[The conjoined latissimus dorsi and parascapular free flap for reconstruction of extensive soft tissue defects]

OBJECTIVE

Durable and resilient soft tissue reconstruction of vast defects of the extremities or the torso.

INDICATIONS

Reconstruction of disproportionately large defects, particularly in cases of simultaneous bone and joint reconstruction.

CONTRAINDICATIONS

History of surgery or irradiation of upper back and axilla, impossibility of surgery under lateral positioning; relative contraindications in wheelchair users, hemiplegics, or amputees.

SURGICAL TECHNIQUE

General anesthesia and lateral positioning. First, the parascapular flap is harvested, with the initial skin incision made medially in order to identify the medial triangular space and the circumflex scapular artery. Flap raising then proceeds from caudal to cranial. Second, the latissimus dorsi is harvested, with the lateral border being dissected free first, before the thoracodorsal vessels are visualized on its undersurface. Flap raising then proceeds from caudal to cranial. Third, the parascapular flap is advanced through the medial triangular space. If the circumflex scapular and thoracodorsal vessels originate separately from the subscapular axis, an in-flap anastomosis is warranted. Subsequent microvascular anastomoses should be performed outside the zone of injury, typically in an end-to-end fashion of the vein and end-to-side fashion of the artery.

POSTOPERATIVE MANAGEMENT

Postoperative anticoagulation with low-molecular-weight heparin under anti-Xa monitoring (semitherapeutic in normal-risk and therapeutic in high-risk cases). Hourly clinical assessment of flap perfusion for 5 consecutive days, followed by stepwise relaxation of immobilization and commencement of dangling procedures in cases of lower extremity reconstruction.

RESULTS

Between 2013 and 2018, 74 conjoined latissimus dorsi and parascapular flaps were transplanted to cover vast defects of the lower (n = 66) and upper extremity (n = 8). The mean defect size was 723 ± 482 cm² and the mean flap size was 635 ± 203 cm². Eight flaps required in-flap anastomoses for separate vascular origins. There was no case of total flap loss.

Modern Approaches to Alternative Flap-Based Breast Reconstruction: Stacked Flaps

Total breast reconstruction following mastectomy requires multiple components to achieve an aesthetic result. In some situations, significant skin is required to provide the needed surface area to allow breast projection and breast ptosis. Additionally, ample volume is required to reconstruct all breast quadrants and provide sufficient projection. All aspects of the breast base must be filled to achieve total breast reconstruction. In very specific circumstances, multiple flaps are employed to accomplish this level of uncompromised aesthetic breast reconstruction. The abdomen, thigh, lumbar region, and buttock can all be used in some combination, as needed, to perform both unilateral and bilateral breast reconstruction. The ultimate goal is to provide superior aesthetic results in both the recipient breast and the donor site while maintaining a very low level of long-term morbidity.