Latissimus Flap with Dr. Geoffroy Sisk

Flap Cast

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  • The latissimus flap is one of the largest muscles in the body and one of our workhorse flaps in plastic surgery
  • Based off of the subscapular system and can be raised as a muscle/myocutaneous flap, multi component including skin, muscle, bone off of the scapula system
  • Can be used as a pedicled flap in breast and chest wall reconstruction, or as a free flap all over the body (lower extremity, scalp, etc)
  • Posterior Trunk Anatomy as it relates to the latissimus…
        • Latissimus originates from the 7-12th thoracic vertebrae, lumbar, and sacral spinous processes as well as the middle/outer rim of the iliac crest
        • Inserts on the medial lip of the intertubercular groove of the humerus
        • Superior border of the muscle is covered by the trapezius, but is superficial to all other muscles of the back
    • Vascular Anatomy:
      • Type 5 muscle flap – dominant pedicle and secondary minor pedicles that the flap CAN survive on
        • Dominant – Thoracodorsal 
          • Subscapular artery arises from third portion of axillary artery, gives off the circumflex scapular, angular branch, serratus branch and then continues as the thoracodorsal
          • TD divides into a lateral branch – parallels anterior border of muscle and medial branch which parallels upper border of muscle
        • Secondary – Intercostal perforators
          • Can be used as a “turnover flap” to cover posterior trunk wounds 
        • Venous drainage is through the thoracodorsal VEIN
        • Innervation – TD nerve which also has a medial/lateral branch which parallel the artery
    • Technical Pearls:
      • Pedicle typically enters the flap 10-12cm below posterior axillary fold
      • Flap can be harvested in the lateral position with the arm abducted, OR in the supine position
      • Many modifications to the latissimus including a “split latissimus” “turnover latissimus” “Extended latissimus” and a TDAP flap (will discuss later)
    • Postoperative Care
      • Donor site morbidity is often discussed, the typical answer is that despite the size of the muscle there is MINIMAL donor site morbidity in terms of functional deficits
      • Some studies do cite up to 7% decrease in shoulder function (variable) but have seen videos of someone doing pullups after a latissimus
    • Most common Complications:
      • Seroma formation
        • Compression therapy
        • Progressive tension sutures
        • Fibrin glue, Triamcinolone
        • DRAINS

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