Journal of Surgical Oncology 47:62-66 (1991)
Latissimus Dorsi Musculocutaneous Flap for El bow Extension MARK PRUZANSKY, MD, MARK KELLY, MD, AND HUBERT WEINBERG, MD From the Department of Orthopedic Surgery (M.P., M.K.) and the Division of Plastic Surgery, Department of Surgery (H.W.), the Mount Sinai School of Medicine, New York, New York
The latissimus dorsi mycocutaneous flap has developed a reputation for its versatility in both skin and soft tissue coverage and for restoration of elbow function in both flexion and extension. In a case presented, a large extra-abdominal desmoid was removed along with the entire deltoid and three-quarters of the triceps. The latissimus dorsi was elevated with a large overlying skin island and rotated on its neurovascular pedicle into the defect in the posterior shoulder and upper arm to replace the resected triceps and deltoid muscle, and to provide coverage in this region. KEYWORDS:desmoid, shoulder tendon transfer
INTRODUCTION The latissimus dorsi mycocutaneous flap has developed a reputation for its versatility in both skin and soft tissue coverage and restoration of elbow function in both flexion and extension. [I-51. Much of the present literature with regard to functional restoration about shoulder and elbow involves transposition of the latissimus dorsi into the flexor compartment of the upper arm [6-81. Descriptions of its use to supplant functionless triceps muscles do exist; however, these involve tunneling the flap into the posterior arm [4,9] transposing the insertion distally, while leaving the origin in place [lo], carrying the primary incision from the back over the posterior axillary fold onto the posteromedial aspect of the arm [ 111, leaving the insertion in place, and transposing the origin distally to the olecranon [12]. In the case presented, the muscle was elevated with a large overlying skin island and rotated on its neurovascular pedicle into a defect in the posterior shoulder and upper arm to replace a restricted triceps and deltoid muscle and to provide coverage in this region. CLINICAL MATERIAL A 48-year-old right-handed manual laborer presented with a slowly enlarging soft tissue mass in the posterolateral aspects of the right arm and shoulder. He complained of rigidity of the right shoulder and progressive loss of elbow motion. Twelve and 11 years earlier, two partial tumor resections had been performed for extra0 1991 Wiley-Liss, Inc.
abdominal fibromatosis of the deltoid muscle. Physical examination revealed a 10 cm X 10 cm firm, nontender mass on the posterolateral aspects of the right shoulder and upper arm; 3- and 4-inch longitudinal scars adherent to the skin and occasional dimpling were noted (Fig. 1 ) . There was no apparent active or passive motion of the glenohumeral joint. All of his shoulder motion (50 degrees) was scapulothoracic. Elbow extension was 0 to 50 degrees, and strength was good (4/5). Latissimus dorsi muscle function was assessed to be normal. Distal neurovascular function was within normal limits, Computed tomography (CT) of the right shoulder revealed the soft tissue mass to be an infiltrating lesion of almost the entire deltoid and upper one-half of the triceps. Four weeks prior to reconstruction, an open biopsy demonstrated recurrent fibromatosis of the deltoid. At surgery the patient was placed in the lateral decubitus position. The two previous scars with a normal margin were included in an ellipse of skin to be excised because of its diffuse adherence to the underlying fascia. Skin flaps were raised around the shoulder to permit access to the entire deltoid origin. The entire right deltoid, the proximal 80% of the triceps, which was also involved by the tumor, and a 12 Accepted for publication December 13, 1990. Address reprint requests to Dr. Mark Pruzansky, 1050 Fifth Avenue, New York, NY 10028. This paper was presented at the American Academy of Orthopaedic Surgeons Meeting. New Orleans, February, 1990.
Latissimus Dorsi Musculocutaneous Flap for Elbow Extension
Fig. 1. Preoperative appearance of the tumor involving almost the entire deltoid and most of the triceps. Dimpling of the skin caused by invasion of superficial structures and the two previous surgical sites can be seen anteriorly (top) and posteriorly (bottom).
63
Fig. 3. The gross pathology of the fibromatosis of the deltoid, triceps and overlying skin.
