INTRODUCTION
Head and neck reconstruction is a continuously
developing area of plastic surgery. Usually a three
dimensional defect develops after a massive tumor
excision which is itself a challenge for plastic
surgeons. Added to the complexity, the aesthetic
requirement of the reconstructed region, the neck
scarring due to previous dissection and the radiated
bed sometimes. The gold standard solution for
these defects is the microsurgical free tissue transfer
which can be of different components of tissue
and/or in several stages [1]. Nevertheless, few
conditions could render some cases difficult for
free tissue transfer [2]. Among these conditions are
the previous radiated or scarred vessels, the fragile
patient who is not fit for a long time anesthesia
and salvage procedures as in tumor recurrence or
early or late failure of a free flap which often
highlight a problem in recipient vessel selection
[3]. In these particular situations, the pedicled Latissimus
Dorsai (LD) myo-cutanous, with its enormous
tissue, flap still finds its own indications and
applications [4-6]. Although this flap has been
described for decades ago [7], technical refinements
of the original description are limited because it
has stepped back in the era of microsurgery. Another
reason for the refinements limitations are is the
lake of adequate planning when the flap is used as
a lifeboat to solve a really complicated problem
in a timely fashion. We hereby reports a case series
with description of some refinements which can
aid optimization of this technique when indicated.
PATIENTS AND METHODS
All patients were seen by the head and neck
cancer multi-disciplinary team at Ain Shams University
Hospitals. The team consists of ENT surgeons,
Plastic surgeons, pathologists, radiologists
and oncologists. All cases underwent surgery in
the same institute from March 2015 till March
2019. In this case series we present thirty two
patients. Twenty six were males and six females.
The mean age was 56 (ranging from 35 years to
72 years) (Table 1).
Although free tissue transfer has been the mainstay
for reconstruction of complex 3D head and
neck defects in our practice, in these selected cases
we used the island latissimus dorsi myocutaneous
16 Vol. 44, No. 1 / Pedicled Island Latissimus Dorsi Myocutaneous Flap
flap. We believe this technique still has a role in
cases where results of free tissue transfer and
microvascular anastomosis is not promising. Selection
criteria for using this technique includes
patients with recurrence or residual lesions where
neck vessels were depleted from previous surgery,
Frozen neck with significant fibrosis resulted from
preoperative radiotherapy and patients with significant
medical comorbidities even in primary tumors.
Nineteen cases had recurrent or residual tumors
and 13 cases were primary tumors in high risk
patients (Table 1).
Table (1): Demography and surgical plan in the study population.
Patient
No.
123456789
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
45
55
48
57
59
43
65
65
41
60
56
48
61
47
53
70
62
35
47
57
55
59
68
43
64
67
47
49
60
64
72
70
Age
MMMMMMF
MMMMMMMMM
F
MMMMFF
M
M
M
MMF
MF
M
Gender
SCC, primary, L
SCC, recurrent, L
SCC, residual, L
SCC, primary, L
SCC, primary, H
SCC, recurrent, L
SCC, recurrent, L
SCC, residual, H
SCC, primary, L
SCC, recurrent, L
SCC, primary, L
SCC, recurrent, L
SCC, recurrent, L
SCC, recurrent, L
SCC, primary, H
SCC, residual, L
SCC, recurrent, L
SCC, primary, L
SCC, recurrent, L
SCC, primary, LF/N
SCC, primary, LF/N
BCC, recurrent, LF/MF/IO
SCC, primary, LF/M/IO
SCC, primary, LF/M/IO
SCC, primary, LF/M/IO
Basi-Sq, recurrent, LF/M/IO
SCC, recurrent, LF/N
SCC, recurrent, LF/N/IO
BCC, recurrent, LF/M/IO
SCC, primary, LF/N/IO
SCC, recurrent LF/M/IO
SCC, recurrent, LF/IO
Pathology/
tumor status & site Excision/defect
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
• Neck skin + total laryngectomy & pharyngeoplasty
(flap forms ant wall)
• Neck skin + total laryngectomy & pharyngeoplasty
(flap forms ant wall)
• Neck skin + total laryngeo - pharyngectomy
• Neck skin + total laryngeo - pharyngectomy
• WLE/lower face & neck skin
• WLE/lower face & neck skin
• WLE/lower & midface skin + IO
• WLE/lower face skin & lat. Segmental
mandiblectomy + IO
• WLE/lower face skin & segmental mandiblectomy
+ IO
• WLE/lower face skin & marginal mandiblectomy +
IO
• WLE/lower face skin& ant. segmental mandiblectomy
+ IO
• WLE/lower face & neck skin
• WLE/lower face & neck skin + IO
• WLE/lower face skin & marginal madiblectomy +
IO
• WLE/lower face and neck skin + IO
• WLE/lower face skin & marginal mandiblectomy
+IO
• WLE, lower face skin + IO
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
1 layer
3 layers
3 layers
1 layer
1 layer
2 layers
2 layers +
recon plate
2 layers +
recon plate
2 layers
2 layers +
rib
1 layer
2 layers
2 layers +
recon plate
2 layers
2 layers
2 layers
Strategy of
flap insetting
*M
F
SCC
BCC
L
H
LF
: Indicates male.
