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Kumar et al. Reverse latissimus dorsi muscle flap for back

and advanced to cover the lower defect. At the end of The layered closure had helped Söyüncü et al. to
[9]
surgery, both muscles were healthy. We identified three decrease the CSF leakage by using omentum and
big lower perforators, but even then the vascularity of latissimus dorsi flap.
the muscle tip was inadequate.
A reverse latissimus dorsi flap can also be usedfor 3D
In case 5 the flap dehisced, there were increased coverage and to control bacterial contamination. [5,6,10]
secretions from the wound, empyema due to incomplete In our experience, complicated acquired defects (like
excision of the tumor and patient was unwilling to in the fourth case) require muscle to fill the dead
undergo further procedures. The flap in case 5 looked space around the fixators as a first layer to cover the
healthy and the skin graft take was more than 90%. implants. Dead space is a potential space for seroma
collection and infection. So, with amuscle flap we were
Otherwise, the other 4 cases had no postoperative able to successfully prevent the formation of seroma
fevers, increase in discharge or particulate matter in and infection.
the drain, which suggested a healthy muscle flap.
Large meningomyelocele defects have also been
There were no donor site complications in any of reconstructed with reverse latissimus dorsi flap and
the above cases. All these patients, except for case skin graft. In one case we decided to leave the wound
[7]
5, followed up for six months and had no problems to heal by secondary intention as the skin necrosis
recorded with regards to shoulder movement. defect was 1 cm in size. We had a healthy muscle
covering the dura and hence, we were able to allow
DISCUSSION for secondary intention without the risk of dura break
down and infection.
The most common indication for the use of the reverse
latissimus dorsi muscle flap has been a complex Latissimus dorsi muscle is a type V muscle flap based
defect or a complicated defect, like infected ulcer, on thoracodorsal artery and perforators from the lumbar
post radiotherapy ulcer, CSF leaks. [4-8] In the present and posterior intercostal vessels. These perforators
study we have used it for complex wounds with CSF are usually present 5 cm from the midline. The
[11]
leak, prosthesis in situ. The reverse latissimus dorsi is perforators were present within 5 cm of the midline
considered only as an alternative for meningomyelocele in our series. All the flaps except 1 survived without
closure. Ayad et al. used the reverse latissimus dorsi any distal necrosis, even though the distal perforators
[4]
flap as a primary reconstruction for large defects. were intact. The distal 2 perforators are enough for
the survival of the muscle for the lower part of the
The reverse latissimus dorsi muscle flaps are based muscle. [12] Hayashida et al. [13] have published a case
on the perforators from the posterior intercostal report on reverse latissimus dorsi flap based on the
vessels and the lumbar vessels. The turnover of the tenth perforator. In the above case the reach of the flap
reverse latissimus dorsi muscle flap from upper back was up to the anterior superior iliac spine. In our cases
to the lower back can cover midline lumbar and sacral the flaps reached the lower sacrum without tension
defects. The reverse latissimus dorsi muscle flap can be or compromise on the muscle vascularity in all cases
transposed to cover the lumbar orthoracic defects and except 1 case. Though, many authors have described
can be used inside the chest. The superior perforators that the flap can survive with the lower 9th and 10th
can be divided for adequate reach of the flap, but the perforators [13] we feel distal flap necrosis may be
inferior pedicles need to be preserved for the survival encountered. We do not have a large series as proof,
of the flap. In case 3 the distal part of the latissimus hence further studies would be needed.
dorsi flap was not healthy and thus we had to debride
part of the flap. We felt the secondary pedicles were The flap reaches down to the lower sacrum, however,
not sufficient to vacularise the distal end. Studies have one might have difficulty covering the lower part of the
found that the vascularity of the reverse latissimusdorsi sacrum. As an option, the gluteus maximus muscle
flap is reliable. [4,5] flap can also be used as described in one of our cases.
The most frequent complication of the latissimus dorsi
There is thinning of the skin over the myelomeningocele. muscle flap is seroma. [14] However, in our serieswe did
There is decreased soft tissue support in the midline if not encounter it.
the skin over the defect is thinned by expansion. The
use of a muscle cover in addition to the fasciocutaneous The reverse latissimus dorsi flap is robust with a
flap, over the repaired dura will give additional support reliable vascularity. The chances of failure are small.
as well as act as a vascularized cover over the dura. Alternatives include the use of local flaps, which do
Plastic and Aesthetic Research ¦ Volume 4 ¦ May 26, 2017 79