Abdominal wall reconstruction with the free functional L‐shaped latissimus dorsi flap: A case report

Abstract

Extensive tridimensional defects of the abdominal wall are usually addressed with soft tissue flaps combined with meshes. In this scenario, the additional value of dynamic abdominal wall reconstruction with functional flaps has yet to be demonstrated. In this paper the authors describe for the first time a unique case of total abdominal wall reconstruction with the free functional L‐shaped latissimus dorsi (LD) flap, designed to increase the surface area of skin flap coverage while minimizing donor site morbidity, highlighting technical tips and long‐term outcomes. A 65‐year‐old patient underwent abdominal wall resection for a dermatofibrosarcoma protuberans, leaving her with a 23 × 15 cm full‐thickness defect. After placing a mesh, a myo‐cutaneous free LD Flap with an L‐shaped configuration was planned. The flap was composed of Paddle A, designed vertically along the anterior margin of the muscle and Paddle B, designed over the inferior aspect of the LD muscle, extending obliquely from the midline and intersecting Paddle A laterally with a 60° angle. End‐to‐end anastomoses to the deep inferior epigastric artery and vein and thoracodorsal nerve coaptation to a sizeable intercostal nerve were performed. The LD muscle was sutured according to its native tension while the two skin islands allowed an almost complete resurfacing of the abdominal wall defect. Donor site was closed primarily. Post‐operative course was uneventful. One year postoperatively, good abdominal contour was observed, with adequate abdominal tone at rest in laying and standing position. Muscle neurotization was confirmed with clinical examination showing voluntary contraction of the transplanted muscle and the patient reported very high functional outcomes at the hernia‐related quality‐of‐life (HerQles) questionnaire. The free L‐shaped LD flap represents an innovative solution to reconstruct extensive full‐thickness defects of the abdominal wall while reducing donor site morbidity. Flap neurotization should be attempted whenever possible to improve functional outcomes of the procedure.

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

“…In this 14-patient series, the authors describe excellent functional outcomes with evidence of reinnervation of the latissimus on EMG, as well as synergistic function between the donor muscle and the residual native abdominal wall at 18 months post-operation [80]. In recent years, several additional groups have reported success utilizing the latissimus muscle for functional abdominal wall reconstruction [82,83].…”

Lower Abdominal vs. Lateral Thigh Perforator Flaps in Microsurgical Sarcoma Reconstruction: The Aesthetics of Donor Site Matters

“…Among the array of available options to treat extensive defects, several significant approaches stand out. The most common solution employed is the latissimus dorsi flap, either muscular and covered with a skin graft or myocutaneous harvested as a “kiss” flap [ 5 , 6 , 7 ], which provides a reliable amount of tissue for coverage, albeit with limitations regarding donor site morbidity and aesthetic outcomes. Another workhorse to reconstruct medium to large-sized defects after sarcoma resection ( Figure 1 A) is the anterolateral thigh (ALT) flap, which, despite its widespread use, unfortunately, may entail higher morbidity at the donor site for flaps exceeding the possibility of primary closure ( Figure 1 B), eventually leading to less aesthetically pleasing outcomes.…”