Fig. 2. Tumor and overlying skin have been removed revealing the rotator cuff muscles posteriorly (top), the biceps anteriorly (bottom), and the radial nerve (middle).
cm X 20 cm area of overlying skin were resected (Figs. 2, 3). The radial nerve was isolated from the posterior cord to the extensor carpi radialis longus, sacrificing branches to the triceps. After acromioplasty and bursectomy were performed, three drill holes were made in the posterolatera1 acromion process. The size of the cutaneous recipient defect was measured. Due to the large size of the underlying muscle, a very large skin defect can be safely covered by the cutaneous portion of this flap. A large ellipse was outlined in the skin and subcutaneous tissues corresponding to the recipient defect (Fig. 4). Skin flaps were elevated in all directions to expose the entire latissimus dorsi muscle. Beginning from the musculotendinous junction superiorly, the entire submuscular plane above the chest wall was dissected distally and medially until the muscle was severed from its paraspinal muscle
I
Fig. 4. The latissimus dorsi muscle has a broad origin from the ribs and lumbar fascia and inserts into the intertubercular groove of the upper humerus.
and lumbar fascia1 attachments (Fig, 5 ).The neurovascular pedicle was identified in the proximal one-third of the muscle where it enters posterolaterally . The thoracodorsal artery and its venae comitantes were mobilized up to
64
Pruzansky et al.
Fig. 5. The latissimus dorsi musculocutaneous flap has been removed from the patient’s back on its pedicle. The shoulder wound is at the top of the picture.
the axillary artery and vein. The thoracodorsal nerve was dissected free from its tissue interval. Dissection of the neurovascular bundle proceeded from both the shoulder and back incisions and converged under the optional skin bridge. The radial nerve was protected as the tendinous insertion of the latissimus dorsi muscle was freed from the intertubercular groove during adduction and internal rotation of the shoulder. A nerve stimulator can be used to test function at this point. In this patient, a small accessory nerve supply to the upper 15% of the muscle was assessed with a nerve stimulator and sacrificed to gain length for the neurovascular pedicle. A subcutaneoustunnel was created by blunt dissection. The flap was passed under the skin bridge into the shoulder defect without twisting the pedicle. The latissimus dorsi tendon of insertion was attached to the acromion with #1 nonabsorbable sutures. The origin of the muscle was trimmed distally, medially and laterally to bleeding margins. With the elbow extended the muscle was interwoven with the remaining triceps tendon distally and fixed with multiple # 1 nonabsorbable sutures (Fig. 6 ) . Flexion of the elbow was 100 degrees without suture or muscle tearing or neurovascular pedicle stretching. The skin defect at the donor site was closed primarily over a deep drain. The skin paddle was sutured into the shoulder defect and the remaining local skin flaps closed over deep drains (Figs. 7, 8). Postoperatively the patient was placed in a long arm over the shoulder splint with 45 degrees of flexion at the elbow.
Fig. 6. Transposition of the latissimus dorsi muscle occurs by rotation of its neurovascular pedicle. Reattachment is made to the acromion proximally and to the triceps tendon distally.
Six weeks postoperatively, the wounds had healed and the patient began active and passive range of motion therapy of the right shoulder and elbow. Electromyogram 4 months postoperatively revealed a functional latissimus dorsi muscle in the upper arm and no activity in the stump of the distally preserved triceps. Physical examination eight months postoperatively revealed: well-healed donor and recipient sites, elbow range of motion of 0 to 95 degrees, and extension strength (9.5). Shoulder motion (right/left) was abduction 90/170, flexion 100/170, extension 20/30, adduction 20/60, external rotation 30135, internal rotation 65/90 (Figs. 9-1 1). Shoulder strength was 445. The patient’s power of elbow extension was completely normal. He attended only 10 rehabilitation sessions and was gratified with the outcome. He could easily perform activities related to the head and neck. He held heavy objects in his outstretched arm in all positions of shoulder rotation. Forcible extension activities in the construction trade were performed satisfactorily, while limited by shoulder strength. Good
Latissimus Dorsi Musculocutaneous Flap for Elbow Extension
65
Fig. 10. Elbow extension to 0 degrees against gravity is shown.
