Clinical Presentation
A 48-year-old White male with a large soft tissue mass over his right shoulder and upper chest had a wide local excision of dermatofibrosarcoma ( Fig. 14.1 ). After the initial resection, he had a 20 × 18 cm soft tissue defect down to the clavicle and ribs as well as the adjacent deltoid and pectoralis major muscles ( Fig. 14.2 ). Portions of those two muscles were also resected ( Fig. 14.3 ). Alloskin grafts were used for temporarily wound closure. Six days later, the final pathology report conformed negative peripheral and deep margins of the sarcoma.
Operative Plan and Special Considerations
Because of the size and location of the soft tissue defect after wide local excision for the soft tissue sarcoma, a pedicle latissimus dorsi muscle flap from the same side can be selected for soft tissue coverage of this large shoulder and upper chest wound. The latissimus flap has a long pedicle and is reliable and large enough to cover a large defect in the shoulder and upper chest. It is a logical and distant flap to choose for soft tissue coverage in this case. The split-thickness skin graft can be added for the wound closure and better contour. The pectoralis major muscle cannot be selected because its pedicle was ligated during the tumor resection.
Operative Procedures
Under general anesthesia with the patient in the left lateral decubitus position, the right latissimus dorsi muscle was marked. With an oblique incision, the latissimus dorsi muscle was first exposed. Once the medial and lateral borders of the muscle had been identified, the dissection was performed to elevate the muscle from the chest wall. The muscle’s attachment to the anterior chest wall, midline back, and posterior iliac crest were divided under direct vision. Once the pedicle vessels had been identified and marked, the muscle flap was dissected free toward the axilla. The muscle attachment to the humerus was divided. With proper traction and protection, the pedicle dissection was extended to the axilla. The surgical dissection of a pedicled latissimus dorsi flap was completed. The flap was then tunneled subcutaneously to the shoulder and upper chest under direct vision. The right back of the latissimus dorsi muscle flap donor site was closed in two layers after placement of 2 flat JP drains.
The patient was then turned to the supine position. The final inset of the latissimus dorsi muscle flap was performed after excess tissue of the flap had been excised. The flap was inserted into the shoulder and upper chest defect with 3-0 Vicryl sutures in a half-buried horizontal mattress fashion. A JP drain was placed under the flap ( Fig. 14.4 ). A meshed split-thickness skin graft, harvested from the right lateral thigh with a dermatome, was placed over the muscle flap and secured with skin staples to the adject healthy edge.
