49.1 Pedicle Twisting Causing Ischemia

The latissimus flap has a remarkably dependable and consistent vascular pedicle. Problems can occur when transposing the flap to the anterior chest, which requires rotation of almost 180 degrees from posterior to anterior. In addition, the flap itself may be rotated on itself to sit comfortably on the anterior recipient site. All of these maneuvers take place when passing the flap through a subcutaneous tunnel high in the axilla. If care is not taken during this transposition, the pedicle can inadvertently be twisted along its vertical axis or kinked if the edges of the subcutaneous tunnel are not generous enough. Failure to release the superior aspect of the tunnel can create a situation in which the pedicle is bent in an L shape as it passes into the mastectomy site causing a kink in the pedicle restricting blood flow.

49.2 Poor Flap Design

Perforators supplying the latissimus muscle are derived from the thoracodorsal axis laterally and the paraspinal perforators medially. Thoracodorsal supply will maintain vascular supply to the entire muscle, although its reach can become more limited at the extreme inferior and medial edges of the flap. Most skin islands placed on the upper half of the muscle for breast reconstruction have an incredibly robust circulation despite interruption of the paraspinal perforators. As the skin island is moved inferiorly and medially, it may become more reliant upon the medial paraspinal circulation.

Technical Pearl

Any skin island designed over the inferior and lateral border of the muscle, particularly if it overhangs the lateral border, is likely to encounter ischemic complications resulting in loss of the skin despite proximal muscle survival (▶Fig. 49.1).

49.3 Pedicle Compression in the Axilla

The contents of the subcutaneous tunnel created to allow passage of the latissimus dorsi (LD) flap onto the anterior chest from the posterior donor site include the following:

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  The vascular pedicle.

  
  
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  The distal insertion of the muscle (now detached from the humerus).

  
  
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  Potentially variable amounts of fat harvested with the flap.

  
  
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  The fat of the axillary skin.

Related posts:

40 Two-Stage Subpectoral Tissue Expander–Implant Reconstruction 47 Latissimus Dorsi Flap Anatomy 44 Two-Stage Prepectoral Prosthetic Breast Reconstruction 42 Prepectoral Direct-to-Implant Breast Reconstruction 39 Prepectoral Breast Reconstruction: Direct-to-Implant versus Two-Stage 51 Transverse Rectus Abdominis Musculocutaneous Flaps

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