Fig. 7. Frontal view demonstrates loss of shoulder bulk due to the total reduction of the deltoid. Fig. 8. Posterior view demonstrates good bulk in the brachium and well-healed donor and recipient sites.
Fig. 11. Elbow flexion to 95 degrees and terres major function to replace latissimus dorsi muscle loss in glenohumeral adduction are well visualized.
Fig. 9. Shoulder abduction to 90 degrees is demonstrated
shoulder motion was aided by the two joint actions of the transposed muscle, which added stability to the glenohumeral joint.
DISCUSSION The latissimus dorsi myocutaneous flap is a useful tool for reconstruction purposes about the shoulder and upper arm. A number of muscle transpositions have been described for restoration of loss of extension using the latissimus dorsi muscle [4,10-121. Its long (9-15 cm) neurovascular pedicle permits rotation up to 180 degrees
without risk of rotation injury [ 131. Studies indicate that the muscle is totally expandable with no functional loss at the shoulder [ 14,151. In the patient described, not only was there loss of active elbow extension and limited elbow flexion, but there was also stiffness of the shoulder and a massive skin defect, following wide resection of extra-abdominal fibromatosis of the deltoid and triceps. The latissimus dorsi musculocutaneous flap replaces the triceps muscle for powerful elbow extension. It has a great excursion, permitting excellent flexion. Stability of the glenohumeral joint is enhanced, permitting better shoulder function. Coverage in a single stage of enormous skin defects facilitates rehabilitation of the extremity. Contour and bulk of the mid- and lower brachium are cosmetically restored. Incisions can generally be closed primarily. Microvascular techniques used in free composite tissue transfers are unnecessary when the latissimus dorsi musculocutaneous flap is transposed to restore muscle function and skin deficit.
66
Pruzansky et al.
REFERENCES 1. Abu-Jamra FN, Massad N, Musharafieh RC: Reconstruction of shoulder and arm defects using the latissimus dorsi myocutaneous flap. A report of five cases. Scand J Plast Reconstr Surg 20(3): 307-31 1, 1986. 2. Bostwick J 111, Nahi J, Wallace JG, Vasconez LC: Sixty latissimus dorsi flaps. Plast Reconstr Surg 63:3141, 1979. 3. Cohen BE: Shoulder defect correction with the latissimus dorsi flap. PIast Reconstr Surg 74:65&656, 1984. 4. Schottstaedt ER, Larsen LJ, Bost FC: Complete muscle transposition. J Bone Joint Surg 37A:897-919, 1955. 5. Stem PJ, Carey JP: The latissimus dorsi flap for reconstruction of the brachium and shoulder. J Bone Joint Surg 70A:526-535, 1988. 6. Brones MF, Wheeler ES, Lesavoy MA: Restoration of elbow flexion and arm contour with the latissimus dorsi myocutaneous flap. Plast Reconstr Surg 69:329-332, 1982. 7. Moneim RS, Omer GE: Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg 1 lA:I35-139, 1986. 8. Zancolli E, Mitre H: Latissimus dorsi transfer to restore elbow
9. 10. 11. 12. 13. 14.
15.
flexion. An appraisal of eight cases. J Bone Joint Surg 55A: 12651275, 1973. Du Toft GT, Levy SJ: Transposition of latissimus dorsi for paralysis of triceps brachii. Report of a case. J Bone Joint Surg 49B: 135-1 37, 1967. Harmon PH: Muscle transplantation for triceps palsy. The technique of utilizing the latissimus dorsi. J Bone Joint Surg 3 lA:409412, 1949. Hovnanian AP: Latissimus dorsi transplantation for loss of flexion or extension at the elbow. A preliminary report of technic. Ann Surg 143:493499, 1956. Landra AP: The latissmus dorsi musculo-cutaneous flap used to resurface a defect on the upper arm and restore extension to the elbow. Br J Plast Surg 32:275-277, 1979. Bartlett SP, May JW, Jr, Yaremchuk MJ: The latissimus dorsi muscle: A fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 67:631436, 1981. Laitune JKG, Peck T: Shoulder function following the loss of the latissimus dorsi muscle. Br J Plast Surg 38:375-379, 1985. Russell RC, Pribaz J, Zook EG, Leighton WL, Eriksson EF, Smith CJ: Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 78:336-344, 1986.
