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A simple approach to harvest of the pedicled descending branch muscle-sparing latissimus dorsi flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, e179ee181
CORRESPONDENCE AND COMMUNICATION A simple approach to harvest of the pedicled descending branch musclesparing latissimus dorsi flap Dear Sir, The pedicled muscle-sparing latissimus dorsi flap (MS-LD) can be a useful adjunct to the surgeon’s reconstructive armamentarium for partial breast deformity, breast reconstruction, trunk and upper limb defects. This article describes a step-by-step approached for an easy, rapid dissection of the MS-LD. The skin paddle is designed over the axis of the descending branch of the thoracodorsal artery (TDA), oriented transversely or with a slightly oblique orientation along one of the natural adipose tissue rolls of the lower back (Figure 1).1,2 Skin paddle perfusion can be optimized by centering it over an LD muscle cuff harvested along the descending branch, but considering the zone of higher perforator density.3,4 The lateral edge of the skin paddle should be 1e2 cm anterior to the muscle border to capture perforators and optimize perfusion,5 however its position can be adjusted after mapping the course of the descending branch of the TDA. Primary closure can assessed by draping the superior skin flap is draped over the proposed lower skin paddle incision. (See Video, Online Supplementary Material 1). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article:
If additional adipose tissue is needed, it can be harvested with the skin paddle as an extended version of the MS-LD.6 Alternatively, the MS-LD can be harvested with simultaneous fat grafting for breast reconstruction for augmented of tissue volume.7 The patient is positioned in the lateral decubitus position. The superior skin flap is elevated first, focusing primarily over the course of the descending branch of the TDA
and progressing towards the axilla. After visualizing the anterior border of the LD muscle, the undermining over the muscle and the axilla is limited to minimize dead space and seroma formation. Once raised, the superior skin flap can be advanced towards the inferior wound edge to confirm donor site closing tension. The inferior skin flap is then elevated with limited undermining medially to minimize dead space formation. Dissection is continued inferiorly only over the corresponding anterior LD muscle which will be included in the flap. The anterior edge of the muscle is released and dissected on the undersurface towards the midline for 4 cm (See Video, Online Supplementary Material 2). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article: The descending branch of the TDA courses along the undersurface of the muscle which can be visualized after anterior edge is released. The course of the descending branch is marked on the superficial surface using a handheld Doppler ultrasound superior to the skin paddle (Figure 2). The line is continued inferiorly, parallel to the anterior border of the muscle, and approximately 3e4 cm from the muscle edge and represents the pedicle width of the muscle to be harvested. Starting towards the posterior midline, the skin paddle is raised off the muscle in a subfascial plane and the dissection progresses laterally to the medial edge of the planned pedicle width of muscle to be harvested (Figure 3). This is approximately 4 cm from the anterior muscle border. The dissection of the inferior portion of MS-LD is carried out from caudal to cephalad along a line 1e2 cm medial to the outlined course of the descending branch, using a vertical muscle splitting technique following the natural orientation of the muscle fibers. The dissection is stopped around 5 cm from the posterior axillary fold or level of the lateral mammary fold in women, which should still be distal from the point of bifurcation of the thoracodorsal artery.5 It is important to preserve the transverse nerve branch to provide innervation to the remaining muscle. (See Video, Online Supplementary Material 3). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009.
http://dx.doi.org/10.1016/j.bjps.2015.07.009 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e180
Figure 1 Preoperative flap marking of MS-LD. The skin paddle is designed over the axis of the descending branch of the TDA, oriented transversely or with a slightly oblique orientation.
The following is (depending on the number) the supplementary video related to this article: A subcutaneous tunnel is planned and created at this stage such that no undue tension will be placed on the pedicle when transferred to the recipient site. A large arc of rotation is made possible by two flap pivot points, which are located at the flap muscle juncture and at the proximal bifurcation point (Figure 4). (See Video, Online Supplementary Material 4). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article: The donor site is routinely closed with progressive tension sutures and 1 drain. Several interrupted sutures are centrally placed, followed by continuous progressive tension sutures parallel to the wound edge in each side with
Figure 2 Identification and marking of the descending branch of the TDA. The course of the descending branch is marked on the superficial surface using a handheld Doppler ultrasound superior to the skin paddle.
