Introduction Oncologic resection around the shoulder often results in large complex tissue defects. Often, vital soft tissue or skeletal structures are left exposed. Bony reconstructions involving allograft and/or alloprosthesis introduce foreign material and an increased risk for infection. Stable and durable soft tissue coverage is thus critical. The purpose of this study was to review our experience with the pedicled latissimus dorsi (LD) flap in reconstruction of the shoulder in this setting.
Methods This was a retrospective review of all patients in whom a pedicled LD flap was used to reconstruct complex shoulder defects resulting from oncologic resection from 1994 to 2004. Patients were identified using our prospectively maintained database and chart review and patient examinations were performed. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were reviewed. Major and minor complications, patient survival, and limb viability were evaluated as outcome variables.
Results Thirty-three patients were identified during the study period (age range 6-74 years, mean age 36.5 years; 15 males and 18 females).Wide excision or radical en-bloc resection of the shoulder tissues were performed in all patients with defects often extending intra-articularly and to the level of the mid-arm. Thirteen patients underwent allograft and alloprosthetic composite shoulder reconstruction. Six patients were reconstructed solely with a metallic prosthesis while three patients underwent bony reconstruction with allograft alone. Defects averaged approximately 287.7 cm2, as recorded in eleven cases. Adjuvant therapy included: radiation therapy in twelve patients and chemotherapy in eighteen patients. Brachytherapy was utilized twice. In twenty eight cases myocutaneous flap transfer was performed. The dimensions of the skin paddles ranged from 3.0 to 10 cm in width (mean 5.8 cm) and 7.0 to 35 cm in length (mean 18.8 cm); mean surface area was 118.9 cm2. Five of the twenty-eight myocutaneous flaps required additional split-thickness skin grafting. In five cases a latissimus muscle flap alone was utilized; split thickness grafts were used in three of these patients. Two patients experienced partial skin flap necrosis treated successfully with conservative management. All other patients went on to heal without additional complications.
As of their last documented follow up visits, only one patient went on to amputation before her later demise. One patient later demonstrated local recurrence that necessitated further resection and reconstruction utilizing pectoralis major, external oblique and local fasciocutaneous flaps on separate occasions. Twenty-six patients are alive and without evidence of local tumor recurrence.
Conclusion The pedicled LD flap is an effective option in the reconstruction of large complex shoulder defects. The flap provides sufficient soft tissue to allow for stable and durable coverage of the shoulder, its vital structures and bony reconstruction, maximizing limb salvage.