Latissimus Dorsi Musculocutaneous Flap for El bow Extension MARK PRUZANSKY, MD, MARK KELLY, MD, AND HUBERT WEINBERG, MD From the Department of Orthopedic Surgery (M.P., M.K.) and the Division of Plastic Surgery, Department of Surgery (H.W.), the Mount Sinai School of Medicine, New York, New York
The latissimus dorsi mycocutaneous flap has developed a reputation for its versatility in both skin and soft tissue coverage and for restoration of elbow function in both flexion and extension. In a case presented, a large extra-abdominal desmoid was removed along with the entire deltoid and three-quarters of the triceps. The latissimus dorsi was elevated with a large overlying skin island and rotated on its neurovascular pedicle into the defect in the posterior shoulder and upper arm to replace the resected triceps and deltoid muscle, and to provide coverage in this region. KEYWORDS:desmoid, shoulder tendon transfer
INTRODUCTION The latissimus dorsi mycocutaneous flap has developed a reputation for its versatility in both skin and soft tissue coverage and restoration of elbow function in both flexion and extension. [I-51. Much of the present literature with regard to functional restoration about shoulder and elbow involves transposition of the latissimus dorsi into the flexor compartment of the upper arm [6-81. Descriptions of its use to supplant functionless triceps muscles do exist; however, these involve tunneling the flap into the posterior arm [4,9] transposing the insertion distally, while leaving the origin in place [lo], carrying the primary incision from the back over the posterior axillary fold onto the posteromedial aspect of the arm [ 111, leaving the insertion in place, and transposing the origin distally to the olecranon [12]. In the case presented, the muscle was elevated with a large overlying skin island and rotated on its neurovascular pedicle into a defect in the posterior shoulder and upper arm to replace a restricted triceps and deltoid muscle and to provide coverage in this region. CLINICAL MATERIAL A 48-year-old right-handed manual laborer presented with a slowly enlarging soft tissue mass in the posterolateral aspects of the right arm and shoulder. He complained of rigidity of the right shoulder and progressive loss of elbow motion. Twelve and 11 years earlier, two partial tumor resections had been performed for extra0 1991 Wiley-Liss, Inc.
abdominal fibromatosis of the deltoid muscle. Physical examination revealed a 10 cm X 10 cm firm, nontender mass on the posterolateral aspects of the right shoulder and upper arm; 3- and 4-inch longitudinal scars adherent to the skin and occasional dimpling were noted (Fig. 1 ) . There was no apparent active or passive motion of the glenohumeral joint. All of his shoulder motion (50 degrees) was scapulothoracic. Elbow extension was 0 to 50 degrees, and strength was good (4/5). Latissimus dorsi muscle function was assessed to be normal. Distal neurovascular function was within normal limits, Computed tomography (CT) of the right shoulder revealed the soft tissue mass to be an infiltrating lesion of almost the entire deltoid and upper one-half of the triceps. Four weeks prior to reconstruction, an open biopsy demonstrated recurrent fibromatosis of the deltoid. At surgery the patient was placed in the lateral decubitus position. The two previous scars with a normal margin were included in an ellipse of skin to be excised because of its diffuse adherence to the underlying fascia. Skin flaps were raised around the shoulder to permit access to the entire deltoid origin. The entire right deltoid, the proximal 80% of the triceps, which was also involved by the tumor, and a 12 Accepted for publication December 13, 1990. Address reprint requests to Dr. Mark Pruzansky, 1050 Fifth Avenue, New York, NY 10028. This paper was presented at the American Academy of Orthopaedic Surgeons Meeting. New Orleans, February, 1990.
Latissimus Dorsi Musculocutaneous Flap for Elbow Extension
Fig. 1. Preoperative appearance of the tumor involving almost the entire deltoid and most of the triceps. Dimpling of the skin caused by invasion of superficial structures and the two previous surgical sites can be seen anteriorly (top) and posteriorly (bottom).
63
Fig. 3. The gross pathology of the fibromatosis of the deltoid, triceps and overlying skin.
