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Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction
Latissimus Secondary
Dorsi Myocutaneous Flap for Head atid Neck Reconst&ction
Gady Har-El, MD, Mahesh Bhaya, MD, and Krishnamurthi
Sundaram,
MD
Purpose: To review our experience and results with the use of pedicled latissimus dorsi myocutaneous flap (LDMF) for secondary reconstrucUon in head and neck surgery. Methods: Twenty-two patients had LDMF, 17 of them for secondary reconstruction. Data were collected regarding the primary surgery, primary method of reconstruction, indication for secondary reconstruction, and outcome. Results: Seventeen LDMF procedures were performed for secondary reconstruction. Flap success rate was 100%. Reconstructive goals were achieved immediately in 16 (94.1%) patients. Conclusion: LDMF is a thin flap with a large surface area and a long pedicle that allows it to reach any region in the head, neck, and scalp. Its main disadvantages are the need for lateral positioning of the patient and the fact that its pedicle is not protected with muscle. In our experience, LDMF provides an excellent reconstructive option especially in complicated cases of secondary reconstruction. It may be used in cases where a free flap is usually used, but with significantly reduced surgical time. (Am J Otolaryngol 1999;20:287-293. Copyright 0 1999 by W.B. Saunders Company)
Primary flap failure, primary flap contraction and dehiscence, orocutaneous or pharyngocutaneous fistula, osteoradionecrosis, chondroradionecrosis, re-exploration for bleeding or recurrent tumor, and other secondary reconstructive indications may dictate the need for a secondary flap procedure. Although free flaps are often times used for this purpose, many head and neck surgeons still prefer the more simple and less time-consuming pedicled flap procedures. Because the pectoralis major flap is the most common pedicled flap used for primary reconstruction in head and neck surgery, secondary reconstruction is usually performed with the trapezius, deltopectoral, or contralateral pectoralis muscle flaps. Although the pedicled latissimus dorsi myocutaneous flap (LDMF) is frequently used by many specialists, especially outside the United States, it has not gained much popularity From the Department of Otolaryngology, SUNY-Health Science Center at Brooklyn, Brooklyn, NY. Presented at the meeting of the Eastern Section of the American Latyngological, Rhinological, and Otological Society, New York, NY, February 1, 1998. Address reorint reauests to Gadv Har-El. MD. Deoartment of Otol~ryngolo~y, SUNY-Health Science benier at Brooklyn, Box 126, 450 Clarkson Ave, Brooklyn, NY 11203. Copyright o 1999 by W.B. Saunders Company 0196-0709/99/2005-0004$10.00/0
among head America.
and
neck
surgeons
in North
METHODS Patients Between 1989 and 1997, 22 pedicled LDMF procedures were performed by the senior author. In 17 cases, the flap was used for delayed secondary reconstruction. There were 11 men and 6 women between 32 and 78 years of age. All patients had previous cancer resection, which included reconstruction with a pectoralis major flap (8), deltopectoral flap (21, forehead flap (2), trapezius flap (2), temporalis myofascial flap (2), and nape of the neck flap (1). Fourteen patients had radiation therapy before the LDMF procedure (5 patients before and 9 patients after the original cancer surgery). The LDMF was used to reconstruct the neck in 8 patients, the mouth, pharynx, and esophagus in 4 patients, and the midface, scalp, and periauricular region in 5 patients.
Technique Detailed description of flap harvest and transfer is beyond the scope of this article. The reader is referred to the excellent descriptions available in the literature.le4 However, we believe that careful attention to the following maneuvers and/or modifications will significantly increase the likelihood of flap survival and successful reconstruction:
American Journal of Otolaryngology, Vol20, No 5 (September-October),
1999: pp 267-293
287
288
HAR-EL,
BHAYA,
AND
SUNDARAM
Fig 1. A 58-year-old man with (A) necrosis of the chin. (B) The design of a do paddle LDMF.
1. Immediately after the skin and muscle paddle are elevated off the chest wall, and before dissecting the pedicle, fine absorbable sutures are used to anchor the dermal layer to the muscle fascia around the skin paddle. This will stabilize the skin paddle and prevent shearing forces on the cutaneous perforators.
