enhancing the outcome of free latissimus dorsi muscle flap
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ENHANCING THE OUTCOME OF FREE LATISSIMUS DORSIMUSCLE FLAP RECONSTRUCTION OF SCALP DEFECTS
Joan E. Lipa, MD, MSc, FRCS(C), Charles E. Butler, MD, FACS
Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd.,
Unit 443, Houston, TX 77030-4009. E-mail: cbutler@mdanderson.org
Accepted 22 May 2003
Published online 23 September 2003 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.10338
Abstract: Background. Reconstruction of scalp and calvarial
defects after tumor ablation frequently requires prosthetic
cranioplasty and cutaneous coverage. Furthermore, patients
often have advanced disease and receive perioperative radio-
therapy. We evaluated the complications of scalp reconstruction
with a free latissimus dorsi muscle flap in this setting.
Methods. The complications and the oncologic and aesthetic
outcomes of six consecutive scalp reconstructions with a free
latissimus dorsi muscle flap and skin graft in five patients with
advanced cancer were retrospectively evaluated. Patient, tumor,
defect, reconstructive, and other treatment characteristics were
reviewed. Reconstructive and perioperative techniques in-
tended to improve flap survival and aesthetic outcome and
reduce complications in these patients.
Results. All patients (52–76 years old) had recurrent tumors
(sarcoma, melanoma, or squamous cell carcinoma) and
received postoperative radiotherapy. The mean scalp defect
size was 367 cm2, and partial-thickness or full-thickness
calvarial resection was required in all six cases. No vein grafts
were needed. The mean follow-up period and disease-free
survival time were 18 and 13 months, respectively. Three
patients died of their disease, and two survived disease free.
There were no flap failures or dehiscences. Complications
consisted of donor site seroma in two patients; partial skin graft
loss in one patient; and radiation burns to the flap, face, and ears
in one patient. Scalp contour and aesthetic outcome were very
good in all cases except for the one case with radiation burns.
Conclusions. Good outcomes were achieved using a free
latissimus dorsi muscle flap with a skin graft for flap recon-
struction in elderly patients with advanced recurrent cancers
who received perioperative radiotherapy. Several technical
aspects of the reconstruction technique intended to enhance
the functional and aesthetic outcome and/or reduce complica-
tions were believed to have contributed to the good results.
B 2004 Wiley Periodicals, Inc. Head Neck 26: 46–53, 2004
Keywords: surgical flaps; latissimus dorsi muscle; scalp;
calvarium; microsurgery; squamous cell carcinoma; sarcoma;
skin graft
Reconstruction of scalp defects after oncologic
resection commonly requires free tissue transfer.
Although local flaps can provide single-stage scalp
reconstruction with good aesthetic results, the size
of the defect and previous reconstructive proce-
dures often preclude the use of local flaps. Further-
more, patients are often elderly, have advanced
malignancies, and receive adjuvant radiotherapy.
In addition, the scalp lesions might have recurred
after previous resection and reconstruction, or the
lesions might be ulcerated and contaminated with
bacteria and the remaining calvarial bone widely
exposed and devoid of periosteum.
Since the inception of free tissue transfer, the
free latissimus dorsi muscle flap has been
recognized as an excellent option for scalp
reconstruction because of its large surface area,
long vascular pedicle, and provision of reliable,
well-vascularized tissue.1,2 However, the revision
Correspondence to: C. E. Butler
Presented in part at the 17th Annual Meeting of the American Society forReconstructive Microsurgery, Cancun, Mexico, January 12, 2002.
B 2004 Wiley Periodicals, Inc.
HEAD & NECK January 200446 Technical Refinements In Scalp Reconstruction
rate with free flaps is high—reported as 20% to
32%.3,4 Because many cancer patients requiring
large resections of scalp and calvarium have a poor
prognosis,5 a single-stage surgical procedure—
without the need for revisions—is desirable to
improve the quality of remaining life in these
patients and to allow for undelayed delivery of
postoperative radiotherapy.