: Indicates female.
: Indicates Squamous Cell Carcinoma.
: Indicates Basal Cell Carcinoma.
: Indicates Larynx.
: Indicates Hypopharynx.
: Indicates Lower Face.
MF
N
M
IO
Recon
WLE
: Indicates Midface.
: Indicates Neck.
: Indicates Mandible.
: Indicates Intra Oral extension.
: Indicates Reconstruction.
: Indicates Wide Local Excision.
Egypt, J. Plast. Reconstr. Surg., January 2020 17
All patients had their workup done including;
blood tests, CAT scan with contrast to assess tumor
extension and lymph nodes involvement. Incisional
biopsies were done in all cases to confirm pathology,
even endoscopic or directly according to site
of the tumor. All resections and neck dissections
were done by the ENT team in joint with Plastic
surgery team. Seventeen patients underwent total
laryngectomy and pharyngeoplasty followed by
reconstruction of neck skin defect by 1 layer flaps,
2 patients underwent total laryngeo- paharngectomy
followed by reconstruction of the pharengeo- esophageal
tube and the neck skin by 3 layered flaps.
Thirteen patients underwent wide local excision
of facial and neck skin involved ± intra oral extension;
with or without madiblectomy (either segmental
or marginal). Four patients underwent mandibular
reconstruction (3 by reconstruction plate.
and 1 by composite rib within the LD flap). In all
13 patients the LD flap was used to reconstruct
the 3D defect either in single or double layers (10
cases double layer reconstruction and 3 cases single
layer reconstruction) (Table 1). Twenty three patient
out of the 32 (71.9%) underwent neck dissection
by the ENT team on the same surgery; 18 underwent
functional neck dissection, 4 underwent selective
neck dissection and 1 patient underwent
modified radical neck dissection.
Surgical techniques: Planning and pre-operative
marking were done while the patient in standing
position, is possible, after accurate measurement
of the expected defect bearing in mind the three
dimensional nature of the defect that prompt us to
use multi-layer technique in insetting of the flap
if needed. We start by identifying the LD muscle
borders; anterior border is detected and marked on
the posterior axillary fold by forceful contraction
of the muscle, posterior border is the back midline,
superior border just pass transversely over the
angle of the scapula, and inferior border is the
posterior iliac crest. The thoracodorsal vessels are
marked just medial to the upper part of the anterior
border and the entry point is marked as well (usually
8cm from the apex of posterior axillary fold) the
skin paddle is designed obliquely along the anterior
border of the muscle usually in the lower half to
insure good arc of rotation without tension on the
pedicle. The lower extension of the skin paddle,
however didn't cross a point 3cm above the iliac
crest, as the skin perfusion beyond this point is
usually not very reliable. In multi layered reconstruction
the skin paddle is divided according to
the defect by lines (1-2cm in thickness) that resemble
areas for de-epithelization that separate different
layers and cavities in the planed 3d reconstruction
(Fig. 1).
After performing the excision by the ENT surgeons
in supine position, the wound is covered
and the patient is put in lateral decubitus and redraped.
The incision is made along the borders of
the planed skin paddle circumferentially and extended
superiorly towards the axilla. Dissection
and identification of the 4 borders of the LD muscle
is then performed with meticulous homeostasis.
The LD muscle is then separated from the underlying
serratus anterior muscle. Finally the thoracodorsal
pedicle is identified under loups magnification
and tracked and dissected meticulously up to
its take of point from the subscapular vessels. Other
branches are tied and divided to allow full mobilization
and freeing of the pedicle; this step is done
while the assistant open the axilla (position the
shoulder in abduction). The LD muscle is then
elevated after dividing all origin attachments using
monopolar cautery. The insertion of the LD muscle
is then identified and separated from the teres
major insertion and then divided Fig. (2). It's very
important after this step to avoid any tension on
the free pedicle; we accomplish this by securing
the tendinous part of the LD insertion to the pectoralis
major fascia on the anterior axillary fold
using two proline suture (0 or 2/0), making sure
there is no tension on the pedicle before passing
the flap to the head and neck region through a
subcutaneous tunnel. Meticulous hemostasis is
then performed on the muscle bed and the donor
site. Direct closure was performed after undermining
in 31 cases among which; 3 flaps required
assistance by local Z flaps in closure (Fig. 3) and
just 1 patient with very big flap required a small
skin graft. Suction drains were used in all donor
sites.