2. We tag the medial and lateral aspects of the skin/muscle paddle with two different sutures. This helps with the orientation of the skin/ muscle paddle during transfer and inset. 3. We begin flap elevation at its anterolateral muscle edge (axillary line). We first identify the thoracodorsal vessel on the deep aspect of the
LDMF
FOR
SECONDARY
HEAD/NECK
Fig 1 (Cont’d). (C) Flap elevation. Vessels to serratus anterior muscle identified. (D) Flap transferred to the neck. Note incision over the clavicle. (E) Intraoral and extraoral flap inset.
RECONSTRUCTION
289
HAR-EL,
4.
5.
6.
7.
8.
9. 10. 11. 12. 13.
14. 15. 16.
muscle. Only then do we continue elevation medially and inferiorly. We then proceed with making the distal and medial skin and muscle incisions. We identify, double ligate, and transect the branches to the serratus anterior muscle. This will prevent tethering of the LDMF vascular pedicle. If the recipient site is in the neck, the circumflex scapular branch may be preserved. The flap will have enough arc of rotation to reach the neck. Preservation of this branch will help with the orientation of the flap and prevent kinking of the pedicle during transfer. However, when the site to be reconstructed is more superior (eg, parotid, temporal, or skull-base region), the circumflex scapular branch may be divided in order to achieve additional length.’ As the elevation proceeds superiorly the vascular hilum is identified. At this point, the vascular pedicle is not protected by the muscle itself. While protecting the pedicle, the muscular and tendinous insertion to the humerus is transected. Once the muscle is transected, the flap and its pedicle should be handled with extreme care. This is an important difference between LDMF and the pectoralis flap. The pectoralis major vascular pedicle is protected with the muscle throughout the flap length. As we dissect the pedicle into the axilla, we try to preserve the thin fascial and connective tissue layers around the vessels. Skeletonizing the vessels is avoided in order to prevent spasm. The skin and muscle are wrapped with warm laparotomy pads. We infiltrate the soft tissues around the pedicle with 2% lidocaine. Extreme stretching and/or extension of the arm are avoided during axillary dissection. A wide tunnel is dissected between the axilla and the recipient site. We like the tunnel to be at least 5 to 7 cm wide. If the original neck dissection incision is not reopened during the secondary reconstructive procedure, we make an additional 5- to T-cm transverse incision at the clavicular region.lJ First, we transfer the skin/muscle paddle through the axilla and out the clavicular incision. Then the flap is transferred from the clavicular region through the cervical tunnel into the recipient site. This maneuver will make the transfer process more gentle to the flap and its pedicle. We pay continuous attention to the orientation of the skin/muscle paddle. We never rotate the flap more than 180'. Most flaps are easily transferable between the clavicle and the skin. However, in some patients clavicular protrusion may result in a very tight tunnel, which may jeopardize the viabil-
17. 18. 19.
20.
BHAYA,
AND
SUNDARAM
ity of the flap.5 In these cases we carefully dissect a subclavicular tunnel. After surgery, the arm is kept flexed across the chest for 5 days. We avoid ipsilateral flexion of the neck, which may kink the vascular pedicle. Postoperatively, we check flap viability and capillary refill as we do for free-tissue transfer. The pedicle may also be examined with a doppler. If swelling and edema develop along the subcutaneous tunnel and the flap becomes congested, the clavicular skin incision may be opened. Only the skin layer is opened and the wound is covered with a xeroform gauze. This wound is left to heal by secondary intention. The donor site in all 17 patients was closed primarily without the need for skin graft.
