Case Report
Reverse Bilateral Latissimus Dorsi Flap Reconstruction After Extensive Mid Back Dermatofibrosarcoma Protuberans Excision: A Case Report
Stefano Bonomi1*, Laura Sala1, Alessandro Gronchi2, Dario Callegaro2 and Umberto Cortinovis2
1Plastic and Reconstructive Surgery Unit, Fondazione IRCCS Istituto Nazionaledei Tumori, Italy,
2Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionaledei Tumori, Italy
*Corresponding author: Stefano Bonomi, Plastic and Reconstructive Surgery Unit, Fondazione IRCCS Istituto Nazionaledei Tumori, Via Venezian 1, 20133, Milan, Italy
Published: 16 Jan, 2018
Cite this article as: Bonomi S, Sala L, Gronchi A, Callegaro
D, Cortinovis U. Reverse Bilateral
Latissimus Dorsi Flap Reconstruction
After Extensive Mid Back
Dermatofibrosarcoma Protuberans
Excision: A Case Report. Clin Surg.
2018; 3: 1857.
Abstract
Surgical resection of soft tissue sarcoma of the trunk can result in large defects requiring complex
reconstruction for coverage of vital neurovascular structures and tissue defect. Large defects of the
back could be reconstructed with multiple random pattern or local pedicled flaps. We present the
case of a 48-year-old patient with a locally advanced dermatofibrosarcoma protuberans of the back.
Wide local excision of the lesion was performed. The soft tissue defect measured 22 cm x 20 cm x 4
cm and was reconstructed with bilateral reverse latissimus dorsi myocutaneous (RLDM) flap. Each
RLDM flap measured 24 cm x 10 cm. The donor site on the back was closed directly on both sides.
The patient recovered well and the two flaps healed uneventfully. Twelve months after surgery the
patient is disease-free. The use of a RLDM flap in mid-back reconstructions provided wide wellvascularized
soft tissue, minimized risk of infection, and maximized back coverage. This flap is an
excellent choice for reconstruction of large defects of the mid-back.
Keywords: Reverse latissimus dorsi myocutaneous flap; Trunk reconstruction; Posterior trunk
defect; Sarcoma; Dermatofibrosarcoma protuberans
Background
Soft tissue sarcomas (STS) represent less than 1% of all malignant tumors. STS can occur
anywhere in the body but 75% are located in the extremities, 10% in the trunk and 10% in the
retroperitoneum[1]. The mainstay 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 patient’s 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 (17;22)
(q22;q13) translocation which leads to the formation of COL1A1-PDGFB fusion transcripts. The
overproduction of the Platelet-Derived Growth Factor (PDGF) beta-chain stimulates tumor cells
growth with an autocrine loop [2].
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 [4,5]. The risk of local failure increases
significantly in case of marginal 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 [6]. Indeed, the complexity of 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, [9] the wound is often deep and with irregular
three-dimensional contour [10]. Inadequate amounts 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 latissimusdorsi 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.
Figure 1
Figure 2
Figure 3
Figure 3
Wound appearance during the Vacuum-Assisted Closure (VAC)
exchange (post- operative day 21). Healthy granulation tissue is present
throughout the wound.
Case Presentation
A 48-year-old man presented with a painless superficial lesion of
the mid-back that had been slowly enlarging for the previous three
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 x 14 cm x 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 present in the middle of the lesion. Contrast-enhanced MRI
showed an expansive subcutaneous lesion with no infiltration of deep
soft tissues (Figure 2). The thoracoabdominal CT-scan did not show
any other lesion. The patient underwent a percutaneous punch biopsy
which revealed a neoplasia composed of CD34-positive spindle cells
without atypia or necrosis and with scant mitosis. A diagnosis of
DFSP was made.
The flaps were drawn with the patient in a standing position. The
resection area measuring 22 cm x 20 cm was outlined on the back
region (lesion: 16 cm x 14 cm, 3 cm oncologically safe distal resection
margins). A bilateral RLDM flap was marked, each measuring 24
cm x 10 cm, with its long axis drawn horizontally. During surgery,
the patient was placed in the prone position. First, the tumor was
resected with wide margins (Figure 3), encompassing the fascia and
superficial layer of the corresponding underlying muscles: the middle
and lower part of the right and left latissimus dorsi muscle, and
part of the sacrospinalis muscles bilaterally were partially resected.
Also the apex of T10-L2 spinous processes was removed. After the
excision, a full-thickness defect measuring 22 cm x20 cm remained in
the middle-lumbar back region (Figure 4). The size of the two RLDM
flaps was reassessed according to the size and shape of the defect. The
musculocutaneous flaps, measuring 24 cm x10 cm, were designed on
the superolateral part of the back, between T8-T11 in both sides. The
skin and subcutaneous tissue were cut down to the latissimusdorsi
muscle, and the flaps were harvested between the latissimus dorsi
and the serratus anterior muscles. The thoracodorsal neurovascular
bundle was identified, 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. These vessels can be preserved if they do not restrict the flap transfer. Otherwise,
some of them can be divided. The two flaps were transposed to the
defect and sutured together (Figure 5 and 6). The donor sites were
closed directly. Four drain tubes were placed (two for the flap donor
sites and two for the lumbar region).
The patient was kept in a prone position in bed to reduce the
tension of the flaps for two 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.
Figure 4
Figure 5
Figure 5
A bilateral reverse myocutaneous latissimus dorsi flap measuring
24 cm x 10 cm has been raised after tumor resection. Flaps ready to be
rotated.
Figure 6
Figure 7
Figure 7
Postoperative picture 12 months after surgery with stable and
durable coverage of the wound.
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 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 perforator reconstruction [12];
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 sometimes
hinder the wide use of perforator flap in lumbar defect reconstruction
[13]. 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 are successful
wound healing, closure of dead space, and the use of well-vascularized
tissue [14]. In the trunk, the pedicled latissimusdorsi flap is usually
used for neck, upper back, and thoracic wall reconstructions. The
reverse latissimusdorsi flap was indicated for mid/lower back and
upper buttock reconstructions. In 1906 the Italian surgeon Tansini
firstly described the utility of the pedicled latissimusdorsi flap for
chest wall defects reconstruction after radical breast amputation [15].
The latissimusdorsi 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 thoracicalspinous processes,
inferior ribs, and iliac crest. The latissimusdorsi 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 [16], which would
allow 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 [16,17]. 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.
[16] have demonstrated, that the RLDM flap is mainly nourished by 3
vessels 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 dissected. Meanwhile, Maruyama et al. [18] reported that
the dorsal perforating pedicle from the ninth 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 25cm 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.
Authors’ Contribution
All authors made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data and have been involved in drafting the manuscript and revising it. Dr. Cortinovis and Dr. Gronchi, as chief Plastic Reconstructive surgery Department and Sarcoma Surgery Unit had given final approval of the version to be published.
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