INTRODUCTION Exposed instrumentation following spinal surgery is associated with significant morbidity. Local muscle flaps may not be available for coverage due to previous surgery, trauma, or radiation, or may not be suitable for defects with large dead space. Here, distant flaps may provide vascularized coverage and deliver antibiotics to the wound. We describe our use of the pedicle omental flap and latissimus dorsi free flap to close such defects. METHODS Four patients with complex back wounds, significant dead space, and exposed instrumentation underwent successful reconstruction. Defect location was thoracolumbar (one) and lumbosacral (three). The latissimus dorsi muscle had been transected and not available in the patient with the thoracolumbar defect. Here, an omental pedicle flap based on the left gastroepiploic pedicle was tunneled through the quadratus lumborum muscle to close the defect. In the other three patients, the lumbosacral defects were beyond reach for a pedicle latissimus dorsi flap, and the gluteal muscles had been previously transected. In these three cases, the latissimus dorsi muscle free flap with anastamosis to the fourth lumbar perforator was used to close each defect. No vein grafts were used. Our approach to reconstructive staging, use of the Vaccuum-Assisted Closure (VAC) device as a bridge to flap coverage, and techniques in flap harvest are illustrated in these cases. RESULTS All wounds healed without complication; three patients are ambulatory and one remains wheelchair bound. CONCLUSION Pedicle omental flap and latissimus dorsi free flap are excellent options for the closure of difficult back wounds with exposed spinal instrumentation when local flaps are unavailable.
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