Correspondence and communication
Figure 3 Skin paddle dissection. The skin paddle is raised off the muscle in a subfascial plane and the dissection progresses laterally to the medial edge of the planned pedicle width of muscle to be harvested.
bidirectional barbed sutures. (See Video, Online Supplementary Material 5). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article: The pedicled descending branch MS-LD with a transversely oriented skin paddle presents distinct advantages. Compared to a full LD muscle harvest, there no disruption of the axillary silhouette,1,8 reduced risk of seroma,1,5,8e11 no detectable difference in strength or range of motion between operated and non-operated sides,1,8 and minimized contour defects of the back.1,12 It’s advantages over its thoracodorsal perforator-based counterpart includes a more simple dissection, versatility in flap design irrespective of perforator location, and better protection of the neurovascular pedicle protection from the muscle cuff retained.1,13 (See Video, Online Supplementary Material 6). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009.
Figure 4 The axis of rotation at the flap-muscle junction. The skin paddle can be rotated up to 90 clockwise or anticlockwise, which increases its area of reach.
Correspondence and communication The following is (depending on the number) the supplementary video related to this article:
Financial disclosures Lin Zhu Financially supported by Chinese Scholar Council. Anita T. Mohan No commercial or financial disclosures to declare. Michel Saint-Cyr Consultant for Allergan, Lifecell, Pacira and Mentor.
Products No commercial products described.
Author contribution Lin Zhu Contributed to the writing, supplementary material and final preparation of manuscript. Anita T. Mohan Contributed to the writing, and review of the manuscript. Michel Saint-Cyr Senior author, contributions to the writing and manuscript review, and primary surgeon for video content.
Level of evidence V.
References 1. Saint-Cyr M, Nagarkar P, Schaverien M, Dauwe P, Wong C, Rohrich RJ. The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr Surg 2009;123:13e24. 2. Bailey S, Saint-Cyr M, Zhang K, et al. Breast reconstruction with the latissimus dorsi flap: women’s preference for scar location. Plast Reconstr Surg 2010;126:358e65. 3. Colohan S, Wong C, Lakhiani C, et al. The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications. Plast Reconstr Surg 2012;130: 776ee7e. 4. Schaverien M, Wong C, Bailey S, Saint-Cyr M. Thoracodorsal artery perforator flap and Latissimus Dorsi Mycocutaneous flapanatomical study of the constant skin paddle perforator locations. J Plast Reconstr Aesth Surg 2010;63:2123e7.
e181 5. Wong C, Saint-Cyr M. The pedicled descending branch musclesparing latissimus dorsi flap for trunk and upper extremity reconstruction. J Plast Reconstr Aesthet Surg 2010;63:623e32. 6. Brackley PT, Mishra A, Sigaroudina M, Iqbal A. Modified muscle sparing latissimus dorsi with implant for total breast reconstruction e extending the boundaries. J Plast Reconstr Aesthet Surg 2010;63:1495e502. 7. Veber M, Guerin AN, Faure C, Delay E, Mojallal A. Breast reconstruction using muscle sparing latissimus dorsi and fat grafting. Ann Chir Plast Esthet 2012;57:366e72. 8. Bonomi S, Settembrini F, Salval A, Gregorelli C, Musumarra G, Rapisarda V. Current indications for and comparative analysis of three different types of latissimus dorsi flaps. Aesthet Surg J 2012;32:294e302. 9. Randolph LC, Barone J, Angelats J, Dado DV, Vandevender DK, Shoup M. Prediction of postoperative seroma after latissimus dorsi breast reconstruction. Plast Reconstr Surg 2005;116: 1287e90. 10. Tomita K, Yano K, Masuoka T, Matsuda K, Takada A, Hosokawa K. Postoperative seroma formation in breast reconstruction with latissimus dorsi flaps: a retrospective study of 174 consecutive cases. Ann Plast Surg 2007;59:149e51. 11. Buntic RF, Horton KM, Brooks D, Lee CK. The free partial superior latissimus muscle flap: preservation of donor-site form and function. Plast Reconstr Surg 2008;121:1659e63. 12. Schwabegger AH, Harpf C, Rainer C. Muscle-sparing latissimus dorsi myocutaneous flap with maintenance of muscle innervation, function, and aesthetic appearance of the donor site. Plast Reconstr Surg 2003;111:1407e11. 13. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg 2004;57:531e9.