Fig. 2. Tumor and overlying skin have been removed revealing the rotator cuff muscles posteriorly (top), the biceps anteriorly (bottom), and the radial nerve (middle).
cm X 20 cm area of overlying skin were resected (Figs. 2, 3). The radial nerve was isolated from the posterior cord to the extensor carpi radialis longus, sacrificing branches to the triceps. After acromioplasty and bursectomy were performed, three drill holes were made in the posterolatera1 acromion process. The size of the cutaneous recipient defect was measured. Due to the large size of the underlying muscle, a very large skin defect can be safely covered by the cutaneous portion of this flap. A large ellipse was outlined in the skin and subcutaneous tissues corresponding to the recipient defect (Fig. 4). Skin flaps were elevated in all directions to expose the entire latissimus dorsi muscle. Beginning from the musculotendinous junction superiorly, the entire submuscular plane above the chest wall was dissected distally and medially until the muscle was severed from its paraspinal muscle
I
Fig. 4. The latissimus dorsi muscle has a broad origin from the ribs and lumbar fascia and inserts into the intertubercular groove of the upper humerus.
and lumbar fascia1 attachments (Fig, 5 ).The neurovascular pedicle was identified in the proximal one-third of the muscle where it enters posterolaterally . The thoracodorsal artery and its venae comitantes were mobilized up to
64
Pruzansky et al.
Fig. 5. The latissimus dorsi musculocutaneous flap has been removed from the patient’s back on its pedicle. The shoulder wound is at the top of the picture.
the axillary artery and vein. The thoracodorsal nerve was dissected free from its tissue interval. Dissection of the neurovascular bundle proceeded from both the shoulder and back incisions and converged under the optional skin bridge. The radial nerve was protected as the tendinous insertion of the latissimus dorsi muscle was freed from the intertubercular groove during adduction and internal rotation of the shoulder. A nerve stimulator can be used to test function at this point. In this patient, a small accessory nerve supply to the upper 15% of the muscle was assessed with a nerve stimulator and sacrificed to gain length for the neurovascular pedicle. A subcutaneoustunnel was created by blunt dissection. The flap was passed under the skin bridge into the shoulder defect without twisting the pedicle. The latissimus dorsi tendon of insertion was attached to the acromion with #1 nonabsorbable sutures. The origin of the muscle was trimmed distally, medially and laterally to bleeding margins. With the elbow extended the muscle was interwoven with the remaining triceps tendon distally and fixed with multiple # 1 nonabsorbable sutures (Fig. 6 ) . Flexion of the elbow was 100 degrees without suture or muscle tearing or neurovascular pedicle stretching. The skin defect at the donor site was closed primarily over a deep drain. The skin paddle was sutured into the shoulder defect and the remaining local skin flaps closed over deep drains (Figs. 7, 8). Postoperatively the patient was placed in a long arm over the shoulder splint with 45 degrees of flexion at the elbow.
Fig. 6. Transposition of the latissimus dorsi muscle occurs by rotation of its neurovascular pedicle. Reattachment is made to the acromion proximally and to the triceps tendon distally.
Six weeks postoperatively, the wounds had healed and the patient began active and passive range of motion therapy of the right shoulder and elbow. Electromyogram 4 months postoperatively revealed a functional latissimus dorsi muscle in the upper arm and no activity in the stump of the distally preserved triceps. Physical examination eight months postoperatively revealed: well-healed donor and recipient sites, elbow range of motion of 0 to 95 degrees, and extension strength (9.5). Shoulder motion (right/left) was abduction 90/170, flexion 100/170, extension 20/30, adduction 20/60, external rotation 30135, internal rotation 65/90 (Figs. 9-1 1). Shoulder strength was 445. The patient’s power of elbow extension was completely normal. He attended only 10 rehabilitation sessions and was gratified with the outcome. He could easily perform activities related to the head and neck. He held heavy objects in his outstretched arm in all positions of shoulder rotation. Forcible extension activities in the construction trade were performed satisfactorily, while limited by shoulder strength. Good
Latissimus Dorsi Musculocutaneous Flap for Elbow Extension
65
Fig. 10. Elbow extension to 0 degrees against gravity is shown.
Fig. 7. Frontal view demonstrates loss of shoulder bulk due to the total reduction of the deltoid. Fig. 8. Posterior view demonstrates good bulk in the brachium and well-healed donor and recipient sites.
