Case 14: Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction

Sophie Osenegg; Oliver Didzun; Amir K. Bigdeli

Journal of Plastic, Breast & Reconstructive Surgery·Peer-reviewed, open-access surgical case reportsPeer-reviewed · Open access

Case 14: Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction · JPBRS

Case report

Case 14: Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction

Sophie Osenegg¹, Oliver Didzun¹, Amir K. Bigdeli¹

¹Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Klinikum Kassel, Teaching Hospital of Philipps University Marburg, Kassel, Germany

Published April 2, 2025502 views11 min read

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Abstract

A 78-year-old multimorbid patient with chronic osteomyelitis and a full-thickness soft tissue defect (12 × 6 × 5 cm) of the right flank required flap reconstruction following multiple debridements. Given the absence of nearby recipient vessels and perforators, an ipsilateral myocutaneous latissimus dorsi sliding flap was selected. The thoracodorsal pedicle was extended by 30 cm using autologous venous grafts to achieve cranial reach while preserving anterograde arterial flow. This case illustrates the rarely described use of a latissimus dorsi sliding flap in complex reconstructions, emphasizing vascular adaptation techniques. Patient medical history A 78-year-old male had undergone right-sided nephrectomy in 1970 for renal cell carcinoma. Following initially uneventful wound healing, a chronic wound developed at the nephrectomy site, which the patient managed conservatively over the subsequent decades. In September 2024, he presented with spontaneous purulent discharge from the right flank, attributable to chronic osteomyelitis of the adjacent ribs. In addition, intraperitoneal infection with Staphylococcus aureus was confirmed. Serial debridements were performed by the departments of general and thoracic surgery, including partial rib resections and an atypical laparotomy. These interventions resulted in a full-thickness soft tissue defect of the right flank, measuring 12 × 6 × 5 cm, with exposed ribs and peritoneum. The patient was subsequently referred to our department for reconstructive management under ongoing open wound therapy. At the time of presentation, his medical history included stage V chronic kidney disease with initiation of hemod

Key learning points

Pearls

–The latissimus dorsi sliding flap represents a reliable technique for the reconstruction of complex flank defects.

–This approach enables coverage of anatomically challenging regions with absent or inadequate recipient vessels for microvascular anastomosis.

–Extension of the thoracodorsal vascular pedicle using autologous vein grafts is a safe and effective method to overcome the absence of suitable local recipient vessels.

–This case demonstrates that pedicle lengthening of the thoracodorsal vessels up to 30 centimeters is technically feasible and can be performed successfully.

To our knowledge, this is the first reported case of a latissimus dorsi sliding flap with pedicle extension using autologous vein grafts up to 30 centimeters.

Pitfalls

– Limited literature is available on the latissimus dorsi sliding flap technique, particularly in the context of extended pedicle lengthening [2,3].

– The procedure requires advanced microsurgical expertise, and using autologous vein grafts to extend the vascular pedicle introduces additional technical complexity.

– Prolonged operative time and the requirement for meticulous postoperative positioning to prevent pedicle compression may increase the risk of complications such as seroma formation, wound healing disturbances, or flap loss. Furthermore, delayed initiation of compression therapy to protect the vascular pedicle may contribute to donor-site seroma formation.

– Strict postoperative positioning, such as sustained left lateral decubitus, may cause considerable patient discomfort and necessitate increased nursing support during recovery.

1. Mathes, S. J., & Nahai, F. (1981). Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plastic and reconstructive surgery, 67(2), 177–187.2. Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsi flap. Ann Plast Surg. 1997 Jan;38(1):41-5.3. Mouton W, Schweizer W, Zuber JC, Tschopp H, Blumgart LH. Myokutaner Latissimus-dorsi-Verschiebelappen zur Rekonstruktion der unteren Thoraxwand bei chronischer Fistel wegen zystischer Leberechinokokkose [Myocutaneous latissimus dorsi sliding flap in reconstruction of the lower thoracic wall in chronic fistula caused by cystic echinococcosis of the liver]. Helv Chir Acta. 1991 Jul;58(1-2):187-90. German.

