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Page 2 of 8 Bonomi et al. Plast Aesthet Res 2018;5:8 I http://dx.doi.org/10.20517/2347-9264.2017.93

of treatment of localized STS is the complete surgical resection of the tumor with adequate margins. Both the
width and quality of the surgical margins are crucial in determining patients prognosis. Low-risk tumors are
typically managed with a wide surgical resection alone. Patients with high-risk tumors may be treated with
adjuvant/neoadjuvant radiotherapy and/or chemotherapy to minimize respectively the local and systemic
risk of failure.

Dermatofibrosarcoma protuberans (DFSP) is a low-grade, locally aggressive, STS of the cutis. Typically, DFSP
arises within the dermis as a slow-growing plaque or nodule and subsequently spread to the subcutaneous
tissues. The pathogenetic driver of this tumor is the t(17;22)(q22;q13) translocation which leads to the
formation of COL1A1-platelet-derived growth factor (PDGF) beta fusion transcripts. The overproduction of
[2]
the PDGF beta-chain stimulates tumor cells growth with an autocrine loop .
DFSP are managed with wide excision of the tumor en-bloc with surrounding soft tissues. The Mohs
micrographic surgery is an option to minimize the amount of tissue resected, especially in critical areas .
[3]
The risk of local recurrence is in the range of 1%-4% at 10 years after wide surgery and the metastatic risk
is about 2% at 10 years in major series . The risk of local failure increases significantly in case of marginal
[4,5]
or microscopically positive resection, thus the quality of surgery is critical. In a minority of patients, the
tumor may harbour a fibrosarcomatous transformation which is associated with a much higher systemic
risk. The most common site of DFSP occurrence is the trunk (72%). Here, the extensive removal of tissue
often requires reconstructive surgery because primary closure is not possible. Furthermore, in case of local
recurrences, the re-resections of superficial soft tissues further deplete the nearby tissues of redundancy
and the transferring of healthy tissue from areas of excess becomes necessary . Indeed, the complexity of
[6]
the defects following soft tissue sarcoma resection has increased, as more patients now receive preoperative
radiotherapy. Radiation decreases the chance for a successful skin graft, and it also renders the wound edges
ischemic. Therefore, well-vascularized tissues are required for reconstruction .
[7,8]
Reconstruction of soft-tissue defects of the posterior trunk can constitute a challenge for plastic surgeons.
Reliable axial pattern flaps for local tissue transfer and recipient vessels for microsurgical reconstruction
are scant , the wound is often deep and with irregular three-dimensional contour . Inadequate amounts
[9]
[10]
of soft tissue can lead to contracture during the healing process, compromising trunk and upper extremity
function. Moreover, the exposure of spinous processes may lead to ulceration or pressure sores after soft
tissue coverage, so they should be readily removed in order to avoid such complications.

Due to the rich random vascular network multiple local flaps are possible; fasciocutaneous flaps may be
raised based on septal and fascial perforators of the axillary subscapular trunks and the posterior intercostals
arteries. These flaps provide missing soft tissue for upper-back moderate size defects. Nevertheless, the
dorsal trunk hosts several muscles that may be transferred as pedicled flaps such as the latissimus dorsi or
the trapezius. Moreover, in selected cases free flaps with vein graft or loops may be used [5-11] .

Here we present the case of a patient undergoing bilateral reverse latissimus dorsi myocutaneous (RLDM)
flap reconstruction after wide excision of a primary DFSP of the middle back.

CASE REPORT
A 48-year-old man presented with a painless superficial lesion of the mid-back that had been slowly enlarging
for the previous 3 years [Figure 1]. He had no family history of cancer and the past medical history was
unremarkable except for hypertension. He had never been a smoker. The clinical examination revealed a
large raised lesion, measuring 16 cm × 14 cm × 6 cm in the middle of the back, extended from the scapula tip
to the iliac crest edge (T12-L3). The lesion was barely mobile and hard. A pink placque-like thickening was