Left Mastectomy Wound Closure with Left Latissimus Dorsi Musculocutaneous Local Flap

CHAPTER 1

This woman had a - probably a lumpectomy I would imagine, and radiation therapy postoperatively, and she had a local recurrence of breast cancer. So we were asked after the mastectomy to come in and close this wound. And as you can see, you might be able to stretch the skin to get it to close, but this skin is all irradiated and the wound would probably dehisce, and it's a basic principle of plastic surgery is - in the irradiated wound is to bring healthy well vascularized tissue into the area. A skin graft has no blood supply. So a skin graft will not bring tissue that has a blood supply into the area. You want to bring a flap into the area. A flap always has a blood supply. So that's our plan today is we're going to take a flap from the back based on the latissimus dorsi muscle. This is probably the number one most commonly used muscles for flap of the body. And we're going to transfer that from the back with the overlying skin to replace the skin in this area. The muscle will be a carrier of the blood vessels to that skin. Okay. Now we're measuring the defect. It's about 13 cm wide. And the height is 9. So we need a flap that's going to be 13 by 9. So let's go to the back now, and we're going to mark that flap. Okay. Okay, so what we're going to do is we're gonna take the skin. There's lots of skin here in the back. See this extra skin? And I'm pitching together lots of skin there, and we're going to transfer it there. And we're gonna take - we're going to base it on the latissimus muscle. I can actually feel the latissimus muscle, I can grab this fat here. I feel the muscle underneath here. The anterior border of this muscle is actually - is actually right - well right there. So - marker? Okay, so the marker - the muscle goes like this. The blood supply to this muscle is the thoracodorsal artery and vein, which comes out of the axilla about 10 cm below the axilla. So there's the anterior border, there's the axilla. So at about in this area, we're going to expect the blood vessel coming into the muscle. Okay. So I have to take a - my skin down here on the muscle. So it will be long enough so that I can then like a pendulum rotate this forward. Almost this entire muscle will be supplied by that one artery - almost that one - I'm not going to go into the specifics of that. It's too much detail, but… So I'm going to then take a piece of skin on top of that muscle from here to fill that defect. Notice that we have the patient in a lateral position. The reason for that is that I like that so that we can see the defect. On the front of the chest, and we also have access to the flap on the back as well. So we see both things, so that we can work as two teams to close the wounds later. How do I design the skin pad on the flap? I could do it this way. I could do it vertically, But notice how tight that is. See how tight that is when I pull it there. But if I orient my flap at an oblique angle like this, going from the anterior superior iliac spine up toward the midline of the back, see how loose that is? So I like to design my flap like that. Now, if I'm doing - if I were doing a breast reconstruction, or something like that, I might make my orientation more horizontal so that the scar from the donor site would be under the bra, but here we're not worried about the scar in the back. We're worried about getting enough skin to close the defect. So - let's see - so, if I pinch that… And I measure that. And we said 9 cm right? So that should be enough. 9, yeah. That should be enough, and we want to be 13. Midline of the back is way down here, so we want to go over about 13. Let's make it over a little bit. Always take a little bit more than you want actually. Okay. Okay. So… I'm drawing my lips. And that should be enough.

CHAPTER 2

Okay, so I want to find where the anterior border is, So I'm going to go up here and I'm going to - to see if I can see where it is. I'm not going to cut my whole flap until I know where I am. I'm just going to raise this part of it. I can always redesign it if I have to. Do you want another one? Because we can ask them for it. The ones that are tough will cut it. It's easier than this. Yeah, just something that doesn't stick to tip of the above Bovie. That's good. I'll hold it. I'll take it. Yeah, just a little retractor, soft of out there.

