Proximal-First Pedicle Approach for Prone Latissimus Dorsi Flap Harvest: Technical Refinement for Posterior Reconstruction

Vollständiger Abstract

Worum geht es in dieser Arbeit?

Background: Reconstruction of posterior body defects often requires intraoperative repositioning, which increases operative time and disrupts surgical workflow. Although the latissimus dorsi (LD) flap is a reliable option for posterior reconstruction, prone-position LD harvest has been infrequently described outside of breast reconstruction. This study introduces a proximal-first pedicle approach for LD flap harvest in the prone position and evaluates its clinical applicability for posterior body reconstruction. Patients and Methods: A retrospective review was conducted of 28 patients who underwent prone-position LD flap harvest between March 2012 and February 2025 for reconstruction of sacrococcygeal, ischial, gluteal, popliteal, or transtibial defects. The operative technique focused on early identification of the thoracodorsal pedicle through the teres major–latissimus dorsi intermuscular window, allowing pedicle-first dissection before flap design. Both musculocutaneous (mcLD) and muscle-sparing (msLD) variants were analyzed. Patient demographics, flap characteristics, operative time, complications, and clinical outcomes were evaluated. Donor-site upper-extremity function was assessed using the QuickDASH questionnaire. Results: Twenty-eight patients (19 males and 9 females; mean age, 55.8 y) underwent prone LD flap reconstruction. Twenty-five flaps were harvested as mcLD flaps and 3 as msLD flaps. The mean flap size was 234.4 cm², and the mean total operative time was 168.2 minutes (range: 105 to 270 min). One case of partial flap necrosis occurred, while all other flaps survived without major complications. Primary donor site closure was achieved in 53.6% of cases. The mean follow-up duration was 48.5 months. The mean QuickDASH score was 2.32±0.78 (n=21). Conclusion: Although a prone LD flap harvest has been described previously, a standardized pedicle-first strategy has not been established. The proximal-first pedicle approach introduced in this study provides consistent early exposure of the thoracodorsal system and facilitates flap harvest without intraoperative repositioning.