RESULTS LDMF success rate was 100% with no ischemit flap loss. Minimal ischemic loss of skin edges (less than 5% surface area) occurred in six cases (35.3%). Reconstructive goals were achieved immediately in 16 patients (94.1%). One patient, a 60-year-old man who required secondary reconstruction for mandibular osteoradionecrosis 2 years after his original composite resection, had dehiscence of the distal LDMF edges, resulting in an orocutaneous fistula. The LDMF itself had no skin or muscle loss. The fistula was eventually closed with local rotation flaps. Donor site morbidity was minimal. One patient had donor-site seroma, which was treated successfully with repeated aspirations. One patient had dehiscence of the wound edges. It was treated successfully with local wound care. CASE HISTORIES The following four case histories provide examples of the secondary use of LDMF for management of uncommon complications in head and neck oncological surgery. Patient 1 is a 58-year-old man who underwent resection of a tumor of the floor of the mouth, as well as bilateral supraomohymoid neck dissection via a visor flap. Both facial arteries were ligated. Successful primary reconstruction was achieved with pectoralis major flap. Later he developed necrosis of the skin at the chin area, which resulted in a delayed orocutaneous fistula. Secondary reconstruction was achieved with a double-paddle LDMF (Fig 1).
LDMF
FOR
SECONDARY
HEAD/NECK
RECONSTRUCTION
Patient 2 is a S&year-old man who underwent composite resection and reconstruction with pectoralis major flap. This was followed with radiation therapy. Six months later he underwent resection of neck recurrence, which was followed by wound dehiscence and carotid blowout. After ligation of the carotid artery he underwent a successful LDMF procedure (Fig 2). Patient 3 is a 69-year-old man who underwent a combined infratemporal, middle/ anterior fossa resection of an aggressive basal cell carcinoma. Primary reconstruction was
Fig 2. A 54-year-old with /A) flap elevation. Flap i&s&. .
man (B) .
291
achieved with temporalis myofascial and pericranial/gales flaps. Primary reconstruction was successful. However, 8 months later he developed osteoradionecrosis of the orbit and anterior skull base, which required debridement. Secondary reconstruction was achieved with LDMF (Fig 3). Patient 4 is a 52-year-old man who underwent composite resection with marginal mandibulectomy. Primary reconstruction was achieved with a pectoralis major flap. Two years later he presented with a mandibular fracture. Exploration showed osteoradionecro-
292
HAR-EL,
BHAYA,
sis. Secondary reconstruction with LDMF (Fig 4).
AND
SUNDARAM
was achieved
DISCUSSION
Fig 3. A 6Qyear-old man 20 months after infratemporal anterior/middle fossa resection; and 12 months after the secondary LDMF reconstruction for osteoradionecrosis of the skull base.
Fig 4. A 52-year-old primary reconstruction
We recently surveyed all otolaryngologists who graduated from an American residency program on June 30,1997. We collected information about training and experience in 20 different pedicled and free flaps. A detailed description of the survey and its results will be given in a separate publication. However, the survey showed clearly that the LDMF is not a popular flap and is not commonly used and taught in otolaryngology residency training programs in the United States. This is most likely because of its disadvantages, which are listed in Table 1. 4,6 Many surgeons express concern regarding the need to reposition the patient during surgery.2r6 However, it should be noted that, in most cases, there is no need for repositioning after harvesting the flap. After intubation via the tracheotomy tube, exploration of the primary surgical site is performed in a supine position. The patient is then rotated into the lateral position. After the
man with (A) fractured marginal mandibulectomy with pectoralis flap (P) and 6 months after secondary
segment (arrow). reconstruction
(B) Thirty with LDMF
months (L).
after
LDMF
FOR
RECONSTRUCTION
293
Vulnerable pedicle Need for repositioning Need for extensive thoracic and axillary dissection Possible shoulder dysfunction if the spinal-accessory nerve has been previously sacrificed Need for working knowledge of axillaty vessels and their variations
to reach virtually any region in the head, neck, and scalp, and its large surface area make this flap especially useful for secondary head and neck reconstruction.1-7 For areas beyond the range of pectoralis major flap, LDMF is also used as a primary reconstructive procedure when a free flap is not available or not possible.‘m7 Donor site morbidity after LDMF procedure is minimal.1~4~5
TABLE 1.