Let me come to the anterior part too. I want to find out where latissimus muscle is. I don't know where it is. Let's come up and do the anterior part. I don't know where the muscle is. I may design my flap more posteriorly, depending on where I find it. Okay. Okay - as soon as we're stopped moving here, I don't want to burn the skin with my Bovie. Ah, okay. The blood supply through the latissimus muscle to this overlying skin comes at different areas, so it's not everywhere. So we're going to try to capture as many blood vessels coming through the muscle as we can. So when I'm on the superior part of skin paddle, I'm going to bevel - I'm going to bevel away from the skin flap - so that I can include some subcutaneous tissues here, which hopefully will have blood vessels going through them that will keep the flap alive. Notice I'm not going straight down like I did on the bottom side. Yeah. And that's the reason I'm doing this before I go looking for the muscle. It would have been nice to keep that in the flap, huh? Remember, a flap has blood supply. So is there a specific angle that you try to keep the Bovie, or not really? You're just trying to bevel out. I'm just beveling away. Okay. Hopefully, I will soon - whoa, and I'm starting to see muscle now. There the muscle has showed up. Is there any way that we can have the patient paralyzed? Yeah. Because this dissection is very difficult with the muscles constantly moving because we're taking the muscle with the skin paddle. So if the patient is paralyzed, then hopefully when I touch it with the Bovie, it will not jump and I'll accidentally cut it. If we hold the sub-q off the muscle, there's a nice plane that we can see. Okay, so we know we have latissimus muscle now because if you look at the fibers of this muscle, they're going in this direction, and that's where latissimus is going headed toward the - headed toward the vessel point. So now I can make life a lot simpler for us. Just come out for a second. We're going to make life easy. We're going to op- we know we have the skin paddle on the muscle. We're going to cut that with a - "bisturí." Bisturí? Bisturí. Bisturí. Yeah. So I might as well - I know I'm going to be opening this whole thing here. So let me do that. And then we'll.. And Kate, if you could grab a small Richardson, that'd be great. And forgive me, plastic surgeons are very meticulous about stopping bleeding. We don't like the sight of blood. Mm hmm. And there's a good reason for that. It obscures your tissue planes. when you're dissecting the flap if you have a lot of blood in the way. So you want to keep it as… Dry as possible? Dry as possible. It makes it easier to do the flap. Okay, now let's get the Richardson right here. I'm going to get a Sims retractor up above. And we're going to raise that up. Okay. Sorry. Don't worry, I'll tell you I'm going to get right up here, so you move along here because I'm beveling away, so - just like that, perfect. That's it, some counter-traction there. That's great. So we start over here. We know where the muscle is, right? Mm hmm. And the... paralyzed? You want me to ask him again? Look at that big blood vessel right there, coming up, see that? Uh huh. You see that right there? Yep. Coming up through the muscle, so we're going to keep that one. We're keeping that - let's move her. So I think we can see that blood vessel coming up right there that I saved. We end the flap - the more, the better. This is not something you do in the outpatient office. No. Okay. Yeah, okay, so we have muscle here. Okay, so I know that's where I want to go, so I have to have my marking pen - marker. I know that's where my blood vessel's going to be. Where's scapula? Okay, right there is scapula. I know my vessels are going to come in about right there, I know we're going to be heading there. So we're going to make life easy for ourselves. We're just going to cut that. Okay. It makes it easier to get the exposure. Okay, so I'm just going to make life easy for us. We can keep this simple. Again, if I'm doing a breast reconstruction where I'm worried about the aesthetics and the scars, I would not do this. I would just lift everything up with a big retractor and do it underneath the skin, but that would be a major event here. I'm just going to make this as easy as we can. I know that most of the blood vessels to this muscle come out up toward the axilla, not down - toward the delt line as we take out skin paddle, so - this is not the best place to go for a blood supply. And today I probably would do a muscle-sparing flap, a perforator flap, to do this, but we really don't have the facilities to do that right here, so I'm not going to do something that complicated. Mm hmm. We're just going to do a musculocutaneous flap. Okay. Kate, do you have a big Rake of any kind? Okay, once I get down here, lets see where I am. Yeah, let me just find where the LD is. Okay, as you can see here as I'm cutting down through this incision, which I'm making for expedience. We're seeing the muscle come in, nicely. Mm hmm. And even if the skin paddle does not move, the muscle, we can put a skin graft on, as our a backup plan if it doesn't have enough blood supply.

