Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

Abstract

We present an expanded latissimus dorsi musculocutaneus (LDMC) flap to treat circumferential upper extremity defects via resurfacing and “spiral reconstruction” in 5 patients during a 17-year period. Five patients with different indications for tissue expansion from burns to congenital hairy nevi were operated. The expansion was done in a longitudinal direction, and a rectangular tissue expander (TE) was inserted under the LD muscle to expand the flap in a longitudinal direction thereby forming a “long” flap rather than a “wide” one. After excising the circumferential lesion, the expanded “elongated” flap was wrapped spirally around the extremity to cover the defect; the donor site was closed as usual. The 5 patients we treated via LDMC flaps in a spiral fashion were free of complications, and all were satisfied with the outcome. All the flaps survived and the spiral reconstruction allowed for a tension-free donor site closure and near complete recipient coverage. This technique is indicated for large circumferential extremity skin defects and deformities. Application of expanded LDMC flaps in a spiral fashion can be used by the reconstructive surgeon to resurface large circumferential upper extremity lesions when indicated. The idea of a long and thinned expansion flap must be in a longitudinal direction and we need this long expanded and thin flap to “spiral” it around the extremity to cover a large defect. The “spiral” flap coverage introduced here for large circumferential extremity defects enables the surgeon to cover the defect with simultaneous donor site closure and good results.

Soft Tissue Reconstruction of Complete Circumferential Defects of the Upper Extremity

“…After removing duplicate entries and applying our inclusion and exclusion criteria, 14 unique articles were included in the final analysis (Table 1) [678910111213141516171819]. …”

“…Because the underlying, deeper structures such as the tendons and muscles are usually spared, functional outcomes are typically “good” or “normal” although follow-up, when available, remains limited in the literature (6 to 36 months) [679]. Functional preservation becomes increasingly challenging when Tajima 3 defects result following R0 resection for neoplastic processes, but can still be sufficiently addressed [10].…”

“…For congenital nevi with circumferential involvement of the upper extremity, tissue expansion of local and/or regional options (from the abdomen, flank, back) is typically performed prior to excision and reconstruction of the resultant Tajima 1 defects. Because the underlying, deeper structures such as the tendons and muscles are usually spared, functional outcomes are typically "good" or "normal" although follow-up, when available, remains limited in the literature (6 to 36 months) [6][7][8][9]. Functional preservation becomes increasingly challenging when Tajima 3 defects result following R0 resection for neoplastic processes, but can still be sufficiently addressed [10].…”

“…A total of 586 articles were identified based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After removing duplicate entries and applying our inclusion and exclusion criteria, 14 unique articles were included in the final analysis ( Table 1 ) 6 7 8 9 10 11 12 13 14 15 16 17 18 19 .…”

The Role of Free Tissue Transfer in Posterior Neck Reconstruction

“…15 Serial expansions at some point may fail to progress as expected, however, and a different strategy will be required to gain an adequately wide coverage. There are previous reposts on pre-expansion of free scapular, 16 latissimus dorsi, 17 anterolateral thigh 18 and DIEP flaps. 19 Shang et al reported the use of pre-expanded DIEP flaps, albeit pedicled, for the resurfacing of 15 patients with burn scar contracture of the upper extremities.…”