SECONDARY
Disadvantages
HEAD/NECK
of LDMF
flap is harvested, there is no need to reposition the patient because flap inset is easily performed while the patient remains in the lateral position. This was performed in 12 of our 17 patients. In 5 cases, the patient was placed in a lateral position at the beginning of the case, and primary site exploration, flap harvesting, and flap inset were all performed with the patient in the same position. Another important disadvantage of LDMF is the vulnerability of the vascular pedicle and the risk for its kinking.5 We have found that the maneuvers described previously in the Methods section resulted in 100% flap success rate. Table 2 lists the advantages of pedicled LDMF. The LDMF’s long vascular pedicle, which allows it TABLE 2.
Advantages
of LDMF
Easy to elevate Minimal donor site morbidity Thin flap Large skin paddle (double-paddle, “megaflap”) Very long pedicle Vascular supply not affected by neck dissection No need for microvascular team Procedure shorter than a free flap
ACKNOWLEDGMENT The authors are grateful Clarke for her assistance.
to Sandra Daley-
REFERENCES 1. Urken ML, Sullivan MJ: Latissimus dorsi, in Urken ML, Cheney ML, Sullivan MJ, et al (eds): Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York, NY, Raven Press, 1995, pp 237-259 2. &huller DE: Latissimus dorsi myocutaneous flap for massive facial defects. Arch Otolaryngol 108:414-417, 1982 3. Olivari N: Use of thirty latissimus dorsi flaps. Plast Reconstr Surg 64:654-661,1979 4. Maves MD, Panje WR, Shagets FW: Extended latissimus dorsi myocutaneous flap reconstruction of major head and neck defects. Otolaryngol Head Neck Surg 92:551-558,1984 5. Haughey BH, Fredrickson JM: The latissimus dorsi donor site. Current use in head and neck construction. Arch Otolarlyngol Head Neck Surg 117:1129-1134,199l 6. Quillen CG, Shearin JC, Georgiade NG: Use of the latissimus dorsi myocutaneous flap reconstruction of major head and neck defects. Plast Reconstr Surg 62:113117,1978 7. Barton FE, Spicer TE, Byrd HS: Head and neck reconstruction with the latissimus dorsi myocutaneous flap: Anatomic observations and report of 60 cases. Plast Reconstr Surg 71:199-204,1983
Dorsi Myocutaneous Flap for Head atid Neck Reconst&ction
Gady Har-El, MD, Mahesh Bhaya, MD, and Krishnamurthi
Sundaram,
MD
Purpose: To review our experience and results with the use of pedicled latissimus dorsi myocutaneous flap (LDMF) for secondary reconstrucUon in head and neck surgery. Methods: Twenty-two patients had LDMF, 17 of them for secondary reconstruction. Data were collected regarding the primary surgery, primary method of reconstruction, indication for secondary reconstruction, and outcome. Results: Seventeen LDMF procedures were performed for secondary reconstruction. Flap success rate was 100%. Reconstructive goals were achieved immediately in 16 (94.1%) patients. Conclusion: LDMF is a thin flap with a large surface area and a long pedicle that allows it to reach any region in the head, neck, and scalp. Its main disadvantages are the need for lateral positioning of the patient and the fact that its pedicle is not protected with muscle. In our experience, LDMF provides an excellent reconstructive option especially in complicated cases of secondary reconstruction. It may be used in cases where a free flap is usually used, but with significantly reduced surgical time. (Am J Otolaryngol 1999;20:287-293. Copyright 0 1999 by W.B. Saunders Company)
Primary flap failure, primary flap contraction and dehiscence, orocutaneous or pharyngocutaneous fistula, osteoradionecrosis, chondroradionecrosis, re-exploration for bleeding or recurrent tumor, and other secondary reconstructive indications may dictate the need for a secondary flap procedure. Although free flaps are often times used for this purpose, many head and neck surgeons still prefer the more simple and less time-consuming pedicled flap procedures. Because the pectoralis major flap is the most common pedicled flap used for primary reconstruction in head and neck surgery, secondary reconstruction is usually performed with the trapezius, deltopectoral, or contralateral pectoralis muscle flaps. Although the pedicled latissimus dorsi myocutaneous flap (LDMF) is frequently used by many specialists, especially outside the United States, it has not gained much popularity From the Department of Otolaryngology, SUNY-Health Science Center at Brooklyn, Brooklyn, NY. Presented at the meeting of the Eastern Section of the American Latyngological, Rhinological, and Otological Society, New York, NY, February 1, 1998. Address reorint reauests to Gadv Har-El. MD. Deoartment of Otol~ryngolo~y, SUNY-Health Science benier at Brooklyn, Box 126, 450 Clarkson Ave, Brooklyn, NY 11203. Copyright o 1999 by W.B. Saunders Company 0196-0709/99/2005-0004$10.00/0
among head America.
