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intercostal vessels can be divided so as to obtain sufficient pedicle length and found that flap survival was not
altered. If the flap vascularity is found to be adequate, then perforators can be divided, facilitating further
caudal and medial transposition of the flap. During the tumor resection, the surgical oncologist should
always be reminded to preserve the integrity of the perforators of the intercostal arteries whenever possible
from an oncological point of view.

The bilateral RLDM flap is suitable to cover thoraco-lumbar defect, until L2-L3 but not the sacral region;
as matter-of-fact longer flaps could have distal viability and ischemic problems. On the other hand it is not
possible to cover defect wider than 25 cm because larger flaps could have rotational problems.

In our opinion the bilateral RLDM flap is the more reliable surgical option to close a large and deep defect
of the mid-low back as in the case described.

DECLARATIONS
Acknowledgments
The authors thank Mr. Peter Panton for language editing.

Authors’ contributions
Acted on the demolition surgical step and subsequent patient oncological follow-up, deepened the oncological
issue of the paper: Gronchi A, Callegaro D
Played a major role in the reconstructive surgical and scientific field: Bonomi S, Sala L, Cortinovis U
Planned the operation, the writing and the final review of the manuscript: all authors

Financial support and sponsorship
None.

Conflicts of interest
There are no conflicts of interest.

Patient consent
Written informed consent was obtained from the patient for publication of this case report and any
accompanying images.

Ethics approval
Ethical approval was not needed for this case report.

Copyright
© The Author(s) 2018.

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