Okay, game plan now is to find where the anterior border of that muscle is. So remember where I felt it over here? Yep. Let's see where it really is. Okay. Now I'm going to switch places with you now, okay? Okay. He's holding it straight up in the air, so there will be a nice, thin adventitial plane right here - I can go through and raise the skin. So I'm dissecting from the posterior aspect of the latissimus muscle to the subcutaneous tissues. Again, today, normally I would do a perforator flap for this. You don't have to take the muscle to do this, but I think another advantage of the muscle though is it's going to give us some bulk - some extra subcutaneous tissues. So knows how avascular this plane is except for a few blood vessels coming in? Let's go see if we can find that. So look at that nice - look at the size of that vessel right there, you see? Yeah. See that? We'll keep getting our flap. Ooh, look at this. I think we're getting toward the anterior border. We can keep that one. All right, so we are now getting very close to our anterior border of the flap so I think we'll be good. We've got something bleeding down here somewhere. Just like doing a gallbladder, isn't it? The technique's similar to when you are taking off the breast tissue off the... It should be exactly the same as a matter of fact because the breast has this thin, areolar like tissue connecting it to the pectoralis major muscle. Uh huh. Where's that anterior border? I want to find out because I know that the - the descending branch of the thoracodorsal runs with the anterior border so it's like imperative that I keep it. I don't know if this is going to have enough blood supply or not, but so be it, we needed the length. So it looks to me like we're getting toward the anterior border of the muscle right here, you see it? Okay. The same branch runs a few centimeters - you see some of the blood vessels here - It runs a few centimeters past the anterior border of the flap so it's important to keep - know where that border is or you'll kill the flap. Yeah, we're good. Nice perforator up here. We're getting toward the blood vessels. Notice the direction of the fibers of the latissimus. They go almost vertically, okay? They're going to separate - because when I get up closer here, toward the scapula, I'm going to run into the serratus anterior muscle. And those muscle fibers will be going this way, almost perpendicular to this. And you don't want to include that with the muscle. But we're on the posterior surface of the muscle. We should not have a problem with that. Although I think I see one right there coming in here. See it? Yep. See it going this way? The serratus, right here? Yep. Okay. Okay, let's go down here, and we'll take a little bit more, we're almost there. Look at the size of that one - that's a big one. We're getting down near the origin now of this - it sort of spreads out a little bit.

