Modified Incision for Muscle-sparing Latissimus Dorsi to Increase Flap Perfusion in the Morbidly Obese

Abstract

Summary: The muscle-sparing latissimus dorsi flap relies on perforators from the descending branch of the thoracodorsal artery. Previous descriptions placed a transverse skin island independent of perforator location, as any design was thought to capture enough perforators to ensure flap survival. We have found this approach prone to complications when attempting breast reconstruction in obese patients who require large flap volumes. Although the most proximal perforators have the most reliable blood flow, inclusion of these perforators reduces the arc of rotation, as the flap would be close to the pivot point at the most cranial point of muscle division, leaving significant volume in the axilla. Here we describe a modified skin incision that includes all of the proximal perforators but also allows us free design of the skin island to harvest those areas of the back with maximal subcutaneous tissue and with enough distance from the pivot point to optimize arc of rotation.

Salvage of infected implant-based breast reconstructions in morbidly obese patients with explantation and replacement with an autologous muscle-sparing latissimus dorsi flap

“…Those patients who failed antibiotic therapy were offered implant removal and immediate replacement with an MSLD flap. 5 Intraoperatively, wound edges were debrided and the implant was removed. Necrotic tissue was excised as was any non-integrated acellular dermal matrix.…”

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Bilateral Autologous Breast Reconstruction

“…Although dissecting larger TDAP flaps that include multiple perforators is possible and, in fact, previously shown to be necessary to prevent complications, 2 this is a technically complex surgery requiring extensive operative time and dissection with multiple myotomies. We have published a modification of the MSLD flap 3 that incorporates all the dominant perforators along the anterior edge of the latissimus dorsi (LD) by adding a vertical incision in this location, leaving patients an inconspicuous scar in the posterior axillary line. Importantly, this also gives us the freedom to place our transverse skin island, where we please to maximize both arc of rotation and flap volume based on the patient’s individual anatomy.…”