and
neck
surgeons
in North
METHODS Patients Between 1989 and 1997, 22 pedicled LDMF procedures were performed by the senior author. In 17 cases, the flap was used for delayed secondary reconstruction. There were 11 men and 6 women between 32 and 78 years of age. All patients had previous cancer resection, which included reconstruction with a pectoralis major flap (8), deltopectoral flap (21, forehead flap (2), trapezius flap (2), temporalis myofascial flap (2), and nape of the neck flap (1). Fourteen patients had radiation therapy before the LDMF procedure (5 patients before and 9 patients after the original cancer surgery). The LDMF was used to reconstruct the neck in 8 patients, the mouth, pharynx, and esophagus in 4 patients, and the midface, scalp, and periauricular region in 5 patients.
Technique Detailed description of flap harvest and transfer is beyond the scope of this article. The reader is referred to the excellent descriptions available in the literature.le4 However, we believe that careful attention to the following maneuvers and/or modifications will significantly increase the likelihood of flap survival and successful reconstruction:
American Journal of Otolaryngology, Vol20, No 5 (September-October),
1999: pp 267-293
287
288
HAR-EL,
BHAYA,
AND
SUNDARAM
Fig 1. A 58-year-old man with (A) necrosis of the chin. (B) The design of a do paddle LDMF.
1. Immediately after the skin and muscle paddle are elevated off the chest wall, and before dissecting the pedicle, fine absorbable sutures are used to anchor the dermal layer to the muscle fascia around the skin paddle. This will stabilize the skin paddle and prevent shearing forces on the cutaneous perforators.
2. We tag the medial and lateral aspects of the skin/muscle paddle with two different sutures. This helps with the orientation of the skin/ muscle paddle during transfer and inset. 3. We begin flap elevation at its anterolateral muscle edge (axillary line). We first identify the thoracodorsal vessel on the deep aspect of the
LDMF
FOR
SECONDARY
HEAD/NECK
Fig 1 (Cont’d). (C) Flap elevation. Vessels to serratus anterior muscle identified. (D) Flap transferred to the neck. Note incision over the clavicle. (E) Intraoral and extraoral flap inset.
RECONSTRUCTION
289
HAR-EL,
4.
5.
6.
7.
8.
9. 10. 11. 12. 13.
14. 15. 16.
muscle. Only then do we continue elevation medially and inferiorly. We then proceed with making the distal and medial skin and muscle incisions. We identify, double ligate, and transect the branches to the serratus anterior muscle. This will prevent tethering of the LDMF vascular pedicle. If the recipient site is in the neck, the circumflex scapular branch may be preserved. The flap will have enough arc of rotation to reach the neck. Preservation of this branch will help with the orientation of the flap and prevent kinking of the pedicle during transfer. However, when the site to be reconstructed is more superior (eg, parotid, temporal, or skull-base region), the circumflex scapular branch may be divided in order to achieve additional length.’ As the elevation proceeds superiorly the vascular hilum is identified. At this point, the vascular pedicle is not protected by the muscle itself. While protecting the pedicle, the muscular and tendinous insertion to the humerus is transected. Once the muscle is transected, the flap and its pedicle should be handled with extreme care. This is an important difference between LDMF and the pectoralis flap. The pectoralis major vascular pedicle is protected with the muscle throughout the flap length. As we dissect the pedicle into the axilla, we try to preserve the thin fascial and connective tissue layers around the vessels. Skeletonizing the vessels is avoided in order to prevent spasm. The skin and muscle are wrapped with warm laparotomy pads. We infiltrate the soft tissues around the pedicle with 2% lidocaine. Extreme stretching and/or extension of the arm are avoided during axillary dissection. A wide tunnel is dissected between the axilla and the recipient site. We like the tunnel to be at least 5 to 7 cm wide. If the original neck dissection incision is not reopened during the secondary reconstructive procedure, we make an additional 5- to T-cm transverse incision at the clavicular region.lJ First, we transfer the skin/muscle paddle through the axilla and out the clavicular incision. Then the flap is transferred from the clavicular region through the cervical tunnel into the recipient site. This maneuver will make the transfer process more gentle to the flap and its pedicle. We pay continuous attention to the orientation of the skin/muscle paddle. We never rotate the flap more than 180'. Most flaps are easily transferable between the clavicle and the skin. However, in some patients clavicular protrusion may result in a very tight tunnel, which may jeopardize the viabil-
17. 18. 19.