Significant wound healing complications occur
in approximately one third of cancer patients
undergoing scalp reconstruction after tumor abla-
tion even when the entire flap survives.4 Potential
complications and adverse outcomes include par-
tial flap necrosis, the need for vein grafts because
of long pedicle length requirement, wound dehis-
cence with bone or cranioplasty exposure, donor
site seromas, and contour irregularities such as
depression of the scalp-flap junction and excessive
bulk at the muscle origin. Methods to reduce flap
and wound healing complications and enhance
aesthetic results would improve the outcome of
scalp reconstruction.
The purpose of this study was to evaluate the
complications and outcomes of scalp reconstruc-
tion using the free latissimus dorsi muscle flap in
patients with advanced malignancies. The tech-
nical aspects of the reconstruction technique that
were used to reduce complications and improve
functional and aesthetic outcome are described
in detail.
PATIENTS AND METHODS
All free latissimus dorsi muscle flap reconstruc-
tions of the scalp performed by the senior author
(CEB) at The University of Texas M. D. Anderson
Cancer Center over a 2-year period (June 30, 1999,
to July 1, 2001) were retrospectively reviewed.
Patients were identified by query of a comprehen-
sive departmental database, and the charts of all
identified patients were reviewed. Patient, tumor,
and defect characteristics, operative details, use
and dose of perioperative radiotherapy, complica-
tions, and outcomes were analyzed.
RESULTS
Six latissimus dorsi muscle flaps were used for
scalp reconstruction in five patients (all men;
mean age, 64.8 years; age range, 52–76 years)
after resection of sarcoma (four flaps), melanoma
(one flap), or squamous cell carcinoma (one flap)
(Table 1). All tumors were local recurrences, and in
all cases the patient had previously undergone a
scalp flap and/or a skin graft reconstruction after
resection. All patients received radiotherapy
(mean dose, 62.4 Gy) postoperatively, and the
patient who received two latissimus dorsi flaps
also had radiotherapy after the second surgery.
The mean scalp defect area was 367 cm2
(range, 195–900 cm2). All six tumor resections
required calvarial bone excision: full-thickness
(mean size, 67 cm2; range, 20–99 cm2) in three
cases and outer table only in three cases (mean
size, 43 cm2; range, 20–90 cm2). The three full-
thickness calvarial defects were reconstructed
with titanium mesh in two cases and methylme-
thacrylate in one case. Resection of the dura was
required in one case (patient 4), which involved
resection of the cerebral cortex; reconstruction of
Table 1. Summary of tumor and defect characteristics and outcomes.
Patient
Tumor
histology*
Calvarial
defect, cm2Scalp
defect, cm2Follow-up,
mo Outcome Complications
1 Angiosarcoma 20 (PT) 900 8 Died, 8 months postop,
metastasis (lungs)
Partial skin graft loss;
severe radiation burns
2a Unclassified sarcoma 20 (FT) 288 27 Local recurrence (scalp),
7 mo postop
None
2b Unclassified sarcoma 30 (PT) 400 20 Alive, NED, 27 mo
postop from primary resection
Donor site seroma
3 Squamous cell carcinoma 90 (PT) 195 26 Alive, NED, 26 mo postop None
4 Angiosarcoma 99y (FT) 210 14 Died, 14 mo postop,
local recurrence (brain)
None
5 Melanoma 81 (FT) 210 18 Died, 18 mo postop,
local recurrence (brain)
and metastasis (lungs and bone)
Donor site seroma
*All were recurrent tumors of the scalp.yIncluded dura and cerebral cortex resection.Abbreviations: FT, full thickness; NED, no evidence of disease; postop, postoperatively; PT, partial thickness.
Technical Refinements In Scalp Reconstruction HEAD & NECK January 2004 47
the dura was performed with allogeneic dura.
Recipient vessels used for the free flaps were the
superficial temporal artery and vein (both end-to-
end) in five cases and the external carotid artery
and internal jugular vein (both end-to-side) in one
case. No vein grafts were required.