Flap insetting:
Insetting of the flap is done after repositioning
the patient in supine position again. The pattern
of insetting was determined according to the defect
size, shape and site. Insetting was completed in
single layer, double layer or triple layer.
Single layered insetting is used in reconstruction
of neck skin and provide muscle coverage over the
site of pharyngeoplasty (direct closure of the defect
on anterior wall of the pharynx) following total
laryngectomy with partial pharengectomy. Single
layer insetting is used also, in simple 2D facial
defects that doesn't entail intraoral extension or
mandiblectomy. During the single layered insetting
the edge of the defect is undermined only for 1cm
to allow securing the muscle part of the flap underneath
the defect edge with bolster sutures to
avoid clumping of the muscle part and to provide
good water tight closure. This is followed by sub-
18 Vol. 44, No. 1 / Pedicled Island Latissimus Dorsi Myocutaneous Flap
cutaneous and skin sutures to secure the skin paddle
to the edge of the defect (Fig. 4).
Fig. (1): Design of the skin paddle according to the purpose and the plane of reconstruction. (A) Design for simple
single layered flap to cover lower face and neck 2D defect. (B) Double layered flap to cover a 3D lower face defect with
intraoral extension, the 2 parts were separated by a 2cm strip to be de epithelized to facilitate separation of oral cavity
from facial skin. (C)Triple layered flap design for total pharyngeal reconstruction, the distal part was meant to reconstruct
the pharyngeal tube (2 layers; anterior and posterior wall) and the proximal part meant to reconstruct the neck skin. The
2 parts are separated by a strip for deepithelization.
(A) (B) (C)
Fig. (2): (A) Dissection of the
thoracodorsal pedicle and isolation
of the LD tendon up to bicipital
groove. (B) Division of the insertion
to allow maximum reach of
the flap. (C) Microdissection and
division of the thoracodorsal nerve
to avoid twitches and contractures
in the muscle later on.
(A) (B)
(C)
Egypt, J. Plast. Reconstr. Surg., January 2020 19
Fig. (3): (A) Undermining of the donor site edges to facilitate direct closure after harvesting of a big flap.
(B) Direct closure facilitated by Z plasty to avoid tension. (C) Complete healing after 3 weeks.
Fig. (4): (Case 4) (A) 57 year old male with primary SCC larynx in a previously radiated neck. (B) The excised specimen
consisted of the whole larynx, the anterior wall of the pharynx as a safety margin and the radiated neck skin. (C)
Pharyngeal cavity lay open indicated by arrow. (D) Pharyngeplasty in layers tested by methylene blue to insure its
water tight. (E) The LD flap after total freeing (F) Insetting of the flap in one layer where the muscle edges were pulled
under the defect edges and secured by bolster sutures to avoid skin necrosis.
Double layered insetting is utilized in reconstruction
of full thickness 3D defects of facial skin
with intraoral extension ± madiblectomy. In the 2
layered insetting, we secure the distal end of the
flap to the edges of the intraoral defect using 3/0
vicryl running sutures (better water tight). Then
we de epithelize a 1cm strip on the skin paddle.
The location of this strip is pre-designed in preoperative
marking and can be modified intra operatively
to be located between the intra and extra
oral portion of the flap. One edge of this de epithelized
strip is sutured to the mucosa intra orally
and the other edge is sutured to the skin extra
orally, then the rest of the extra oral portion of the
flap is secured similar as in single layered insetting.
This de epithelized strip provide robust separation
between the 2 layers of the flap and betweein the
oral cavity and the skin Fig. (5). In cases where
lower lip is excised completely we did not do
deepithelization as the line of separation between
the intra oral part and the facial skin supposed to
be the new lip (Fig. 6).
(A) (B) (C)
(A) (B) (C) (D)
(E) (F) (G)
20 Vol. 44, No. 1 / Pedicled Island Latissimus Dorsi Myocutaneous Flap
Fig. (5): (Case 23) (A) 68 year old female with intra oral SCC infiltrating the mandible and the lower face and neck skin.
