IDEAS AND INNOVATIONS

Anterior Chest Wall Reconstruction with a Low

Skin Paddle Pedicled Latissimus Dorsi Flap:
A Novel Flap Design
Munique Maia, M.D.
Georgette Oni, M.R.C.S.
Corrine Wong, M.R.C.S.
Michel Saint-Cyr, M.D.
Dallas, Texas

D
istal anterior chest wall defects remain a resonance imaging scan revealed sternal osteomyelitis and cos-
challenge for the reconstructive surgeon. tochondritis. A sternal biopsy confirmed infection consistent
with Aspergillus fumigatus. The patient was placed on voricon-
To reconstruct this region, the most com- azole. She underwent aggressive surgical débridement, with
monly used flaps are the pectoralis and rectus partial sternectomy and resection of the right fourth, fifth, and
abdominis flaps.1,2 When these flaps cannot be sixth costal cartilages. Large portions of the bilateral pectoralis
used, the pedicled latissimus dorsi flap and the muscles were also resected centrally. A temporary bovine peri-
omentum flap are suitable options.3,4 The use of cardium was placed in the wound to protect the exposed lung,
and vacuum-assisted closure therapy was initiated (Fig. 1). After
the pedicled latissimus dorsi flap for chest wall a 48-hour period of observation in the intensive care unit, the
reconstruction was first described by Tansini5 in patient underwent anterior chest wall coverage with a low skin
1906 and was subsequently popularized by Olivari paddle pedicled latissimus dorsi flap.
in 1976.6 Since then, the latissimus dorsi flap has Flap Selection
gradually evolved, with many modifications and The common reconstructive options available for chest wall
refinements described in the literature.7–10 reconstruction include the pectoralis major flap (advancement
In the traditional pedicled latissimus dorsi and turnover flaps) and the rectus abdominis flap.11 The omen-
flap, the skin paddle is typically placed in the mid tum flap and the latissimus dorsi flap are also common options.
to upper back region. With this location, the arc In this case, flap selection was influenced by the patient’s history
of previous operations, immunosuppression, and other medical
of rotation and reach of the skin paddle can make comorbidities. This patient had previous abdominal surgery
it difficult to cover anterior chest wall defects. with a transverse incision in the upper abdomen, and she also
Thus, when the latissimus dorsi flap is used for had bilateral inframammary incisions for lung transplant sur-
coverage of the anterior chest wall, skin grafting gery. In addition, following débridement and partial sternec-
over the muscle is often required, resulting in less tomy, the internal mammary artery was ligated on the right side,
in addition to partial resection of the patient’s pectoralis mus-
than optimal cosmetic results. To provide a latis- cles. These factors precluded the use of pectoralis major flaps
simus dorsi flap with a wider arc of rotation and or pedicled transverse rectus abdominis myocutaneous or ver-
increased skin paddle reach to and past the chest tical rectus abdominis myocutaneous flaps. The omental flap
anterior midline, we designed the low skin paddle was excluded because of concerns of breaching the abdominal
pedicled latissimus dorsi flap. The preoperative cavity and the associated potential morbidity. In this case, the
latissimus dorsi flap presented as one of the few options for the
design and vascular basis of the flap are discussed patient. Skin coverage of the central anterior chest wall defect
and a case report is presented. was possible with the design of a low skin paddle pedicled
latissimus dorsi flap.
CASE REPORT Flap Design and Operative Technique
A 27-year-old woman with a history of cystic fibrosis under-
The patient was marked preoperatively. The anterior border
went bilateral lung transplantation in 2004. She subsequently
of the latissimus dorsi muscle was outlined as shown. The skin
presented with a 6-month history of progressive increasing ster-
paddle was placed low and oblique on the back (Fig. 2), with
nal pain. On physical examination, an area of induration as-
the anterior border designed adjacent to the anterior border of
sociated with a rash was noted in the distal sternum. A magnetic
the latissimus dorsi muscle. The dominant blood supply to the

From the Department of Plastic Surgery, University of Texas

Southwestern Medical Center.
Received for publication April 12, 2010; accepted August Disclosure: The authors have no financial inter-
31, 2010. ests in this research project or in any of the tech-
Copyright ©2011 by the American Society of Plastic Surgeons niques or equipment used in this study.
DOI: 10.1097/PRS.0b013e318205f2f7

