 2008 to July 2011 (3 years) after taking permission from the institutional ethical committee. The present work is based upon a study of 23 patients who underwent reconstruction during the study period. The study was carefully and meticulously performed and an attempt was made to cover every possible aspect. The patients were admitted through plastic surgery outpatient department or referred from orthopaedics department. Flap selection was done regarding size, site, shape of defect, status of surrounding tissue, presence of external fixator, mobility of different joints, and patient comfort. The cases included here belonged to different age groups and both sexes.

Inclusion criteria

  1. The patients must have functional latissimus dorsi muscle.
  2. The muscle should be expendable.
  3. The donor site effect should be acceptable to all patients.
Exclusion criteria

  1. Patient having previous posterolateral thoracotomy scar.
  2. Poliomyelitis victims (in whom it may be the only lateral muscle capable of elevating the pelvis for a forward step).
Indications

The present work included cases mostly involving the following:

  1. Trauma
  2. Burn
The clinical study was done under the following headings:

  1. History - Careful relevant history was taken and recorded on preformed working performa.
  2. Physical examination - Including general examination, examination of local part.
  3. Investigation
    1. Laboratory investigation
    2. Radiological study
    3. Hand Doppler
    4. Angiography
  4. Orthopaedic management - Regarding fixation of the fracture site and vascular reconstruction.
  5. Surgical management - The operation was taken in general anaesthesia in semi-prone position. Prophylactic antibiotics and postoperative immobilization was used in all patients. Blood transfusion was instituted when necessary. In cases of free-flaps, 1-0 polyamide monofilament, 4 mm 3/8 circle round-bodied micro point suture was used.
  6. Result evaluation was done taking flap survival, aesthetic and final results, donor site morbidity, and patient satisfaction.
  7. Postoperative management - Aspirin was continued for 2 weeks and low molecular weight dextran-40 was given for 3 days where free-flap was done for reconstruction. [6],[7],[8] A careful study of postoperative management was done. Complications regarding donor and recipient sites were recorded and managed accordingly.
Follow-up

Necessary rehabilitation for functional and aesthetic debility was provided at follow-up. Physiotherapy was given regarding gradual weight bearing in case of lower limb recipient site and range of motion of adjacent joint. Debulking of flap was done as required.


  Results Top


There were 21 males (91.3%) and 2 females (8.6%) in the study. All patients were operated as elective, except 5 patients who were operated on emergency basis. The minimal age was 5 years and maximum age was 65 years, most common age group requiring flap coverage was between 21 and 30 years (34.7%) [Table 1].
Table 1: Distribution of cases according to complications

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Hospital stay was prolonged in certain cases because we did not discharge the patients until flap was completely healed as suitable facilities for managing minor problems at rural and semi-urban areas are scarce. Moreover, most patients had accompanying fracture; although the patients were discharged from the plastic surgery unit, they remained admitted under orthopaedic unit for management of orthopaedic management.

Hospital stay in 1 case (12.5%) of pedicle-flap was prolonged as he sustained blast injury bilateral upper limb, which required reconstructive procedures for the opposite extremity [Table 2]. Moreover, postoperative period was complicated by dehiscence in donor site and marginal flap necrosis. Hospital stay in 1 case (6.7%) of free-flap was prolonged because of sinus at heel sit that required curettage and in another case required supplement split skin graft at recipient site. In 2 cases of pedicle-flap (25%) and 2 cases of free-flap (13.4%), hospital stay was prolonged because of complete flap loss [Figure 1]. Two cases (25%) of pedicle-flap had marginal flap necrosis requiring debridement and split thickness graft. One case (6.7%) of free-flap had dehiscence of donor site [Figure 2] and [Figure 3] that required secondary suturing, followed by cellulites at recipient site. One case (12.5%) of pedicle-flap required prolonged treatment because he had burns and required admission for other areas to heal. One case (6.7%) of free-flap case had pin tract infection with sequestrectomy done. Donor site wound dehiscence requiring secondary suturing was also required.
Figure 1: Complete flap necrosis

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Figure 2: Donar site scar hypertrophy

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Figure 3: Donar site wound dehiscence

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Table 2: Distribution of cases according to postoperative hospital stay

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Follow-up

Of the 23 patients in the study, 13 (56.5%) turned back for follow-up. Eight patients (61.5%) were treated for lower limb reconstruction, 4 (30.7%) for upper limb reconstruction, and 1 (7.6%) for defect on upper back. They were evaluated for weight bearing and mobilization and range of motion of adjacent joint at the recipient site and self-related cosmesis at donor and recipient sites.

Eight patients who underwent lower limb reconstruction, weight bearing was partial in 1 (12.5%) patient and complete in 6 (75%) patients. In one case (12.5%), the fracture had not united. Joint stiffness in small joints of hands was observed in 3 cases (13%) and was managed by physiotherapy effectively.