(B) Excision in block and reconstruction of mandible by a reconstruction 2.7 plate. (C) Suturing the distal end of the flap to
the edges of the intra oral defect to create the 1st layer of insetting (D) De epithelization of a strip of skin paddle to separate
the 2 layers of the flap where the distal edge of the de epithelized strip will be sutured in continuity with the edges of intra oral
defect, and the proximal edge will be sutured to the face skin defect, the purpose is to separate the oral cavity from the face
skin by 2 water tight layers. (E) Insetting of the second layer to cover face and neck skin defect. (F) Complete healing of the
2nd layer after 4 months. (G) Complete healing of the 1st layer creating the floor of the mouth.
Fig. (6): (Case 26) (A) A 67 year old male suffered from recurrent aggressive basi squamous carcinoma of skin infiltrating
the anterior mandible. (B) WLE was done with segmental anterior mandiblectomy. (C) Design of the composite osteomyocutaneous
LD flap for composite 3D reconstruction. (D) Although 2 layered insetting of the flap was planned no de epithelization of a
strip of the skin paddle was done as the lip couldn't be salvaged in this case. (E) Arrow indicated the 9th rib harvested within
the composite flap. (F) Immediate insetting in 2 layers (G,H) 3 months post-operative.
(A) (B) (C)
(D) (E) (F) (G)
(A) (B) (C) (D)
(E) (F) (G) (H)
Egypt, J. Plast. Reconstr. Surg., January 2020 21
Triple layered insetting is utilized to reconstruct
neck skin and total pharyngeal (cirumfrantial)
reconstruction following total laryngeopharengectomy.
The 1st layer reconstruct the
posterior pharyngeal wall and it consists of the
most distal part of the flap. The 2nd layer is the
anterior pharyngeal wall and entails the middle
portion of the flap to form a tube with the posterior
wall. The upper edge of the tube is anastomosed
with oropharynx and the lower end of the tube is
anastomosed with the esophageal end. The 3rd
layer is separated from the 2nd layer by a strip of
de epithelization similar to what was done in the
2 layered insetting; where one edge of the de
epithelized strip is sutured to the most distal edge
of the flap to close the pharyngeal tube laterally.
The other edge is sutured to the neck skin on one
side of the neck defect and then the rest of the
flap (3rd layer) is inset and secured to reconstruct
the neck skin (Fig. 7).
Fig. (7): (Case 19) A 47 yr old male with recurrent SCC larynx and multiple pharyngeo cutaneous fistulas (B) Underwent
WLE of neck skin and total pharyngectomy, the white arrow indicates the tongue base and the black arrow indicated the
esophagus. (C) The reach of the triple layered flap to the defect with strip de epithelization to separate the reconstructed
pharyngeal tube from the reconstructed neck skin. (D) Tubing of the distal portion of the flap around a pre inserted Ryle where
the tube was anastomosed superiorly to the remnants of the oropharynx and inferiorly to the esophagus. (E) The most proximal
part of the flap, the 3rd layer was used to reconstruct the neck skin. (F) One month post-operative (G) Bariam swallow on the
4th week shows no significant fistulas.
Post-operative care and follow-up:
Vascularity of the flaps was monitored clinically
post-operative together with wound and tracheostomy
care. Feeding was maintained immediately
post-operative via nasogastric tube in 39 patients
and by gastrostomy tube in 3 patients. Oral intake
started 10-15 days post-operative guides by healing.
We did barium swallow study only in complicated
and suspicious patients before starting oral intake.
Post-operative radiotherapy started 4-6 weeks after
removal of Ryle tube and insuring good healing.
Chemotherapy was added in few selective patients
based on the oncologist's recommendations. Early
and late complications were reported.
RESULTS
One patient died in early post-operative
course in the ICU due to pre-existing cardiovascular
compromise. All flaps survived with two
partial distal flap losses and were managed by
another regional flap (pec. Major) and resetting
(advancement of LD). Wound dehiscence happened
in 3 patients and healed spontaneously in
2 and required secondary sutures in 1 Fig. (8).
Two patients developed minor problems in the
donor site; a partial graft loss in one patient and
wound dehecence in another patient, both were
managed conservatively. 1 patient with total
(A) (B) (C)
(D) (E) (F) (G)
Fig. (8): (A) Vascular compromise of the tip of the skin paddle of LD flap used to reconstruct neck skin after total
laryngerctomy and pharyngeoplasty. (B) The healthy LD muscle underneath , that was secured under the
defect edges by bolster sutures, saved the patient from another surgery and made the conservative management
of wound possible. (C) The patient while drinking water 2 month after surgery after complete healing.
