Download (PSL) Muscle Flap: Preservation of Donor Site Form and Function

The Free Partial Superior Latissimus (PSL) Muscle Flap: Preservation of Donor Site Form and
Function
Karen M. Horton, MD, MSc; Rudolf F. Buntic, MD; Darrell Brooks, MD; Charles K. Lee, MD
PURPOSE: The latissimus dorsi muscle is a widely applied, reliable and versatile flap for pedicled and
microvascular reconstruction. Harvest of the entire muscle results in sacrifice of form, the lateral
thoracic silhouette, creates a large donor space, and may create functional loss. Use of the superior
portion of the muscle only decreases donor site morbidity and provides a flap of variable size. We
describe the partial superior latissimus (PSL) muscle flap, its harvest technique, and application as a
microvascular transplant for a variety of complex defects is described in thirteen patients.
METHODS: A transverse incision is made parallel to the upper border of the latissimus muscle 5-10 cm
below the inferior scapular angle. The superior portion of the muscle is isolated on the transverse branch
of the thoracodorsal artery. The pedicle to the PSL flap is followed as far proximal as needed for
sufficient pedicle length. For functional muscle transfer, the transverse branch of the thoracodorsal nerve
is dissected intraneurally, leaving the branch to the lateral latissimus intact. Following harvest, the PSL
flap tends to widen and shorten by approximately one-third, as described for other partial muscle flaps.
Patients are treated with postoperative intravenous Dextran infusion and aspirin for assistance with
anticoagulation.
RESULTS: Thirteen patients underwent PSL flap procedures. Eleven flaps were used for extremity
salvage and complex wounds; two neurotized flaps were transplanted for facial reanimation and one
sensory innervated flap was used to achieve a sensate heel. Flap dimensions ranged from 10 x 5 cm to
24 x 12 cm. Pedicle length ranged from 10 to 16 cm, depending on flap design and recipient site needs.
Combined flap and pedicle length totaled up to 31 cm. Operative time with a two-team approach was
less than 6 hours. All flaps survived. No seromas or donor site infections occurred. One postoperative
hematoma was encountered in a patient on perioperative heparin infusion. A symmetrical lateral thoracic
silhouette was maintained and the remaining latissimus muscle functioned postoperatively in all
patients.
DISCUSSION: Harvest of the superior portion of the latissimus muscle on the transverse branch of the
thoracodorsal vessels preserves the entire lateral and inferior elements of the muscle via the descending
branch, together with its nerve supply. This preserves the lateral thoracic angle form and decreases
potential functional muscle loss. Similar to the partial medial rectus flap, a reliable muscle flap of
variable size can be designed while preserving donor site form and function. “Muscle-sparing”
latissimus flaps have been described; however, lateral muscle dissection or complete muscle harvest
were used. Innervation of the PSL flap and neurrorhaphy to a recipient motor nerve enables functional
muscle transplantation.
CONCLUSIONS: The PSL flap has the following advantages: (1) small, medium or large flap size, (2)
large caliber vessels, (3) a potentially long vascular pedicle, (4) preservation of the majority of the
latissimus muscle in situ, (5) maintenance of the dorsal thoracic silhouette of the back, (6) the potential
for neurotization and sensory/functional muscle reconstruction and (7) use as a myocutaneous flap by
including the overlying skin territory. Thirteen cases have been successfully completed for a variety of
anatomic defects and reconstructive purposes.
Figure 1. Partial Superior Latissimus (PSL) Flap. The PSL flap is isolated on the transverse arterial
branch (TB) of the latissimus muscle. Additional pedicle length is gained by harvest of the
thoracodorsal artery (TDA) and vein, with or without the subscapular system. The lateral descending
branch (DB) has been ligated. Vascularity of the remaining muscle is preserved through intercostal and
thoracolumbar fascia perforators.
REFERENCES:
1. Bostwick J III, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg
63:31-41, 1979.
2. Buncke HJ. Microsurgery: Transplantation-Replantation. Volume 2006. San Francisco, 1991.
3. Spear SL, Hess CL. A review of the biomechanical and functional changes in the shoulder following
transfer of the latissimus dorsi muscles. Plast Reconstr Surg 115:2070-2073, 2005.
4. Kim DH, Glazer PA. Progression of idiopathic thoracolumbar scoliosis after breast reconstruction
with a latissimus dorsi flap: a case report. Spine 25:622-625, 2000.
5. Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap:
anatomic basis and clinical application. Ann Plast Surg 51:23-29, 2003.
6. Mackinnon SE, Dellon AL. Technical considerations of the latissimus dorsi muscle flap: a
segmentally innervated muscle transfer for facial reanimation. Microsurgery 9:36-45, 1988.
7. Buntic RF, Brooks D. Free partial medial rectus muscle flap for closure of complex extremity
wounds. Plast Reconstr Surg 116(5):1434-1437, 2005.
8. Chang KN, Buncke HJ. Sensory reinnervation in reconstruction of the foot. Foot Ankle 7:124-132,
1986.
9. 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 111:1407-1411, 2003.
10. Wei W, Zuoliang Q, Xiaoxi L, et al. Free split and segmental latissimus dorsi muscle transfer in one
stage for facial reanimation. Plast Reconstr Surg 103:473-480, 1999.
11. Manktelow RT, Zuker RM. The principles of functioning muscle transplantation: applications to the
upper arm. Ann Plast Surg 22:275-282, 1989.
12. Chang KN, DeArmond SJ, Buncke HJ, Jr. Sensory reinnervation in microsurgical reconstruction of
the heel. Plast Reconstr Surg 78:652-664, 1986.
13. Menke H, Erkens M, Olbrisch RR. Evolving concepts in breast reconstruction with latissimus dorsi
flaps: results and follow-up of 121 consecutive patients. Ann Plast Surg 47:107-114, 2001.
14. Kroll SS, Schusterman MA, Reece GP, Miller MJ, Robb G, Evans G. Abdominal wall strength,
bulging, and hernia after TRAM flap breast reconstruction. Plast Reconstr Surg 96:616-619, 1995.
15. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps
and free TRAM flaps for breast reconstruction. Br J Plast Surg 50:322-330, 1997.