Patient history

A 78-year-old male had undergone right-sided nephrectomy in 1970 for renal cell carcinoma. Following initially uneventful wound healing, a chronic wound developed at the nephrectomy site, which the patient managed conservatively over the subsequent decades. In September 2024, he presented with spontaneous purulent discharge from the right flank, attributable to chronic osteomyelitis of the adjacent ribs. In addition, intraperitoneal infection with Staphylococcus aureus was confirmed. Serial debridements were performed by the departments of general and thoracic surgery, including partial rib resections and an atypical laparotomy. These interventions resulted in a full-thickness soft tissue defect of the right flank, measuring 12 × 6 × 5 cm, with exposed ribs and peritoneum. The patient was subsequently referred to our department for reconstructive management under ongoing open wound therapy. At the time of presentation, his medical history included stage V chronic kidney disease with initiation of hemodialysis in 2022. Additional comorbidities included arterial hypertension, lumbar osteochondrosis, skin lipomatosis, hyperuricemia, and hypercholesterolemia.

Examination

Upon admission to our clinic, the 78-year-old patient presented in reduced general condition with a slim nutritional status. His weight was 71 kg at a height of 178 cm (BMI: 22.4 kg/m²). A full-thickness soft tissue defect of the right flank, measuring 12 × 6 × 5 cm, was noted. The wound bed was partially granulating, with exposed ribs dorsally and visible peritoneum at the base of the defect, without clinical signs of acute infection. Lumbar osteochondrosis had resulted in a scoliotic curvature of the spine; however, the patient remained ambulatory without assistance. Laboratory results revealed elevated serum creatinine and urea levels, along with reduced hemoglobin, consistent with his known end-stage renal disease.

Pre-operative considerations

Defect reconstruction of the flank represents a complex surgical challenge due to the paucity of suitable recipient vessels and the limited availability of local soft tissue, particularly in patients with low body mass index.

The following preoperative considerations were considered:

1. Defect characteristics: A full-thickness soft tissue defect measuring 12 × 6 × 5 cm on the right flank resulted from chronic osteomyelitis of the ribs following nephrectomy. The defect involved exposed ribs and peritoneum, necessitating robust vascularized tissue coverage.

2. Reconstructive requirements: The surgical objective was to achieve stable coverage using well-perfused tissue with sufficient volume to obliterate dead space, protect exposed structures, and resist infection recurrence.

3. Evaluation of flap options: Given the defect depth and anatomical location, several reconstructive options were evaluated:

3.1. Local flaps: Local or regional rotational flaps were deemed unsuitable due to the defect’s proximity to the spinal axis, which limited tissue mobility, the patient’s minimal subcutaneous fat reserves, and the defect's complex three-dimensional configuration.

3.2. Tissue expansion: Tissue expansion was ruled out due to the presence of active infection (osteomyelitis and peritoneal contamination), the need for prompt reconstruction, and the associated risk of infection-related complications with delayed techniques.

3.3. Pedicled Transverse Rectus Abdominis Muscle (TRAM) Flap: A pedicled TRAM flap was considered but excluded due to unfavorable anatomical conditions, including a measured distance of 32 cm between the pedicle origin and the superior border of the defect, which exceeded the flap’s reliable arc of rotation.

3.4. Free Anterolateral Thigh (ALT) Flap: A free ALT flap, potentially incorporating part of the vastus lateralis muscle, was evaluated for its volume potential. However, the absence of suitable recipient vessels in the immediate vicinity of the defect would have necessitated interposition grafting for both the artery and the vein. Moreover, the defect’s location cranial to the level of the iliac recipient vessels would have required retrograde arterial flow. These limitations made the free ALT flap an unsuitable option for reconstruction in this case.