Fig. (9): (Case 23) (A) Early flap congestion was noted few hours after surgery, this was relieved by re-exploration
and insure no tension on the pedicle by re insetting of the LD tendon to the pectoral fascia at a nearer point,
together with release some stiches. (B) 2 days later with significant improvement in color.
Table (2): Complications and their management.
Complications
Partial flap loss
Wound dehiscence
Early fistula
late pharyngeo-cutanous fistula
Donor site complication
Total rate of complications
Number
2 patients
3 patients
2 patients
1 patient
2 patients
Percentage
6.2%
9.4%
6.2%
3.1%
6.2%
31%
Treatment
Resetting/pec-major
2 conservative/1 secondary sutures
Conservative
Pec major
Conservative
12.4% surgical
22 Vol. 44, No. 1 / Pedicled Island Latissimus Dorsi Myocutaneous Flap
circumferential pharyngeal reconstruction suffered
from a late high output fistula that was
managed surgically by a pectoralis major flap.
Three patients suffered from tumor recurrence
during the follow-up who were managed in a
palliative way as per our multi-disciplinary team.
Early flap congestion happened in two patients
who underwent tunnel exploration and pedicle
resetting in the same day and the flaps survived
Fig. (9), (Table 2).
(A)
(B) (C)
(A) (B)
Egypt, J. Plast. Reconstr. Surg., January 2020 23
DISCUSSION
On one hand, most of the defects of the head
and neck tumor excision are complicated as the
aim to achieve a histological margin of 0.5cm and
a clear nodes if possible [8]. On the otherhand,
head and neck tumors are subjected to immediate
reconstruction in most of occasions as a gold
standard [9] due to the complexity and position of
the defect making the operation inherently longer
and morbid. Compared to a large series of free
flaps (1000) free flap [10] our total flap failure is
0% compared to 5.8%, and 6.2% our partial necrosis
to 7.6% in the free flap series also donor site
complications was lower in our series (6.2% compared
to 8% in the free flap series).
In our practice, the pedicled LD flap for head
and neck reconstruction is usually indicated in
complicated patients than free flaps, which in turn
gives major and minor complications a bigger
chance. However, because the reliability and easiness
of this flap, our overall complication rate is
comparable to the same flap in the literature [11,12].
Furthermore, the major complications related to
the flap itself are very scarce. In the same context,
free flaps in these situations will indeed have an
unacceptably high rate of complications.
The insetting of the flap in the defect is of vast
importance and influences the outcome. There is
scarcity of reports of the literature describing the
insetting. Watson and John advocated one stage
pharyngeal reconstruction and mentioned few
details in insetting as a tube and skin cover in a
case report [13]. Richard and Vahram have reported
56 cases but most of them were for zygomaticofacial
defects with very few details of the insetting
using imaginary diagrams rather than pictorial
documentation. Few reports followed without focusing
on insetting technique [14,15]. Thus, in our
report we focus on the classification of insetting
for various types of defects (one layer for skin or
mucosal defect, two layers for double surface
defects and three layers in circumferential reconstruction)
as described in methods. Fixing the
muscle flap underneath the edge of the defects by
bolster sutures saved us from facing major complications
like fistula. This does not only provide a
water seal layer under the skin paddle, but also
allows wound dehiscence and minor skin paddle
vascular compromise to be managed successfully
in a conservative way due to the viable muscle
layer underneath.
Denervation of the LD is our usual practice as
for breast reconstruction to avoid post-operative
twitching [16] which we think decreases the time
of healing and the liability of disruption. The
Subcutaneous tunneling of the Islanded flap and
anchoring of the LD tendon to the Pectoralis major
fascia has found to be sufficient and saves us the
un-necessary invasive dissection of the transaxillary
rout [12] or subclavian rout which might
lead to complications as injury of axillary vein
and entail osteotomy of clavicle sometimes [17].
Although we have applied this technique due
to its advantages in selected patients, it still has
some limitations. One of those is the difficulty to
monitor the distal portion of the flap which is
frequently invisible and discovered only by complications
as fistula. Another issue is the technicality
to inset a pedicled flap which is more difficult than
insetting of a free (mobile) flap before the anastomosis.
As a result, a relatively long time is still
consumed (average 5 hours for flap harvest and
inset) and this is also due to change in position.
Finally, the defect size is often over estimated
resulting in a bulky flap which is unsafe for debulking
at least in the same session.
In Conclusion: The Island pedicled LD flap for
major 3d head and neck reconstruction is still a
lifeboat for difficult cases when carefully planned
beforehand and meticulously applied to get the
best of its benefits.
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