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Sophie Osenegg, Oliver Didzun, Amir K. Bigdeli. Case 14: Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
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Sophie Osenegg1, Oliver Didzun1, Amir K. Bigdeli1
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
BeforeAfterA 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.
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.
The following preoperative considerations were considered:
The defect, measuring 12 × 6 × 5 cm, was assessed. Radical debridement was performed to excise all necrotic and fibrotic tissue, ensuring an optimal wound bed. Intraoperative microbiological swabs were obtained for culture, followed by thorough irrigation with antiseptic solution. The wound margins were excised until punctate bleeding and viable subcutaneous fat were observed, confirming tissue viability.
A skin island measuring 20 × 6 cm was planned over the latissimus dorsi muscle using the pinch test to ensure tension-free primary closure of the donor site. The dimensions were selected to achieve maximum coverage of the defect with the skin paddle.
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The skin island was dissected down to the latissimus dorsi fascia. A myocutaneous latissimus dorsi flap was then elevated according to standard surgical principles. The muscle was mobilized both anteriorly and posteriorly to expose the thoracodorsal vascular axis. The serratus branch and thoracodorsal nerve were ligated and divided to optimize flap mobility. The thoracodorsal artery and vein were dissected to their origin from the subscapular vessels. A skin bridge was preserved, and a subcutaneous tunnel was created to facilitate flap transfer to the defect site.
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Microvascular dissection of the left great saphenous vein (GSV) was carried out through multiple separate incisions, with side branches ligated using vascular clips. A proximal bifurcation in the upper third of the lower leg limited the usable vein length to approximately 30 cm. Consequently, the right small saphenous vein (SSV) was also dissected to a length of 35 cm. Both veins were prepared by distal ligation and flushed with heparinized saline solution to ensure intraluminal patency.
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Microvascular dissection of the left great saphenous vein (GSV) was carried out through multiple separate incisions, with side branches ligated using vascular clips. A proximal bifurcation in the upper third of the lower leg limited the usable vein length to approximately 30 cm. Consequently, the right small saphenous vein (SSV) was also dissected to a length of 35 cm. Both veins were prepared by distal ligation and flushed with heparinized saline solution to ensure intraluminal patency.
5
Prior to microvascular anastomoses, 1000 IU of intravenous heparin was administered. The thoracodorsal artery and vein were then divided and proximally clamped. The thoracodorsal vein was first anastomosed to an interposed segment of the great saphenous vein (GSV), approximately 30 cm in length, using venous coupler devices for both proximal and distal connections. Subsequently, the thoracodorsal artery was anastomosed to a 30 cm segment of the small saphenous vein (SSV) using 8-0 Ethilon sutures in an open-book technique. Following a second dose of 1000 IU intravenous heparin, the clamps were released, confirming adequate flap perfusion.
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The myocutaneous LD flap was transferred into the defect site through the prepared subcutaneous tunnel. Due to persistent tension on the venous graft, an additional autologous vein segment measuring approximately 5 cm was interposed to achieve adequate length. The flap was positioned with careful orientation of the vascular pedicle to ensure tension-free placement and was secured using fibrin glue. The latissimus dorsi muscle was used to obliterate the defect and was fixed in place with multiple braided resorbable sutures, supplemented by polypropylene pull-out sutures for enhanced anchorage. The skin island was inset to achieve optimal aesthetic coverage, and closure was performed using interrupted subcutaneous monofilament resorbable sutures, followed by a running superficial layer. Two Redon drains were placed beneath the flap for postoperative drainage. A split-thickness skin graft was harvested from the right thigh and applied to the remaining areas of exposed muscle using skin staples. The donor site was closed in a tension-free, multilayered fashion using resorbable sutures following meticulous hemostasis.
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The donor site of the latissimus dorsi flap healed uneventfully. A seroma at the donor site showed a regressive course under conservative management and was resolved by the four-week follow-up visit. At that time, the patient reported a full return to daily activities without functional limitations. The latissimus dorsi flap healed without complications, with no signs of wound healing disorders or partial flap necrosis.
After completing outpatient rehabilitation, the patient resumed all daily activities without restrictions.
8
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.