20.
BHAYA,
AND
SUNDARAM
ity of the flap.5 In these cases we carefully dissect a subclavicular tunnel. After surgery, the arm is kept flexed across the chest for 5 days. We avoid ipsilateral flexion of the neck, which may kink the vascular pedicle. Postoperatively, we check flap viability and capillary refill as we do for free-tissue transfer. The pedicle may also be examined with a doppler. If swelling and edema develop along the subcutaneous tunnel and the flap becomes congested, the clavicular skin incision may be opened. Only the skin layer is opened and the wound is covered with a xeroform gauze. This wound is left to heal by secondary intention. The donor site in all 17 patients was closed primarily without the need for skin graft.
RESULTS LDMF success rate was 100% with no ischemit flap loss. Minimal ischemic loss of skin edges (less than 5% surface area) occurred in six cases (35.3%). Reconstructive goals were achieved immediately in 16 patients (94.1%). One patient, a 60-year-old man who required secondary reconstruction for mandibular osteoradionecrosis 2 years after his original composite resection, had dehiscence of the distal LDMF edges, resulting in an orocutaneous fistula. The LDMF itself had no skin or muscle loss. The fistula was eventually closed with local rotation flaps. Donor site morbidity was minimal. One patient had donor-site seroma, which was treated successfully with repeated aspirations. One patient had dehiscence of the wound edges. It was treated successfully with local wound care. CASE HISTORIES The following four case histories provide examples of the secondary use of LDMF for management of uncommon complications in head and neck oncological surgery. Patient 1 is a 58-year-old man who underwent resection of a tumor of the floor of the mouth, as well as bilateral supraomohymoid neck dissection via a visor flap. Both facial arteries were ligated. Successful primary reconstruction was achieved with pectoralis major flap. Later he developed necrosis of the skin at the chin area, which resulted in a delayed orocutaneous fistula. Secondary reconstruction was achieved with a double-paddle LDMF (Fig 1).
LDMF
FOR
SECONDARY
HEAD/NECK
RECONSTRUCTION
Patient 2 is a S&year-old man who underwent composite resection and reconstruction with pectoralis major flap. This was followed with radiation therapy. Six months later he underwent resection of neck recurrence, which was followed by wound dehiscence and carotid blowout. After ligation of the carotid artery he underwent a successful LDMF procedure (Fig 2). Patient 3 is a 69-year-old man who underwent a combined infratemporal, middle/ anterior fossa resection of an aggressive basal cell carcinoma. Primary reconstruction was
Fig 2. A 54-year-old with /A) flap elevation. Flap i&s&. .
man (B) .
291
achieved with temporalis myofascial and pericranial/gales flaps. Primary reconstruction was successful. However, 8 months later he developed osteoradionecrosis of the orbit and anterior skull base, which required debridement. Secondary reconstruction was achieved with LDMF (Fig 3). Patient 4 is a 52-year-old man who underwent composite resection with marginal mandibulectomy. Primary reconstruction was achieved with a pectoralis major flap. Two years later he presented with a mandibular fracture. Exploration showed osteoradionecro-
292
HAR-EL,
BHAYA,
sis. Secondary reconstruction with LDMF (Fig 4).
