The latissimus dorsi free flap is a muscle flap that can be harvested with a skin paddle. It has a long vascular pedicle from the thoracodorsal artery and vein, allowing it to reach distant sites. The large size of the latissimus dorsi muscle makes it suitable for covering large wounds. It is one of the most commonly used flaps in reconstructive microsurgery, along with the rectus abdominis and radial forearm flaps. While harvesting the flap requires the patient to be in a side-lying position, it provides ample tissue to reconstruct large defects of the head, neck, and other areas.

1. Latissimus dorsi Free flap
JAMEEL KIFAYATULLAH

2. Latissimus dorsi Free flap
• Tissue: Muscle flap. May be
harvested with a skin paddle.
• Innervation: The thoracodorsal
nerve.
• Blood supply: Thoracodorsal
artery via the subscapular
artery.
• Artery: Can be up to 2 or 5
mm if harvested up to the
subscapular artery.
• Vein(s): Comparable to the
artery. A single venae
commitans.
• Pedicle length: Up to 15
centimeters.

3. Latissimus dorsi Free flap
• The latissimus dorsi muscle is the largest muscle in the body, up to
20 by 40 centimeters, allowing coverage of extremely large
wounds.
• In spite of its size, no significant donor functional deficit results
from removal of the muscle.
• It is the largest flap that can be harvested on a single predicle, and
can even be combined with the serratus, scapular or parascapular
flaps, to create a flap complex that can cover massive wounds.
• In the normal population the muscle is quite thin (less than 1
centimeter thick), allowing it to be draped over irregular surfaces
with ease.
• With the rectus muscle and radial forearm flap, it represents one
of the workhorse flaps in reconstructive microsurgery.
• When re-innervated using the thoracodorsal nerve, the latissimus
can be used as a functional muscle.

4. Anatomy
• The muscle takes origin on the iliac
crest inferiorly and the
thoracolumbar fascia posteriorly
near the midline.
• It inserts into the humerus where it
acts as a humeral adductor and
internal rotator.
• The posterior axillary fold is made
up of the most superior aspect of
the muscle that begins to narrow
before it forms the tendon of
insertion.
• The nerve supply is via the
thoracodorsal nerve, a branch of
the posterior cord of the brachial
plexus. Lesions of C-7 will affect
latissimus function. The nerve
closely accompanies the
thoracodorsal artery.

5. Anatomic landmarks
1. Axilla
2. Tip of scapula
3. Anterior margin of
latissimus is palpable
4. Iliac crest
5. Midline of back X
axilla
Tip of scapula
Anterior marg
latissmus
Iliac crest
Midline of back

6. Anatomic landmarks
• The margins of the latissimus dorsi muscle
extend from the tip of the scapula to the
midline of the back posteriorly and with its
fascial extension to the iliac crest inferiorly
• The anterior border of the muscle passes on
an oblique line from the midpoint of the iliac
crest to the axilla. This prominent border
forms the posterior axillary fold together with
the subscapular and the teres major muscles

7. Flap dimensions
Muscle dimensions
• Length: 35cm (range 21–42cm)
• Width: 20cm (range 14–26cm)

8. Operative procedure
• The patient is placed in
the lateral decubitus
position on a beanbag,
with an axillary roll placed
in the dependent
axilla. The ipsilateral arm
is prepped completely
and left in the operative
field, allowing it to be
freely moved about the
field

9. Operative procedure
• The latissimus border is
outlined with a marking
pen. The incision is then
marked extending from the
axilla or the posterior axillary
fold, then inferiorly and
medially over the latissimus
muscle. The length of muscle
needed will dictate the
incision length. Alternatively, if
a skin paddle is necessary, it is
marked over the flap. A pencil
Doppler can be used to ensure
the presence of a perforator in
the skin paddle.
The patient is marked in the lateral decubitus
position for the extent of the muscle, skin
incision and possible skin paddle.

10. Operative procedure
• Anterior and posterior flaps
are raised superficial to the
muscle to expose the
latissimus. A small amount of
muscular fascia can be left on
the latissimus, but this is not
necessary. Any comfortable
plane for the surgeon is
adequate. The skin and fat
flaps are elevated to the
extent of the pocket necessary
for adequate muscle size
harvest. Smaller muscle can be
taken if the entirety of the
muscle is not needed.
The pocket is dissected

11. Operative procedure
• The superior edge of
the latissimus is
identified at the inferior
angle of the scapula.
The serratus muscle can
be identified easily with
this approach.

12. Operative procedure
• The superior edge of the
latissimus, below the
inferior angle of the scapula
is then elevated. This
areolar plane is easy to
dissect, and any large
caliber perforators can be
ligated and divided. The
dissection is then directed
toward the midline, and the
insertions of the muscle
near the midline of the back
is divided. The dissection
proceeds inferiorly freeing
the medial muscle insertion. The superior edge of the muscle is
elevated

13. Operative procedure
• When the inferior portion
of the muscle is reached,
the attachment plane here
is not clear and muscle be
created with the
electrocautery. After the
medial and inferior muscle
is released, the dissection
proceed underneath the
muscle toward the axilla.
The plane becomes very
thin and areolar and easy to
dissect. The muscle is freed of medial and
inferior attachments

14. Operative procedure
• The vessels to the
latissimus and serratus
become clear as the axilla
is neared. The branch to
serratus is ligated and the
circumflex scapular
branch can be if more
length is needed. The
nerve is divided and the
artery and vein can be
ligated and divided when
the recipient area is
ready.
The muscle harvest is complete and
pedicle remains attached

15. Operative procedure
• The wound is closed with a deep and
superficial layer. Two suction drains are
placed through the anterior skin flap.

16. POSTOPERATIVE CARE
• Allow the patient to use the ipsilateral arm
postoperatively and no special dressings are
required. The donor area should be inspected
daily for hematoma formation. This donor
area often forms a seroma, necessitating the
use of drains for often more than a
week. Leave them in for 2 weeks or longer
until the output is diminished. Seromas should
be aspirated.

17. Advantages
• Rapid and easy dissection
• Longer vascular pedicle and large caliber of
the vessels facilitating microvascular transfer
• A skin island can be orientated vertically,
obliquely or transversely as desired or
required by the defect
• extremely long vascular pedicle, making the
flap especially suitable for large skin defects or
anastomotic sites remote from the defect

18. Disadvantages
• Requires patient to be in prone position or on side with
arms abducted
• Bulky flap
• the functional deficit of shoulder and arm function
from loss of the latissimus dorsi muscle is estimated to
average approximately 7% in most individuals. Some
sports and muscle activities can be negatively affected.
• Other disadvantages are directly related to donor site
complications. Pains at the donor site and seroma
formations are occasionally seen. Most of these
symptoms disappear over time, and persistent
complaints are rare

19. Indications
• For covering huge defects in calvarial area
• Filling of orbital defects
• Reconstruction of maxillary defects when no
bone is required
• Perforating defects of the cheek,nose and palate
• Reconstruction of tongue following total
glossectomy
• For covering large skin and soft tissue defects in
the neck area