Latissimus Dorsi/Rib Intercostal Perforator Myo-Osseocutaneous Free Flap Reconstruction in Composite Defects of the Scalp: Case Series and Review of Literature

Abstract

Adequate coverage of complex, composite scalp defects in previously radiated, infected, or otherwise compromised tissue represents a challenge in reconstructive surgery. To provide wound closure with bony protection to the brain, improve cranial contour, and prevent or seal cerebrospinal fluid (CSF) leaks, composite free tissue transfer is a reliable and safe option. We report our experience with the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap in the reconstruction of bony and soft tissue defects of the cranium and overlying scalp. The surgical technique, design, and outcomes of the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in five patients with cranial defects between 2003 and 2007 were retrospectively evaluated. Patient characteristics, defect size, underlying cause, reconstructive details, and complications were analyzed. All patients (age 43 to 81) had composite defects ranging from 36 to 750 cm2 (mean size 230 cm2) for the bony component and from 16 to 400 cm2 (mean size 170 cm2) for the soft tissue defect. All patients had a history of prior or current infection of the affected area, and two patients had a CSF leak. Defects were due to malignancy and infection (n = 2), infiltrative cutaneous mucormycosis with osteomyelitis (n = 1), and hemorrhagic stroke requiring craniectomy (n = 2), complicated by infection and failed cranioplasty in one patient and continuous CSF leak in the other. The latissimus dorsi composite free flap consisting of skin, muscle, and vascularized rib can successfully cover large complex cranial defects, provide skeletal support, improve contour, and significantly enhance functional outcome with limited donor site morbidity.

Autologous Immediate Cranioplasty with Vascularized Bone in High-Risk Composite Cranial Defects

“…7 An incision was first made at the anterior border of the latissimus dorsi muscle to identify the thoracodorsal vessels. Thoracodorsal perforators supplying the skin were identified and preserved for the skin paddle.…”

The versatility of the thoracodorsal artery based composite flaps with vascularized rib and a systematic review of the literature

“…A 100% union rate was achieved in all cases but the average time for bone union was not specified in any studies. Seitz et al reported three partial flap necrosis and one donor site complication (pneumothorax) has been observed by Lee et al…”

“…Five publications were identified that treated a total of 22 patients with a thoracodorsal based composite flap with vascularized rib for infected cranioplasty, osteomyelitis, and brain tumor. A 100% union rate was achieved in all cases but the average time for bone union was not specified in any studies.…”

“…Free flaps have been widely used in combination with either alloplastic materials or nonvascularized autologous bone grafts for skull defects in previously irradiated, traumatized, scarred or infected areas . Due to the higher success and lower complications rate, autologous bone graft has been regarded as the gold standard for cranioplasty .…”

“…Thoracodorsal system–based flaps can adequately restore the shape of the scalp by applying the curve characteristic of the rib and by filling even extensive defect with large muscles. After the first description of this flap in a dog model, several authors have reported successful results in scalp reconstruction with rib‐muscle composite flaps and so far, 22 cases have been reported with a union rate of 100% . Although these promising results, clinical application of this approach has not been done extensively, given the reported risk of complications related to thoracotomy while harvesting ribs …”