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Page 6 of 8 Bonomi et al. Plast Aesthet Res 2018;5:8 I http://dx.doi.org/10.20517/2347-9264.2017.93

options can be considered for closure of posterior trunk defects. For small wounds that can be closed tension-
free, it may be possible to bring wound edges together for primary closure. This is particularly true when
resection is superficial and no vital structures are exposed. Once a large area of tissue has been harvested,
however, direct closure becomes more difficult. When underlying vessels, nerves, tendons, ligaments, or
even bone have been removed, primary closure is not advisable. Not only it could be impossible to advance
flaps far enough to achieve closure, but even if the near tissue might be undermined to allow wound edges
to close, the lack of elasticity in the resulting scar tissue is at high risk of causing problems. Furthermore,
STS surgery may often result in large composite tissue defects, in which functional structures are frequently
exposed and susceptible to infection and mechanical trauma. Therefore, reconstruction of complex defects
requires durable and stable coverage of vital neurovascular and bony structures. The posterior trunk soft-
tissue defects can be reconstructed by local skin flaps, fasciocutaneous flaps, perforator flaps, muscle or
musculocutaneous flaps and free flaps. Each option has its own advantages and disadvantages.

The abundance of perforating vessels in the posterior trunk offers multiple options for random pattern
[12]
perforator reconstruction ; however the use of these flaps is highly dependent on the quality of the
surrounding tissue that might be compromised due to radiation and scarring. Compared with myocutaneous
flap, there is no muscle composition in perforator flap. Moreover, these flaps are usually thin and not suitable
to fill dead spaces. Meanwhile, tedious dissection of the perforators and possible herniation after surgery can
[13]
sometimes hinder the wide use of perforator flap in lumbar defect reconstruction . In these cases the use
of muscle or musculocutaneous flaps is advisable.

Myocutaneous flaps are a reliable source of tissue for coverage. The major advantages of myocutaneous flaps
[14]
are successful wound healing, closure of dead space, and the use of well-vascularized tissue .
In the trunk, the pedicled latissimus dorsi flap is usually used for neck, upper back, and thoracic wall
reconstructions. The reverse latissimus dorsi flap was indicated for mid/lower back and upper buttock
reconstructions.

In 1906, the Italian surgeon Tansini firstly described the utility of the pedicled latissimus dorsi flap for
[15]
chest wall defects reconstruction after radical breast amputation. The latissimus dorsi muscle flaps offers
great variety and options to cover large defects in the mid-thoracic and upper-thoracic posterior trunk. It
can be raised up to 30 cm × 40 cm in size and may be transferred as a muscular (eventually with additional
skin grafts) or myocutaneous flap. The latter option makes postoperative monitoring considerably easier. It
origins at the thoracical spinous processes, inferior ribs, and iliac crest. The latissimus dorsi muscle inserts
at the intertubercular groove of the humerus. Its dominant vascular pedicle is the thoracodorsal artery,
which is part of the scapular vascular system, whereas the non-dominant pedicles origin from intercostal
and lumbar arteries. It is therefore a class V muscle according to the popular classification of Mathes and
Nahai ; thus, survival of the flap may also be based on the non-dominant pedicles , which would allow
[16]
[17]
utilization of this flap as a “reverse” flap in order to cover contralateral or more caudal defects .
[9]
The RLDM flap receives its blood supply from the perforating branches of the intercostal and lumbar
arteries [17,18] . During flap elevation, all medial muscle origin from the spinous processes of the vertebrae can
be released, facilitating inferior transposition of the flap. The function of the muscle part in the RLDM flap
is the enhancement of bulkiness of the flap in obliterating the dead space. Moreover, multiple perforators of
the medial branches of the posterior intercostal vessels and lumbar arteries can be visualized in the midline
of the back. Stevenson et al. have demonstrated, that the RLDM flap is mainly nourished by 3 vessels
[17]
originating from the 9th, 10th, and 11th intercostal arteries and veins located 5 cm from the midline of the
back. These perforators can be preserved if they do not limitate flap transfer, otherwise they can also be
[19]
dissected. Meanwhile, Maruyama and Iwahira reported that the dorsal perforating pedicle from the 9th