Lin Zhu Department of Plastic Surgery, Peking Union Medical College Hospital, China Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA Anita T. Mohan Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA Restoration of Appearance and Function Trust (RAFT), London, UK Michel Saint-Cyr Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA E-mail address: [email protected] 30 May 2015
CORRESPONDENCE AND COMMUNICATION A simple approach to harvest of the pedicled descending branch musclesparing latissimus dorsi flap Dear Sir, The pedicled muscle-sparing latissimus dorsi flap (MS-LD) can be a useful adjunct to the surgeon’s reconstructive armamentarium for partial breast deformity, breast reconstruction, trunk and upper limb defects. This article describes a step-by-step approached for an easy, rapid dissection of the MS-LD. The skin paddle is designed over the axis of the descending branch of the thoracodorsal artery (TDA), oriented transversely or with a slightly oblique orientation along one of the natural adipose tissue rolls of the lower back (Figure 1).1,2 Skin paddle perfusion can be optimized by centering it over an LD muscle cuff harvested along the descending branch, but considering the zone of higher perforator density.3,4 The lateral edge of the skin paddle should be 1e2 cm anterior to the muscle border to capture perforators and optimize perfusion,5 however its position can be adjusted after mapping the course of the descending branch of the TDA. Primary closure can assessed by draping the superior skin flap is draped over the proposed lower skin paddle incision. (See Video, Online Supplementary Material 1). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article:
If additional adipose tissue is needed, it can be harvested with the skin paddle as an extended version of the MS-LD.6 Alternatively, the MS-LD can be harvested with simultaneous fat grafting for breast reconstruction for augmented of tissue volume.7 The patient is positioned in the lateral decubitus position. The superior skin flap is elevated first, focusing primarily over the course of the descending branch of the TDA
and progressing towards the axilla. After visualizing the anterior border of the LD muscle, the undermining over the muscle and the axilla is limited to minimize dead space and seroma formation. Once raised, the superior skin flap can be advanced towards the inferior wound edge to confirm donor site closing tension. The inferior skin flap is then elevated with limited undermining medially to minimize dead space formation. Dissection is continued inferiorly only over the corresponding anterior LD muscle which will be included in the flap. The anterior edge of the muscle is released and dissected on the undersurface towards the midline for 4 cm (See Video, Online Supplementary Material 2). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article: The descending branch of the TDA courses along the undersurface of the muscle which can be visualized after anterior edge is released. The course of the descending branch is marked on the superficial surface using a handheld Doppler ultrasound superior to the skin paddle (Figure 2). The line is continued inferiorly, parallel to the anterior border of the muscle, and approximately 3e4 cm from the muscle edge and represents the pedicle width of the muscle to be harvested. Starting towards the posterior midline, the skin paddle is raised off the muscle in a subfascial plane and the dissection progresses laterally to the medial edge of the planned pedicle width of muscle to be harvested (Figure 3). This is approximately 4 cm from the anterior muscle border. The dissection of the inferior portion of MS-LD is carried out from caudal to cephalad along a line 1e2 cm medial to the outlined course of the descending branch, using a vertical muscle splitting technique following the natural orientation of the muscle fibers. The dissection is stopped around 5 cm from the posterior axillary fold or level of the lateral mammary fold in women, which should still be distal from the point of bifurcation of the thoracodorsal artery.5 It is important to preserve the transverse nerve branch to provide innervation to the remaining muscle. (See Video, Online Supplementary Material 3). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009.
http://dx.doi.org/10.1016/j.bjps.2015.07.009 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e180
Figure 1 Preoperative flap marking of MS-LD. The skin paddle is designed over the axis of the descending branch of the TDA, oriented transversely or with a slightly oblique orientation.
The following is (depending on the number) the supplementary video related to this article: A subcutaneous tunnel is planned and created at this stage such that no undue tension will be placed on the pedicle when transferred to the recipient site. A large arc of rotation is made possible by two flap pivot points, which are located at the flap muscle juncture and at the proximal bifurcation point (Figure 4). (See Video, Online Supplementary Material 4). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article: The donor site is routinely closed with progressive tension sutures and 1 drain. Several interrupted sutures are centrally placed, followed by continuous progressive tension sutures parallel to the wound edge in each side with
Figure 2 Identification and marking of the descending branch of the TDA. The course of the descending branch is marked on the superficial surface using a handheld Doppler ultrasound superior to the skin paddle.