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Volume 127, Number 3 • Anterior Chest Wall Reconstruction

latissimus dorsi muscle is from the descending branch of the the anterior chest wall through a tunnel through the axilla and
thoracodorsal artery; thus, placing the skin paddle axis parallel sutured into place. At the end of the procedure, the entire skin
to the axis of the thoracodorsal artery descending branch allows paddle, including its entire extended portion, which covered
maximal perfusion to the skin paddle. the lower third of the sternal defect, was well perfused (Fig. 4).
Intraoperatively, the patient was placed in the lateral decu- The donor site was closed primarily with quilting sutures and
bitus position and the latissimus dorsi muscle was harvested suction draining.
routinely. The distal extended 6 cm of the skin paddle was The postoperative course was uneventful, with no signs of
harvested with no underlying latissimus dorsi muscle or fascia infection, dehiscence, or flap necrosis. The patient was dis-
(Fig. 3). Once the flap was fully mobilized, it was rotated onto charged 9 days postoperatively, and functional and cosmetic
results were satisfactory (Fig. 5). No further surgery was re-
quired and the patient remained infection-free at latest fol-
low-up more than 4 years after her initial operation.

DISCUSSION
Chest wall infections carry a high incidence of
complications because of the proximity of vital or-
gans, and the potential life-threatening course war-
rants prompt and aggressive treatment. Surgical
débridement and subsequent coverage with
well-vascularized tissue has been shown to control
infection and reduce the incidence of comp-
lications.11 Flap selection is an important step in
planning the reconstructive procedure, and with
the increasing complexity of chest wall defects, the
selection of the optimal flap can be limited. Many
Fig. 1. Preoperative view of a full-thickness chest wall defect af- variables have to be considered for both recipient
ter débridement of sternal osteomyelitis. Note bovine pericar- and donor sites. For the recipient site, careful
dium at the base of the wound. Skeletal stability was ascertained evaluation of the defect is required, including size,
preoperatively. depth of tissue loss and location, and skeletal sta-

Fig. 2. (Left) Preoperative markings of the skin island, anatomical landmarks, and sche-
matic drawing of branches of the thoracodorsal artery. (Right) Computed tomographic
angiography scan of a cadaveric right hemiback illustrating the latissimus dorsi muscle
perfusion and branches of the thoracodorsal artery. The location of the low skin paddle
based on the descending branch of the thoracodorsal artery is also shown.

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Fig. 4. Immediate postoperative result shows complete cover-

age of the sternal defect with a well-perfused low skin paddle
pedicled latissimus muscle flap.

Fig. 3. (Above) Intraoperative photograph of the low skin paddle

pedicled latissimus muscle flap. Note the extension of the skin
paddle beyond the boundaries of the latissimus dorsi muscle.
(Below) Inferior view of the latissimus dorsi flap showing the distal
tip of the skin paddle with no muscle underneath. In this portion,
the skin island is perfused only by linking vessels.

bility. For donor site, proximity of the defect, pro-

vision of enough soft-tissue coverage, and minimal
morbidity should be considered. One must also
consider patient characteristics such as previous
operations, comorbidities, and overall health, all
of which are important factors.

Flap Selection Fig. 5. (Above) Anterior view of the reconstructed defect 15 days
postoperatively. (Below) Appearance of the donor site 15 days
Various reconstructive options are available for
postoperatively.
chest wall reconstruction.12–15 The pectoralis major
flap is often used for midline sternal wounds. It can
be used in a number of ways; based on the thora-
coacromial vessels, it can be islanded, which can be over flap, which is useful for lower sternal defects,
sufficient to cover defects of the entire mediastinal or used as a pedicled perforator flap for smaller
space. It can also be raised on perforators based on mediastinal defects. The omental flap can also be
the internal mammary vessels, such as the turn- used to cover large sternal wounds when local

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muscle flaps are unavailable.16,17 However, the

omental flap requires a laparotomy, and there is
always an inherent risk of peritoneal infection,
epigastric hernia, and bowel obstruction second-
ary to late adhesion formation. Laparoscopic har-
vest of the omentum18 has been described for
chest wall reconstruction, but this required cov-
erage with either pectoralis major flaps, skin graft,
or a local skin flap, options that were not available
in our patient. The superiorly based rectus abdo-
minis flap, supplied by the superior epigastric ar-
tery, is also very useful for reconstructing lower
sternal and diaphragmatic defects. In our case,
flap selection was influenced by the patient’s his-
tory of multiple previous operations that pre-
cluded the use of traditional first-line option flaps
such as the pectoralis major or rectus abdominis
(vertical or transverse rectus abdominis musculo-
cutaneous) flaps. The pedicled latissimus dorsi
muscle flap, although able to fill sternal defects,
often requires skin grafting. The traditional
placement of the skin paddle in the mid to lower
back makes it very difficult to reach lower third
anterior chest wall defects. Extending the skin
paddle design more distally, beyond the inser-
tion onto the lumbar fascia, significantly in-
creases the arc of rotation. This in turn allows
the skin paddle to reach past the midline with-
out tension and provides easier coverage for the
lower third of sternal wounds.

