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Luisa Lotter. Case 2 - 2025: Reconstruction of an extensive foot defect using a combined sensory split latissimus dorsi and serratus anterior muscle flap. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
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Luisa Lotter1
A 67-year-old male patient sustained a complex foot injury with an open Lisfranc dislocation of the medial cuneiform bone and shaft fractures of the 2nd to 4th metatarsals in July 2024, as a result of a crush trauma. After initial osteosynthetic treatment, a pronounced necrosis developed in the area of the hindfoot and forefoot over time and an implant-associated wound infection. The patient was then transferred to our tertiary care hospital for specialized defect reconstruction. At first radical necrosectomy was performed, resulting in a 10 x 12 cm soft-tissue defect in the heel area, which extended medially and laterally. In the area of the forefoot, there was also a full-thickness wound measuring 4 x 3 cm with exposed osteosynthetic material, bone, and tendon. Patient medical history The patient has no pre-existing conditions. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg. Before and After Patient examination Upon admission to our hospital, on assessment, the 67-year-old male patient was in good general health with a slim nutritional status. On the heel area of the right foot was a 10 x 12 cm soft-tissue defect, which extended medially and laterally. In the area of the forefoot, there was also a full-thickness wound measuring 4 x 3 cm with exposed osteosynthetic material, bone, and tendon. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg. Pre-operative considerations The reconstruction of complex soft tissue injuries with exp
BeforeAfterThe patient has no pre-existing conditions. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg.
Upon admission to our hospital, on assessment, the 67-year-old male patient was in good general health with a slim nutritional status. On the heel area of the right foot was a 10 x 12 cm soft-tissue defect, which extended medially and laterally. In the area of the forefoot, there was also a full-thickness wound measuring 4 x 3 cm with exposed osteosynthetic material, bone, and tendon. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg.
The wound bed was prepared by debriding non-viable tissue and taking precise measurements of the skin and soft tissue defect. Exposed functional structures were identified and measured. A 3 cm section of the osteosynthesis material, as well as the tendon of the extensor hallucis longus muscle, were exposed. Additionally, there was only a very thin soft tissue covering over the heel.
Before the defect was covered by a free microsurgical flap, the osteosynthesis material was replaced by the orthopaedic team due to a preceding implant-associated infection. The posterior tibial artery and the saphenous nerve were exposed up to 5 cm.
2
For the defect coverage, a combined microsurgical flap procedure consisting of the lateral portion of the latissimus dorsi and the distal three slips of the serratus anterior muscle was planned. At the beginning, the vascular supply of the M. latissimus dorsi, including the thoracodorsal nerve, long thoracic nerve, and serratus arcade, is visualized. It is particularly important that the dorsal branch of the thoracodorsal nerve is preserved, as it is essential for the motor function of the medial portion of the latissimus muscle, which will be left in situ.
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This is followed by mobilization of the latissimus dorsi muscle and detachment of the lateral portion, as well as the distal three slips of the serratus anterior muscle. The common vascular pedicle is followed up to the origin of the circumflex scapular artery, and the flap is then detached along with the thoracodorsal nerve. The medial part of the latissimus dorsi muscle is preserved (marked in green).
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Microsurgical anastomoses of the perforator: arterial anastomose to the posterior tibial artery were established in an end-to-side fashion using Dafilon 8-0. The vein was anastomosed end to end to the concomitant veins of the posterior tibial artery using a 2.5 mm coupler. The branch of the thoracodorsal nerve was connected to the sensory branch of the saphenous nerve epineurally using a 3 cm nerve allograft and Dafilon 9-0.
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The flaps were accurately modelled to meet the defect configuration and two Charrier Redon drains were inserted. The skin was removed, and the entire flap was covered with mesh graft from the ipsilateral thigh.
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Follow-up
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