Self-related cosmesis at donor site was good in 10 (76.9%) cases, average in 1 (7.6%) case, and poor owing to hypertrophic scar at donor site in 2 (15.3%) cases. Self-related cosmesis at recipient site was good in 9 (69.2%) cases, average in 3 (23%) cases, and poor in 1 (7.6%) case. The aesthetic result was good compared to the post injury status, but the patient hoped for completely normal looking leg and foot.

Of 13 follow-ups, time taken by patients to return to job after discharge was <1 month in 6 (46.1%) cases, 1-3 months in 2 (15.3%) cases, and more >3 months in 3 (23%) cases; 2 patients (15.3%) changed their job.

Subjective donor site shoulder weakness was observed in 2 patients (15.3%). One was a mill worker and another was a daily wages worker. The range of movement of shoulder joint was normal. Both of them had to change their jobs and they were advised physiotherapy. One patient (6.7%) of free-flap complained of gait instability and ulcer over planter aspect of foot due to thick-free latissimus dorsi flap, which was placed over foot and sole. Debulking was done with flap tightening.


  Discussion Top


In present series, the total numbers of complications were 30, 18 occurring in free-flap and 12 in pedicle-flap. Marginal necrosis [Figure 4] was seen in 3 cases (37.5%) in pedicle-flaps and in 1 case (6.7%) of free-flap and they were of partial thickness. They were managed by meticulous debridement, followed by skin grafting. One patient (12.5%) of pedicle-flap having complete flap loss of pedicle-flap was treated by thoracoepigastric flap as saphenous venous graft was exposed after excising the necrotic flap. One patient (6.7%) where free-flap was done to cover posterior aspect of thigh with exposed supracondylar femur fracture had unstable fracture reduction. He developed chronic osteomyelitis of distal-end femur. Although the flap was healthy, above knee amputation was done to control the infection. In the series of Nielson et al.,[9] total numbers of complications were 30, 25 occurring in free-flap and 5 in pedicle-flap [Table 1], [Table 3], and [Table 4].
Figure 4: Gangrene of great toe and marginal flap necrosis of free flap

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Table 3: Distribution of flap loss in different series

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Table 4: Factors causing complete flap failure and their frequency in present series

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Donor site wound dehiscence was managed by skin grafting [Figure 5] in 1 case (12.5%) of pedicle-flap, frequent dressings in 1 case (6.7%) of free-flap, and secondary suturing in 3 cases (20%) of free-flap. Seroma at donor site was observed in 2 cases (25%) of pedicle-flaps and 1 case (6.7%) of free-flaps and was managed with local wound care. Pressure sore over sacrum region was observed in 1 patient (6.7%) of free-flap due to prolonged recumbent position [Table 5] and [Table 6]. It was superficial and healed with a change of posture and regular dressing.
Figure 5: Hyperpigmented split skin graft at recipient site and supplement split skin graft

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Table 5: Comparisons of complications of latissimus dorsi flap in different series -1

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Table 6: Comparisons of complications of latissimus dorsi flap in different series - 2

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One patient (6.7%) of free-flap had persistent sinus at junction of flap and normal skin in the region of heel [Figure 6] and [Figure 7]. X-ray showed underlying sequestrum. He was managed by sequestrectomy. Another patient (4.3%) developed persistent sinus at the site of placement of pin for external fixator. She was managed by local debridement and dressings. One patient (6.7%) of free-flap developed cellulites of recipient leg. Ultrasonography showed collection of fluid in fascial plane and subcutaneous tissue. X-ray revealed underlying necrotic bone. Incision and drainage of pus with excision of necrotic bone was done.
Figure 6: Sinus at heel

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Figure 7: Unstable fracture reduction with chronic osteomyelitis

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In the series of 24 cases by Russell et al., 80% reported no significant problem or changes in daily living activities, while 17% noted difficulty in putting on panty hose, getting into or out the bathtub, or sleeping on the donor site. [10] Muscle strength testing revealed mild/moderate loss of motion and strength after a mean follow-up of 16 months. Relative weakness tends to diminish as the follow-up period was prolonged. They determined that operated shoulder was 34% weaker than the nonoperated shoulder in 73% patients. However, majority of patients experienced some social change regarding their occupation, household activities, or activities of daily life. Laitung and Peck, in their study found no statistically significant difference in power in patients and control groups, when dominant and nondominant sides were considered separately; 60% patients reported subjective difficulty in performing activities of daily life and no patient had any occupational difficulty related to muscle transfer. [11] The loss in clinical terms appeared to be minimal to the investigators.

Nielson et al., reported no permanent functional loss at the donor site in their series. Direct closure of donor site seemed cosmetically preferred, despite the fact that the scar appeared rather bad. When the donor area was split skin grafted, main drawback was cosmetic. [9] Bostwick et al., observed that the donor defect was acceptable to all patients when closed primarily. [12] May et al., in their series observed that most patients noted numbness over the skin of their resected latissimus muscle, but in no patient was this significant problem. [13] There was no noticeable functional difference among 30 patients with full latissimus dorsi muscle transfer and the 5 patients with hemilatissimus transfer. The aesthetic asymmetry noted from removal of latissimus dorsi was less apparent in women than in men, but was much less apparent in both groups than transfer of the muscle with skin as seen when this unit moved as a combined transfer.