Vascular Territories and Skin Paddle Orientation

Positioning the skin island distally in the back
may raise some concerns regarding the skin pad-
dle’s vascularity. The extended latissimus dorsi
flap is often used for breast reconstruction, and
there are instances when the distal tip of the skin
paddle may become ischemic. However, this can
often be attributed to the orientation of the skin
paddle in relation to the vasculature perfusing the
flap or the inclusion of a tissue expander or im-
plant beneath the flap at the time of insetting.
From our recently published work, we have dem- Fig. 6. (Above) Delayed reconstruction following mastectomy
onstrated that the pedicled latissimus dorsi flap with a low skin paddle latissimus dorsi muscle-sparing pedi-
can be used to reconstruct defects of the upper cled flap and silicone breast implant. (Center) Final result with
lateral chest wall and upper extremity with no skin nipple-areola complex reconstruction. (Below) Note the low
paddle necrosis,19 and we are currently working on position of the scar.
a case series of patients who have undergone this
low skin paddle technique for breast reconstruc-
tion (Fig. 6). of the thoracodorsal artery. The descending
From our previous anatomical studies,20 we branch of the thoracodorsal artery bifurcates from
demonstrated that the skin paddle of the latissi- the transverse branch of the thoracodorsal artery
mus dorsi muscle is maximally perfused when de- at a mean distance of 5.1 cm inferior to the pos-
signed overlying the axis of the descending branch terior axillary fold. After bifurcating, it provides

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along its course cephalad the largest and greatest muscle. At this level, the blood supply to the skin
number of perforators compared with the trans- flap is no longer supported by the muscle or fascia.
verse branch of the thoracodorsal artery (Fig. 2). The skin paddle perfusion of the distal tip is sup-
To maximize distal skin paddle perfusion to the ported entirely by direct and indirect linking ves-
extended latissimus dorsi flap, two strategies can sels that run through the latissimus dorsi muscle
be used. First, as many perforators from the de- and through the subcutaneous tissue proximally.
scending branch of the thoracodorsal artery Incorporating more subcutaneous tissue or ex-
should be incorporated into the flap design as tending the flap design as proximally as possible
possible. This is best achieved by designing the ensures that a maximal amount of perforators are
skin paddle axis in a vertical oblique direction incorporated to perfuse the distal portion of the
over the descending branch of the thoracodor- skin paddle by means of direct and indirect linking
sal artery to incorporate as many myocutaneous vessels (Fig. 7).
perforators as possible. The skin paddle design
at this level also follows the direction of the
muscle fibers.21 A second strategy to harvest as SUMMARY
many perforators from the descending branch The vascular supply of the low skin paddle
as possible is to extend the skin paddle more pedicled latissimus dorsi flap is based primarily on
superiorly (the superior portion is later deepi- the dominant perforators from the descending
thelialized) or to harvest subcutaneous tissue branch of the thoracodorsal artery. The distally
superiorly for the same purpose. based skin paddle allows for a wider arc of rota-
As we described in the section Flap Design and tion, expanding on the traditional use of the la-
Operative Technique, the distal portion of the tissimus dorsi pedicled flap. As such, it extends the
skin paddle extended beyond the latissimus dorsi reach of an existing tool for the reconstructive

Fig. 7. Computed tomographic angiography sequence of perforator being in-

jected with contrast, demonstrating indirect linking vessels within the subdermal
plexus.

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surgeon to use in the management of anterior Emory 20-year experience. Ann Surg. 1997;225:766–776; dis-
chest wall defects. cussion 776–778.
12. Lee AB Jr, Schimert G, Shaktin S, Seigel JH. Total excision
Michel Saint-Cyr, M.D. of the sternum and thoracic pedicle transposition of the
Department of Plastic Surgery greater omentum: Useful strategems in managing severe
University of Texas Southwestern Medical Center mediastinal infection following open heart surgery. Surgery
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Dallas, Texas 75390-9132 13. McCraw JB, Penix JO, Baker JW. Repair of major defects of
[email protected] the chest wall and spine with the latissimus dorsi myocuta-
neous flap. Plast Reconstr Surg. 1978;62:197–206.
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ton H. Laparoscopically harvested omental flap for chest
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19. Wong C, Saint-Cyr M. The pedicled descending branch
8. Marshall DR, Anstee EJ, Stapleton MJ. Soft tissue reconstruc-
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10. Banic A, Ris HB, Erni D, Strifeller H. Free latissimus dorsi flap flap: Anatomical study of the constant skin paddle perforator
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