No complete or partial flap losses were encoun-
tered. Complications occurred in three patients. In
one patient who underwent a near-total scalp
reconstruction, 7% of the skin graft over the distal
flap area did not survive. Fortunately, the distal
aspect of this large muscle flap was purposely
oriented over the unresected portion of the right
temporalis muscle (rather than bone) to facilitate
treatment if vascular insufficiency of the flap
occurred in this location (Figure 1). This area
likely would have reepithelialized after debride-
ment and dressing changes; however, a skin graft
was placed to allow prompt initiation of radio-
therapy. The patient had significant radiation
burns to his face, ear, neck, chest, and flap site and
refused further treatment because of the develop-
ment of rapidly progressive metastatic disease.
The other two patients with complications had a
seroma develop in the flap donor site; both
FIGURE 1. (A) Near-total scalp defect after radical excision of an angiosarcoma in a 52-year-old man. (B) The latissimus dorsi muscle
was inset into the defect after microsurgical anastomosis to the left superficial temporal vessels. The distal (least reliable) aspect of the
flap was intentionally oriented over the unresected portion of right temporalis muscle to facilitate treatment if this portion of the flapdeveloped vascular insufficiency.
Table 2. Technical considerations to improve outcome.
Purpose Techniques
I. Improve flap survival. Wide undermining and scoring of galea in pedicle tunnel. Orientation of submuscular drainage catheter parallel to flap
vascular axis. Diligent postoperative patient positioning to prevent com-
pression of flap and pedicle
II. Reduce pedicle length requirements (and need for vein
grafts). Use of superficial temporal recipient vessels when possible. Intramuscular pedicle dissection. Incision/excision of scalp tissue between defect and
recipient site to accommodate flap base. High dissection of thoracodorsal donor vessels
III. Reduce recipient site complications. Use of proximal portion of muscle flap for calvarial and
cranioplasty coverage. Orientation of least reliable flap areas to minimize morbidity if
partial flap necrosis occurs. Vest-over-pants flap inset. Evenly distributed, low-pressure compression head dressing
IV. Reduce donor site seromas. Dependent, closed suction catheter drainage. Postoperative compression binder. Use of fibrin sealant
V. Improve aesthetic results. Tangential excision/debulking of muscle origin. Vest-over-pants inset to improve flap-scalp junction contour. Non-meshed skin grafts with quilting sutures
HEAD & NECK January 200448 Technical Refinements In Scalp Reconstruction
seromas resolved with percutaneous drainage and
continued use of a compression binder. There were
no other significant complications.
Except for the patient with radiation burns, all
patients had very good scalp contour. The
latissimus dorsi muscle atrophied to approxi-
mately 50% of its original thickness over the first
4 months, and the cranioplasty site did not show
significant contour deformity in any patient.
One patient had two synchronous areas of
local recurrence in the occipital scalp, posterior
to the latissimus dorsi scalp reconstruction,
7 months postoperatively. After radical resection
of the recurrences, the other latissimus dorsi
muscle was used for free flap reconstruction.
The mean follow-up period after reconstruc-
tion was 18 months (range, 8–27 months). Three
of the five patients died of their disease a mean of
13 months postoperatively (range, 8–18 months).
The remaining two patients were alive with no
evidence of disease at 26 and 27 months’ follow-up
(Table 1). The mean disease-free survival
for all five patients was 12.6 months (range,
3–27 months), and the mean overall survival was
18.2 months (range, 8–27 months).
DISCUSSION
Free tissue transfer is widely used for reconstruc-
tion of large scalp defects caused by oncologic
resection, because it enables placement of well-
vascularized tissue over the calvarium (fre-
quently devoid of periosteum) and the prosthetic
cranioplasty.2–10 However, despite the use of free
tissue transfer in scalp reconstruction, complica-
tions and poor aesthetic results often necessitate
surgical revision.