Fig. 11. Elbow flexion to 95 degrees and terres major function to replace latissimus dorsi muscle loss in glenohumeral adduction are well visualized.
Fig. 9. Shoulder abduction to 90 degrees is demonstrated
shoulder motion was aided by the two joint actions of the transposed muscle, which added stability to the glenohumeral joint.
DISCUSSION The latissimus dorsi myocutaneous flap is a useful tool for reconstruction purposes about the shoulder and upper arm. A number of muscle transpositions have been described for restoration of loss of extension using the latissimus dorsi muscle [4,10-121. Its long (9-15 cm) neurovascular pedicle permits rotation up to 180 degrees
without risk of rotation injury [ 131. Studies indicate that the muscle is totally expandable with no functional loss at the shoulder [ 14,151. In the patient described, not only was there loss of active elbow extension and limited elbow flexion, but there was also stiffness of the shoulder and a massive skin defect, following wide resection of extra-abdominal fibromatosis of the deltoid and triceps. The latissimus dorsi musculocutaneous flap replaces the triceps muscle for powerful elbow extension. It has a great excursion, permitting excellent flexion. Stability of the glenohumeral joint is enhanced, permitting better shoulder function. Coverage in a single stage of enormous skin defects facilitates rehabilitation of the extremity. Contour and bulk of the mid- and lower brachium are cosmetically restored. Incisions can generally be closed primarily. Microvascular techniques used in free composite tissue transfers are unnecessary when the latissimus dorsi musculocutaneous flap is transposed to restore muscle function and skin deficit.
66
Pruzansky et al.
REFERENCES 1. Abu-Jamra FN, Massad N, Musharafieh RC: Reconstruction of shoulder and arm defects using the latissimus dorsi myocutaneous flap. A report of five cases. Scand J Plast Reconstr Surg 20(3): 307-31 1, 1986. 2. Bostwick J 111, Nahi J, Wallace JG, Vasconez LC: Sixty latissimus dorsi flaps. Plast Reconstr Surg 63:3141, 1979. 3. Cohen BE: Shoulder defect correction with the latissimus dorsi flap. PIast Reconstr Surg 74:65&656, 1984. 4. Schottstaedt ER, Larsen LJ, Bost FC: Complete muscle transposition. J Bone Joint Surg 37A:897-919, 1955. 5. Stem PJ, Carey JP: The latissimus dorsi flap for reconstruction of the brachium and shoulder. J Bone Joint Surg 70A:526-535, 1988. 6. Brones MF, Wheeler ES, Lesavoy MA: Restoration of elbow flexion and arm contour with the latissimus dorsi myocutaneous flap. Plast Reconstr Surg 69:329-332, 1982. 7. Moneim RS, Omer GE: Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg 1 lA:I35-139, 1986. 8. Zancolli E, Mitre H: Latissimus dorsi transfer to restore elbow
9. 10. 11. 12. 13. 14.
15.
flexion. An appraisal of eight cases. J Bone Joint Surg 55A: 12651275, 1973. Du Toft GT, Levy SJ: Transposition of latissimus dorsi for paralysis of triceps brachii. Report of a case. J Bone Joint Surg 49B: 135-1 37, 1967. Harmon PH: Muscle transplantation for triceps palsy. The technique of utilizing the latissimus dorsi. J Bone Joint Surg 3 lA:409412, 1949. Hovnanian AP: Latissimus dorsi transplantation for loss of flexion or extension at the elbow. A preliminary report of technic. Ann Surg 143:493499, 1956. Landra AP: The latissmus dorsi musculo-cutaneous flap used to resurface a defect on the upper arm and restore extension to the elbow. Br J Plast Surg 32:275-277, 1979. Bartlett SP, May JW, Jr, Yaremchuk MJ: The latissimus dorsi muscle: A fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 67:631436, 1981. Laitune JKG, Peck T: Shoulder function following the loss of the latissimus dorsi muscle. Br J Plast Surg 38:375-379, 1985. Russell RC, Pribaz J, Zook EG, Leighton WL, Eriksson EF, Smith CJ: Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 78:336-344, 1986.
