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Page 4 of 8 Bonomi et al. Plast Aesthet Res 2018;5:8 I http://dx.doi.org/10.20517/2347-9264.2017.93

Figure 3. The tumor was widely resected. Intraoperative specimen

Figure 4. Wound defect after wide local excision of dermatofibrosarcoma protuberans that measured 22 cm × 20 cm in diameter

muscle, and the flaps were harvested between the latissimus dorsi and the serratus anterior muscles. The
thoracodorsal neurovascular bundle was identified, ligated and divided with preservation of the vessels and
nerve distributing to the serratus anterior muscle. The myocutaneous flaps were freed from the underlying
chest wall along the superior and lower borders of the muscle, preserving dorsal intercostal perforating
vessels. When the harvesting was close to the paraspinous region, multiple paraspinal perforators of the
posterior intercostal arteries could be seen entering the deep surface of the muscle. We based the two flaps
on the 9th and 10th intercostals perforators, in order to allow flap transfer without restriction. The two flaps
were transposed to the defect and sutured together [Figures 5 and 6]. The donor sites were closed directly.
Four drain tubes were placed (2 for the flap donor sites and 2 for the lumbar region).

The patient was kept in a prone position in bed to reduce the tension of the flaps for 2 days. Peri-operative
antibiotics were given. He was discharged after 7 days. Drain tubes were removed on the 15th day after the
operation. The final pathology showed a completely excised DFSP with clear margins all around. No further
therapies were needed. Twelve months after surgery the patient has no evidence of disease recurrence [Figure 7].
The range of motion of shoulder joints and arms were not impaired after surgery. The initial flaps bulging
gradually resolved.

DISCUSSION
The thoraco-lumbar superficial tissues are relatively thick, strongly adherent to the underlying layers, and
relatively inelastic. Depending on the extent of the defect and adjacent structures involvement, a variety of