We had good outcomes and a low incidence of
complications with free latissimus dorsi flaps for
scalp reconstruction in our small series of mostly
elderly patients, all of whom had locally advanced
recurrent disease and received perioperative
radiotherapy. Several operative and perioperative
technical considerations likely reduced complica-
tions and improved flap survival and aesthetic
outcome (Table 2).
Techniques to Improve Outcome. Before insetting
the flap, the pedicle of the flap was carefully
passed through a wide tunnel to the recipient
vessel site. To prevent compression and kinking
of the pedicle within the tunnel, wide under-
mining between the scalp defect and the incision
site over the recipient vessels was carried out,
with scoring of the galea parallel to the pedicle
axis. Alternately, the tissue overlying the pedicle
was incised and undermined to accommodate the
proximal aspect of the muscle flap.
The pedicle length requirement was reduced,
and vein grafts were avoided by using the super-
ficial temporal vessels as recipients whenever the
orientation of the flap allowed (Figure 2). Despite
FIGURE 2. The superficial temporal vessels are used formicrovascular anastomoses when available and near the defect.
This often minimizes the pedicle length required and avoids the
need for vein grafts.
FIGURE 3. (A) Scalp and calvarial defect after resection in a 66-year-old man with recurrent squamous cell carcinoma of the occipital
scalp and calvarium. (B) The external carotid system and internal jugular vein were used as recipient vessels to minimize pedicle length. Ascalp incision and wedge excision were performed into which the flap base was inset, allowing the vascular pedicle of the flap to reach the
recipient vessels without vein grafts. Debulking of the muscle insertion area was performed to improve the contour. Considerable muscle
atrophy can be expected to occur over time. (C) Posterior and 1(D) lateral views of the scalp reconstruction 6 months postoperatively,
demonstrating a smooth scalp contour without excessive bulk at the flap base.
Technical Refinements In Scalp Reconstruction HEAD & NECK January 2004 49
HEAD & NECK January 200450 Technical Refinements In Scalp Reconstruction
reports of the superficial temporal vein being
insufficient for microvascular anastomosis in a
number of cases, 4 we found that the superficial
temporal vessels, if palpable preoperatively, were
consistently reliable with adequate caliber in all
of the five cases in which they were used. In one
case, the neck vessels were used as recipients,
because the scalp defect extended posteriorly and
a shorter pedicle length was possible by coursing
the pedicle posterior to the ear. The thoracodorsal
vessels were dissected completely to their origin
from the axillary vessels if required, the pedicle
was dissected intramuscularly to increase pedicle
length when needed, and adjacent scalp tissue
between the defect and recipient vessels was
selectively incised and/or excised to accommodate
the muscle inset (Figure 3). The most proximal
aspect of the muscle flap near its tendinous
insertion was carefully resected or debulked
tangentially to facilitate insetting and improve
the resulting contour and aesthetic outcome.
Calvarial exposure after scalp reconstruction
in cancer patients is a complication that fre-
quently requires reoperation.4 To reduce the risk
of flap inset dehiscence leading to exposure of the
calvarium or the cranioplasty, as well as to
improve the contour of the flap-scalp junction,
we performed circumferential subgaleal wound
edge undermining for approximately 2 cm. A vest-
over-pants flap inset was used (Figure 4) by
suturing the muscle flap edge to the galea of the
undermined scalp wound edge to provide an
approximately 1.5-cm zone of ‘‘scalp-over-muscle’’
coverage around the entire circumference of the
inset flap. This maneuver improved the aesthetic
outcome by preventing the depression often seen
at the scalp-muscle junction and reduced the risk
of wound dehiscence in the event of partial
muscle edge necrosis. The dermis of the scalp
edge was then secured to the surface of the
latissimus dorsi muscle flap with interrupted
absorbable sutures before the placement of a
nonmeshed, split-thickness skin graft. When
possible, the most proximal aspect of the muscle
was used for calvarial and cranioplasty coverage
and the most distal (least reliable) aspect of the
flap was positioned so that the least morbidity
would result if partial flap loss were to occur. For
example, the distal aspect of the flap was
commonly placed over intact temporalis muscle
and/or intact periosteum, remote from the pros-
thetic calvarial bone reconstruction.