AND
SUNDARAM
was achieved
DISCUSSION
Fig 3. A 6Qyear-old man 20 months after infratemporal anterior/middle fossa resection; and 12 months after the secondary LDMF reconstruction for osteoradionecrosis of the skull base.
Fig 4. A 52-year-old primary reconstruction
We recently surveyed all otolaryngologists who graduated from an American residency program on June 30,1997. We collected information about training and experience in 20 different pedicled and free flaps. A detailed description of the survey and its results will be given in a separate publication. However, the survey showed clearly that the LDMF is not a popular flap and is not commonly used and taught in otolaryngology residency training programs in the United States. This is most likely because of its disadvantages, which are listed in Table 1. 4,6 Many surgeons express concern regarding the need to reposition the patient during surgery.2r6 However, it should be noted that, in most cases, there is no need for repositioning after harvesting the flap. After intubation via the tracheotomy tube, exploration of the primary surgical site is performed in a supine position. The patient is then rotated into the lateral position. After the
man with (A) fractured marginal mandibulectomy with pectoralis flap (P) and 6 months after secondary
segment (arrow). reconstruction
(B) Thirty with LDMF
months (L).
after
LDMF
FOR
RECONSTRUCTION
293
Vulnerable pedicle Need for repositioning Need for extensive thoracic and axillary dissection Possible shoulder dysfunction if the spinal-accessory nerve has been previously sacrificed Need for working knowledge of axillaty vessels and their variations
to reach virtually any region in the head, neck, and scalp, and its large surface area make this flap especially useful for secondary head and neck reconstruction.1-7 For areas beyond the range of pectoralis major flap, LDMF is also used as a primary reconstructive procedure when a free flap is not available or not possible.‘m7 Donor site morbidity after LDMF procedure is minimal.1~4~5
TABLE 1.
SECONDARY
Disadvantages
HEAD/NECK
of LDMF
flap is harvested, there is no need to reposition the patient because flap inset is easily performed while the patient remains in the lateral position. This was performed in 12 of our 17 patients. In 5 cases, the patient was placed in a lateral position at the beginning of the case, and primary site exploration, flap harvesting, and flap inset were all performed with the patient in the same position. Another important disadvantage of LDMF is the vulnerability of the vascular pedicle and the risk for its kinking.5 We have found that the maneuvers described previously in the Methods section resulted in 100% flap success rate. Table 2 lists the advantages of pedicled LDMF. The LDMF’s long vascular pedicle, which allows it TABLE 2.
Advantages
of LDMF
Easy to elevate Minimal donor site morbidity Thin flap Large skin paddle (double-paddle, “megaflap”) Very long pedicle Vascular supply not affected by neck dissection No need for microvascular team Procedure shorter than a free flap
ACKNOWLEDGMENT The authors are grateful Clarke for her assistance.
to Sandra Daley-
REFERENCES 1. Urken ML, Sullivan MJ: Latissimus dorsi, in Urken ML, Cheney ML, Sullivan MJ, et al (eds): Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York, NY, Raven Press, 1995, pp 237-259 2. &huller DE: Latissimus dorsi myocutaneous flap for massive facial defects. Arch Otolaryngol 108:414-417, 1982 3. Olivari N: Use of thirty latissimus dorsi flaps. Plast Reconstr Surg 64:654-661,1979 4. Maves MD, Panje WR, Shagets FW: Extended latissimus dorsi myocutaneous flap reconstruction of major head and neck defects. Otolaryngol Head Neck Surg 92:551-558,1984 5. Haughey BH, Fredrickson JM: The latissimus dorsi donor site. Current use in head and neck construction. Arch Otolarlyngol Head Neck Surg 117:1129-1134,199l 6. Quillen CG, Shearin JC, Georgiade NG: Use of the latissimus dorsi myocutaneous flap reconstruction of major head and neck defects. Plast Reconstr Surg 62:113117,1978 7. Barton FE, Spicer TE, Byrd HS: Head and neck reconstruction with the latissimus dorsi myocutaneous flap: Anatomic observations and report of 60 cases. Plast Reconstr Surg 71:199-204,1983