Correspondence and communication
Figure 3 Skin paddle dissection. The skin paddle is raised off the muscle in a subfascial plane and the dissection progresses laterally to the medial edge of the planned pedicle width of muscle to be harvested.
bidirectional barbed sutures. (See Video, Online Supplementary Material 5). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009. The following is (depending on the number) the supplementary video related to this article: The pedicled descending branch MS-LD with a transversely oriented skin paddle presents distinct advantages. Compared to a full LD muscle harvest, there no disruption of the axillary silhouette,1,8 reduced risk of seroma,1,5,8e11 no detectable difference in strength or range of motion between operated and non-operated sides,1,8 and minimized contour defects of the back.1,12 It’s advantages over its thoracodorsal perforator-based counterpart includes a more simple dissection, versatility in flap design irrespective of perforator location, and better protection of the neurovascular pedicle protection from the muscle cuff retained.1,13 (See Video, Online Supplementary Material 6). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.07.009.
Figure 4 The axis of rotation at the flap-muscle junction. The skin paddle can be rotated up to 90 clockwise or anticlockwise, which increases its area of reach.
Correspondence and communication The following is (depending on the number) the supplementary video related to this article:
Financial disclosures Lin Zhu Financially supported by Chinese Scholar Council. Anita T. Mohan No commercial or financial disclosures to declare. Michel Saint-Cyr Consultant for Allergan, Lifecell, Pacira and Mentor.
Products No commercial products described.
Author contribution Lin Zhu Contributed to the writing, supplementary material and final preparation of manuscript. Anita T. Mohan Contributed to the writing, and review of the manuscript. Michel Saint-Cyr Senior author, contributions to the writing and manuscript review, and primary surgeon for video content.
Level of evidence V.
References 1. Saint-Cyr M, Nagarkar P, Schaverien M, Dauwe P, Wong C, Rohrich RJ. The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr Surg 2009;123:13e24. 2. Bailey S, Saint-Cyr M, Zhang K, et al. Breast reconstruction with the latissimus dorsi flap: women’s preference for scar location. Plast Reconstr Surg 2010;126:358e65. 3. Colohan S, Wong C, Lakhiani C, et al. The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications. Plast Reconstr Surg 2012;130: 776ee7e. 4. Schaverien M, Wong C, Bailey S, Saint-Cyr M. Thoracodorsal artery perforator flap and Latissimus Dorsi Mycocutaneous flapanatomical study of the constant skin paddle perforator locations. J Plast Reconstr Aesth Surg 2010;63:2123e7.
e181 5. Wong C, Saint-Cyr M. The pedicled descending branch musclesparing latissimus dorsi flap for trunk and upper extremity reconstruction. J Plast Reconstr Aesthet Surg 2010;63:623e32. 6. Brackley PT, Mishra A, Sigaroudina M, Iqbal A. Modified muscle sparing latissimus dorsi with implant for total breast reconstruction e extending the boundaries. J Plast Reconstr Aesthet Surg 2010;63:1495e502. 7. Veber M, Guerin AN, Faure C, Delay E, Mojallal A. Breast reconstruction using muscle sparing latissimus dorsi and fat grafting. Ann Chir Plast Esthet 2012;57:366e72. 8. Bonomi S, Settembrini F, Salval A, Gregorelli C, Musumarra G, Rapisarda V. Current indications for and comparative analysis of three different types of latissimus dorsi flaps. Aesthet Surg J 2012;32:294e302. 9. Randolph LC, Barone J, Angelats J, Dado DV, Vandevender DK, Shoup M. Prediction of postoperative seroma after latissimus dorsi breast reconstruction. Plast Reconstr Surg 2005;116: 1287e90. 10. Tomita K, Yano K, Masuoka T, Matsuda K, Takada A, Hosokawa K. Postoperative seroma formation in breast reconstruction with latissimus dorsi flaps: a retrospective study of 174 consecutive cases. Ann Plast Surg 2007;59:149e51. 11. Buntic RF, Horton KM, Brooks D, Lee CK. The free partial superior latissimus muscle flap: preservation of donor-site form and function. Plast Reconstr Surg 2008;121:1659e63. 12. Schwabegger AH, Harpf C, Rainer C. Muscle-sparing latissimus dorsi myocutaneous flap with maintenance of muscle innervation, function, and aesthetic appearance of the donor site. Plast Reconstr Surg 2003;111:1407e11. 13. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg 2004;57:531e9.
Lin Zhu Department of Plastic Surgery, Peking Union Medical College Hospital, China Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA Anita T. Mohan Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA Restoration of Appearance and Function Trust (RAFT), London, UK Michel Saint-Cyr Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA E-mail address: [email protected] 30 May 2015