A closed-suction drain was placed under the
muscle flap, away from the cranioplasty site or
vascular pedicle and oriented parallel to the flap’s
vascular axis. This parallel orientation reduces
the risk of vascular compromise to flap areas
distal to the drain location (directly over bone),
particularly if a compressive dressing is used to
help immobilize the skin graft.
FIGURE 4. A vest-over-pants inset is used to prevent subsequent depression and/or bone exposure at the flap-scalp junction. The
periphery of the scalp defect is elevated through the subgaleal plane for approximately 2 cm, the muscle edge is sutured to the galea
beneath the undermined scalp, and then the scalp defect edge is secured over the muscle flap surface.
Technical Refinements In Scalp Reconstruction HEAD & NECK January 2004 51
To optimize skin graft survival, we used non-
meshed skin grafts with multiple 6-0 chromic
quilting sutures (Figure 5), meticulous skin graft
insetting with interrupted and running chromic
sutures, and carefully constructed, uniformly
compressive, low-pressure head dressings. The
dressing we found most useful was N-TerFace
(Winfield Laboratories, Dallas, TX), covered by
sterile cotton and an elastic ‘‘fishnet’’ tubing to
secure the dressing. Transcutaneous Doppler
arterial and venous signals were marked with a
Prolene suture and exposed by separating the
cotton and cutting a hole in the N-TerFace for the
ultrasound transducer. The skin-grafted flap could
also be directly visualized through this opening.
One of the most important postoperative
considerations is proper patient positioning to
avoid compression of the flap or pedicle, which are
both located directly over bone or bony recon-
struction. Our patients were positioned with the
head of the bed elevated 45 to 70 degrees and the
patients’ heads maintained in a neutral position
using pillows or foam pads placed on both sides of
and behind the head, inferior to the occiput. This
was sufficient in most cases to prevent compres-
sion on the flap site, even during sleep. If this is
ineffective in preventing flap compression, partic-
ularly with posterior reconstructions, a halo
device should be considered.
To reduce the risk of seromas, two closed-
suction drainage catheters were positioned in the
donor site to provide dependent drainagewhile the
patient was supine or upright. A circumferential
compression binder was worn postoperatively over
the donor site area until all drainage catheters had
been removed for at least 3 weeks. Each drain was
removed when its 24-hour output was less than
25 mL per drain for 2 consecutive days.
Recently, we have started using aerosolized
fibrin sealant (Tisseel, Baxter Healthcare Corp.,
Deerfield, IL) sprayed into the latissimus dorsi
muscle donor defect immediately before closure;
in our preliminary experience, we have observed
less drainage fluid and a lower incidence of
seromas with this technique. The thrombin
component of a 5-mL Tisseel kit is diluted 100-
fold (from 500 to 5 IU/mL per manufacturer’s
dilution instructions). This dilution allows addi-
tional time for approximating the edges of the
donor site wound before polymerization. After
application of the fibrin sealant, several sutures
preplaced through the wound edges are immedi-
ately tied to allow the fibrin sealant to set with
the donor site tissues in the proper position.
CONCLUSIONS
The free latissimus dorsi muscle flap with a split-
thickness skin graft is an excellent, reliable
option for reconstruction of large scalp defects.
We believe that certain technical aspects contrib-
ute to a good functional and aesthetic outcome,
even in elderly patients with advanced disease
receiving perioperative radiotherapy.
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FIGURE 5. Nonmeshed split-thickness skin grafts are meticu-
lously inset over the muscle flap with edge eversion and secured
to the flap with absorbable quilting sutures.
HEAD & NECK January 200452 Technical Refinements In Scalp Reconstruction
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Technical Refinements In Scalp Reconstruction HEAD & NECK January 2004 53
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