Now you're going to - your job - and you may want to be on that side of the table - is to do the same thing up to about this level of the flap, okay? Okay. All right. So you might get this muscle off here? Okay. Okay? Separate it from the fat. Okay, that's it, keep going. Yeah, that's good. If you leave a little bit of fat there, no one's going to care, okay? Just stick - but stay on the muscle. I'm trying to just go on up because there's nice - mm hmm - I think you have a perforator. There you go, you're okay. Don't go on the muscle there, okay? Okay. Stay above the fascia atop the muscle. Yes, sir. Okay, now you're getting yourself into a hole. So you want to raise this stuff up here, okay? Okay. So you don't get in the hole, okay? I'm going to come down and try to help you a little bit, we're going to - we're actually going to sort of hold up towards the sky. See exactly where that plane is now, right there. And the problem with this kind of Bovie tip is that it gets the - the eschar all over it. Okay, so you want to stay down on the muscle, so you have to come through this stuff here. Okay. They have protected tips, but I don't know if you… What's a protective tip mean? No, I don't want a protective tip. Mm hmm. That makes it more difficult to access what we're doing. You know that's a perforator, so you have to get it before you cut it. You see it right there? You got it. What are we doing now? What we're doing right now is we're just dissecting the subcutaneous fat off of the - off of the posterior surface of the latissimus muscle. So we know where we're going to be going. Get over here. Here, let's get this before we - I don't her to get a hematoma. So I'm currently in the right plane, correct? Yes, you are. You see that white fascia on the muscle. Yeah, down here you could - down here you need a little bit - it needs a little bit down here though and not down there. You want to be over to the end of the muscle flap, which is over here. Okay. So you have to be - this part has to be raised here. All right. Go from known to unknown. Always go from known to unknown. Yep, now you're getting there. Yep. There's a big vessel coming up. That's a big vessel coming up. Yep, it's coming out through here, so you can just go down and coagulate down there and you'll be good. Yeah we need some… We need 3-0 Vicryl just for ties, you know? There's a bleeder. Get all the bleeders as you go. We need to have some 3-0 suture ligatures and stuff, you know? All right. Make sure we have that under control. Yep, I think so. I see a big blood vessel going up, do you see it? Yes, sir. You want to coagulate that before you get into trouble. Get that out of the way. Okay, is it still bleeding from there too? The tip is so covered with eschar. A little bit there, that's great. Okay, and still a bleeder here. Use your sponge. Okay, the blood vessel's coming from here. It's coming from here. Uh huh. So we're going to coagulate it on this side of it. There we go, okay. We still have a little bit more to go here. All right. You want to connect the edge of the flap, but you don't want to go down through there, you want to keep as much on the flap as you can, so you're going to come like this. Now you're going to come up and leave sub-q. Oh, okay. That's great, so you have a little bit right there you want to get, and that will be good through there. Okay, so - get our rakes in there. Okay, I'm trying to hold it up for you. Keep going, or we're good? It's hard for you to see back there, why don't you finish up up here. Okay. We have one big latissimus muscle. Yeah, I think we're getting to the upper body of latissimus now. Almost there. Okay, I think there's a bleeder here. See that? Stop - a little dab for you. There you go. There could be one over here. Okay, so now we very simply have that exposed. We're going to come down here and cut the rest of the flap. And voila. Is that to take it one step further, or...? Yes. Now. Okay. So usually you do try to cut past the dermis on the initial, or no? No, I want to cut deep enough so that when I go with my bovie, I don't cut the skin. Okay. Okay. All right, yeah, so I'm just trying to - yeah, it'll set this, and I got to leave a little bit of dermis. Plastic surgery is just very - tedious, you know? Mm hmm. I just hope I find LD done here. Let's see, where's our muscle over there? Do you want me to ask him for more? Yeah, more paralysis would be nice. You need to ask him for what? More paralysis. Ohh, I think I see LD down here, so I think I'm okay guys. That's what's fun about doing flaps is you always run into interesting things. Mm hmm. Anatomy is not always constant. Yep. But it's fairly constant in muscle flaps. Perforator flaps are never constant. See I don't really need to take the muscle, I just have to take the blood vessels, you know? But that would be an all day event. Okay. But I'm not quite through here, I'm almost there.

We've gone all the way around the skin paddle now. It's all totally on the muscle. Is it alive? It's alive. Yes. It's alive. I see capillary refill.

