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Vakhshori et al. Plast Aesthet Res 2023;10:36 https://dx.doi.org/10.20517/2347-9264.2022.78 Page 3 of 22

[13]
adequately power elbow flexion, as described by Stevanovic et al. . The latissimus dorsi is evaluated by
palpating or gently pinching the muscle at the posterior axillary fold during adduction, extension, and
internal rotation of the arm. The patient may also be asked to cough while the clinician holds the posterior
axillary fold to palpate muscle contraction. Patients may also perform exercises with a physical therapist
prior to surgery to maximize the strength of the latissimus dorsi muscle.

A pedicled transfer has the advantage of not requiring microsurgical anastomoses. The patient is placed in
the lateral decubitus position, and the entire upper extremity, along with the lateral side from the shoulder
girdle to the pelvis, is included in the surgical field. As described in prior studies, the defect in the anterior
arm is measured along with the distance from the proximal aspect of the planned incision to the coracoid.
This measurement is used to plan the skin paddle location relative to the axis of rotation to ensure coverage
[13]
of the arm soft tissue . The incision is made from the posterior axillary fold to the midpoint of the iliac
crest, allowing identification and exposure of the latissimus dorsi [Figure 1]. With the latissimus in the
stretched position (abduction, forward flexion, and external rotation of the arm), marking sutures may be
placed at 5 cm intervals along the latissimus prior to mobilization to use for setting tension at the recipient
site [13,14] . The latissimus dorsi muscle is then elevated off the thoracic wall, with care to avoid injury to the
thoracodorsal artery pedicle, which enters the muscle 10-12 cm from the axilla . The thoracodorsal nerve
[14]
is also protected to maintain innervation to the transferred muscle [Figure 2]. The serratus anterior can be
elevated along with the latissimus dorsi as a chimeric flap when a larger defect requires coverage, though
this is not often the case in the upper extremity . After pedicle mobilization, when a bipolar transfer is
[15]
planned, the insertion on the humerus is released and sutures are placed in the tendon. In cases where a
unipolar transfer is planned, the humeral insertion is left intact . A bipolar transfer has the advantage of
[1]
allowing proximal fixation to the coracoid, acromion, or lateral clavicle which can provide a more direct
line of pull while stabilizing the shoulder .
[1]

To transfer the muscle to the anterior arm, the latissimus is tubularized. An incision is made over the
coracoid, where the origin of the transferred muscle is planned. A subcutaneous tunnel is created
connecting the posterior and anterior incisions, and the latissimus tendinous insertion is passed below the
pectoralis major tendon to the coracoid where it is secured with sutures or suture anchors [Figure 3]. The
remainder of the tubularized latissimus is passed to the anterior arm [Figure 4]. Care must be taken to avoid
[14]
twisting the pedicle while passing the muscle, which may lead to flap ischemia . To set the tension of the
transferred latissimus, the muscle is stretched distally, the elbow is extended, and the distal latissimus is
secured to the distal biceps tendon [Figure 5]. Since the marking sutures were placed with the latissimus in
extension at the donor site, securing the muscle at the recipient site with the elbow in extension should be
[14]
performed after re-establishing the 5 cm interval between marking sutures . After securing the muscle, the
shoulder and elbow are ranged to ensure there is not excessive tension on the pedicle. After closure, the
shoulder is immobilized with an abduction pillow and the elbow is immobilized in 90 degrees of flexion [13,14] .

Reported outcomes are shown in Table 1. The majority of patients achieved at least antigravity strength with
pedicled latissimus transfer, with a low rate of reported complications. Of the studies reporting motor
outcomes, 87% of patients achieved at least antigravity flexion strength. Range of motion was inconsistently
reported in the literature. In the publications describing final elbow flexion, all but two reports revealed a
mean postoperative elbow flexion of 90° or more.

Latissimus dorsi (free)
A free latissimus dorsi transfer allows more flexibility in use for restoration of elbow flexion, but it is
technically more demanding than a pedicled transfer, given the need for microsurgical anastomoses. Either