4. Selection of Ipsilateral Myocutaneous Latissimus Dorsi Sliding Flap: Preoperative planning ultimately favored a myocutaneous LD sliding flap from the ipsilateral side. This flap provided sufficient volume, a robust type V vascular supply via the thoracodorsal vessels [1], and the option for pedicle extension through interposed autologous vein grafts to reach the cranial aspects of the defect. The latissimus dorsi muscle’s anatomical proximity, broad surface area, and pliability made it particularly suitable for conforming to the irregular three-dimensional geometry of the flank. Furthermore, pedicle extension allowed for vascular reach while maintaining physiologic anterograde arterial flow.

The decision-making process involved extensive discussions with the patient, focusing on the advantages and disadvantages of each reconstructive option, anticipated outcomes, potential complications, and the impact on quality of life. Additionally, the patient was informed about the potential for intraoperative adjustments to the planned procedure should a more suitable option arise.

References

Mathes, S. J., & Nahai, F. (1981). Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plastic and reconstructive surgery, 67(2), 177–187.
Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsi flap. Ann Plast Surg. 1997 Jan;38(1):41-5.
Mouton W, Schweizer W, Zuber JC, Tschopp H, Blumgart LH. Myokutaner Latissimus-dorsi-Verschiebelappen zur Rekonstruktion der unteren Thoraxwand bei chronischer Fistel wegen zystischer Leberechinokokkose [Myocutaneous latissimus dorsi sliding flap in reconstruction of the lower thoracic wall in chronic fistula caused by cystic echinococcosis of the liver]. Helv Chir Acta. 1991 Jul;58(1-2):187-90. German.

Post-operative plan

Three days postoperatively, the patient sustained a fall, resulting in a large hematoma at the donor site. Emergency surgical exploration revealed active bleeding due to disruption of the venous coupler device. Hemostasis was achieved, and the venous anastomosis was successfully revised. The flap demonstrated adequate perfusion throughout the procedure. The patient was transferred to the intensive care unit in stable condition for close postoperative monitoring.

Postoperatively, the patient was instructed to maintain strict left lateral decubitus positioning and adhere to bed rest for five days to minimize mechanical stress on the flap and its vascular pedicle. Hourly flap monitoring was performed for the first 48 hours, combining clinical assessment of the skin island and muscle with Doppler ultrasound evaluation of the vascular pedicle.

The patient was discharged 14 days after surgery with a stable reconstruction. Weekly outpatient follow-ups were scheduled, and a compression garment was applied during the two-week follow-up visit.

Pearls

–The latissimus dorsi sliding flap represents a reliable technique for the reconstruction of complex flank defects.

–This approach enables coverage of anatomically challenging regions with absent or inadequate recipient vessels for microvascular anastomosis.

–Extension of the thoracodorsal vascular pedicle using autologous vein grafts is a safe and effective method to overcome the absence of suitable local recipient vessels.

–This case demonstrates that pedicle lengthening of the thoracodorsal vessels up to 30 centimeters is technically feasible and can be performed successfully.

To our knowledge, this is the first reported case of a latissimus dorsi sliding flap with pedicle extension using autologous vein grafts up to 30 centimeters.

Pitfalls

– Limited literature is available on the latissimus dorsi sliding flap technique, particularly in the context of extended pedicle lengthening [2,3].

– The procedure requires advanced microsurgical expertise, and using autologous vein grafts to extend the vascular pedicle introduces additional technical complexity.

– Strict postoperative positioning, such as sustained left lateral decubitus, may cause considerable patient discomfort and necessitate increased nursing support during recovery.

How to cite this article

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Case 14: Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction

Abstract

Key learning points

Patient history

Examination

Pre-operative considerations

References

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Step 1 — Preparation of the Recipient Site

Step 2 — Flap Preparation

Step 3 — Flap Harvesting

Step 4 — Harvesting Autologous Grafts for Interposition - Step A

Step 5 — Harvesting Autologous Grafts for Interposition - Step B

Step 6 — Microvascular Anastomoses

Step 7 — Flap Transfer, Positioning, and Closure

Step 8 — Follow-Up (4 weeks)

Post-operative plan

Pearls

Pitfalls