Brumback et al., in their series, reported that none of the patients noted any change in the activities of daily life with regard to shoulder function. Only 1 patient described soreness of the donor shoulder, following work performed with arms over the head. Passive ranges of motion were not reduced in these patients. [14] Spear and Hess reviewed the functional and biomechanical changes in the shoulder. They stated that it was not the loss of power, but a more rapid onset of fatigue during prolonged activities like swimming, ladder climbing, and overhead painting. [15]

To conclude, when used as a free-flap or pedicle-flap, latissimus dorsi can cover extensive and distant defects without obvious donor site loss of function. [16],[17] Vulnerability of the vascular pedicle to kink and bulkiness of the flap, precluding its use in small defects were few of the limitations seen in this study.


  Acknowledgment Top


We are thankful to the medical superintendents of C.S.S.H. Hospital attached to Subharti Medical College, Meerut for granting us the permission to publish this material. We declare that this is our work, except where acknowledged specifically as the published or unpublished work of others. We are also grateful to patients and their relative for their cooperation during this study.

 
  References Top

1.Barton FE Jr, Spicer TE, Byrd HS. Head and neck reconstruction with latissimus dorsi flap-Anatomic observations and report of 60 cases. Plast Reconstr Surg 1983;71:199-204.  Back to cited text no. 1
    
2.Har-El G, Bhaya M, Sundaram K. Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction. Am J Otolaryngol 1999;20:287-93.  Back to cited text no. 2
    
3.Bailey BN, Godfrey AM. Latissimus dorsi muscle free flaps. Br J Plastic Surg 1982;35:47-52.  Back to cited text no. 3
    
4.Gordon L, Buncke HJ, Alpert BS. Free latissimus dorsi muscle flap with split thickness skin graft cover-A report of 16 cases. Plast Reconstr Surg 1982;70:173-8.  Back to cited text no. 4
    
5.Tizian C, Borst HG, Berger A. Treatment of total sternal necrosis using latissimus dorsi muscle flap. Plast Reconstr Surg 1985;76:703-7.  Back to cited text no. 5
    
6.Dejesus RA, Paletta JD, Dabb RW. Reconstruction of the median sternotomy wound dehiscence using latissimus dorsi myocutaneous flap. J Cardiovasc Surg (Torino) 2001;42:359-64.  Back to cited text no. 6
    
7.Wax MK, Hurst J. Pulmonary atelectasis after reconstruction with latissimus dorsi myocutaneous flap. Laryngoscope 1996;106 (3 Pt 1):268-72.  Back to cited text no. 7
    
8.Fraulin FO, Louie G, Zorilla L, Tilley W. Functional evaluation of the shoulder following latissimus dorsi muscle transfer. Ann Plast Surg 1995;35:349-55.  Back to cited text no. 8
    
9.Nielsen IM, Lassen M, Gregersen BN, Krag C. Experiences with latissimus dorsi Flap. Scand J Plast Reconstr Surg 1985;19:53-63.  Back to cited text no. 9
    
10.Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E, Smith CJ. Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 1986;78:336-44.  Back to cited text no. 10
    
11.Laitung JK, Peck F. Shoulder function following the loss of latissimus dorsi muscle. Br J Plast Surg 1985;38:375-9.  Back to cited text no. 11
    
12.Bostwick J 3 rd , Nahai F, Wallace JG, Vasconez LO. Sixty Latissimus dorsi flaps. Plast Reconstr Surg 1979;63:31.  Back to cited text no. 12
    
13.May JW Jr., Gallico GG 3 rd , Jupiter J, Savage RC. Free latissimus dorsi muscle flap with skin graft for treatment of traumatic chronic bony wounds. Plast Reconstr Surg 1984;73:641-9.  Back to cited text no. 13
    
14.Brumback RJ, McBride MS, Ortolani NC. Functional evaluation of shoulder after transfer of the vascularised latissimus dorsi muscle. J Bone Joint Surg Am 1992;74:377-82.  Back to cited text no. 14
    
15.Spear SL, Hess CL. A review of the biochemical and functional changes in the shoulder following transfer of the latissimus dorsi muscle. Plast Reconstr Surg 2005;115:2070-3.  Back to cited text no. 15
    
16.Girod A, Boissonnet H, Jouffroy T, Rodriguez J. Latissimus dorsi free flap reconstruction of anterior skull base defects. J Craniomaxillofac Surg 2012;40:177-9.  Back to cited text no. 16
    
17.Oh SJ, Lee J, Cha J, Jeon MK, Koh SH, Chung CH. Free-flap reconstruction of the scalp: Donor selection and outcome. J Craniofac Surg 2011;22:974-7.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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