CHAPTER 3

Okay, now I'm going to take down the origin of the muscle. and then we're going to work back towards the insertion, which we're not going to have to take its insertion down, but we do have to take the origin down. So I'm going to come across the muscle now, dividing it. Just take it. I'm just dividing it. I'm just taking down the origin of the latissimus now. Okay. Do we have a 3-0 silk on board? A 3-0 silk? So serratus here, correct? Yeah, I'm just trying to get the anterior border up. Ooh boy, I'm down to ribs there. Yes, that's the serratus there, I don't want to include that with my flap. let me know when I get there, I'll get close to my - so, I'm just raising the anterior border now. Throw a 3-0 silk in that - in this, okay? Put a 3-0 silk on and use that as traction, okay? Okay. Hemostat? Okay, over and over. While you do that, I'll work down here. Okay once he usually does that. Yeah, that's fine - okay. Let me try to figure out where this muscle is. There's a bleeder right here. Good to get them as we go. Okay, why don't you just hold this back here like that a little bit. You're in charge of that. So I try to bring the muscle up from its orgins down here. The same technique is looking for the areolar tissue now, peeling the lat off. That's not true we're down to the origin. Don't - yeah… We have to be careful we don't get into chest. Uh huh. Okay Kate, we're over here now working, okay? So it's a little bit tedious here, but once we get this down it'll be easy. Yeah, don't grab it, don't grab it. We're going to leave it. Okay. It supplies blood to the skin, right? Okay. If you grab it it'll start bleeding. Could some of you blot that place for me. You can see the plane now coming in. And we want to be above. So this is still - this is still latissimus here. This right here? Okay. No, this right here. Okay, so let me see what I'm doing here. And I don't know if that's latissimus or not. That may not be. It doesn't look like it. Now you see you're in the crossroads there, down below that next layer. Yeah. Because the LD has - coming across this of course. One of several. Mm hmm. This muscle may not be - I don't think that muscle's part of that one. We'll come back and get - yeah, let's get that off. Now hold this right here. Yeah, I think that's not part of it. So let's get rid of that. Okay, here we are - we're raising the anterior border of LD now. Let me see where I am over here. Okay, so I think I'm past the - yeah, just hold it there. You sure?

So we're not going to take the entire muscle, we're going to come - probably come back here and then divide it here. Yeah, that's the plane I want to be in right there. The thoracolumbar fascia - I'm dividing that. Okay. Perforator. Yep, see that big perforator? That has to be a lumbar perforator coming up. We're going to have to tie that one off. Okay. Hemostats times two. Okay, so as you raise it back here posteriorly, you run into… Oh, this maybe a lumbar perforator, or it's a - some secondary blood vessels coming from intercostals. Bovie. Oh, you're going to Bovie? Never mind, never mind. Oh yeah. Okay, do we have ties? And… You're going to cut, Kate. Okay. Are you good right there? Yep. Cut. Are you using it now, or? I don't need all the muscle, so I'm not taking it all, but I'm taking a lot of it. So we decided not to take all that muscle that we got exposed, but it was good practice, right? Mm hmm.Okay.Another big blood vessel. Kate, you have to get in there with a sponge and blot for me. All right, so we're rolling now. Nice. So my blood vessel's coming up here, so I know I'm into another large vessel here, so I know we're not gonna pull too much, we don't want to rip that apart. Mm hmm. What are you doing?Yeah, put another one.Yep. Okay. All right, go? Be very gentle, very gentle. Turn it away from me, and then I know that I'm not going to slip, okay? So I don't need that thing to put it around. It's an extra tool, extra step. Okay, there you go. Now, where are we? I'm just going to get some of this spots here I don't like bleeding I don't like bleeding. Yeah, there's a bleeder there. Okay, that's good. Yeah, so I can come up here still, I have some more work I have to do here. So the next thing you worry about when you're doing this - as I approach the scapula - as I approached the scapula, which is right here. Yeah. That is a warning that I'm getting close to where the blood vessels go into the undersurface, the anterior surface, of the muscle, so I have to be careful. And I know back here I don't have any problems. That's good. We've now reached the superior border of the muscle right here. Right there. Scapula right here. Yeah, so the next muscle over would be teres major. Okay, so… Which we did not see, we don't need to. Okay, so now we're on the undersurface here. You always run into this fat pad here. Let me see, I have a bleeder here that's just persistent. I don't know where it is. I'm going to come around it first. All right, now you can go around. And I'm going to leave a little extra here. The tie slips off, I'll have more down here. The… Okay, now let me take that off, and you tie that, okay you got it. Kate, you're cutting. Okay. And Kate, if you can hold that flap away from her, so it doesn't fall in her way. She can tie that more readily. Okay, we have another vessel coming up here. Mm hmm. We want to get into this fat pad here. Hemostat. Now spread it. Okay, tie them. Yeah, I would put hemoclips on this normally or tie them, but just getting it with the Bovie is dangerous because they escape from you. Hemostat. I've got to be careful here, we don't know where the vascular pedicle to the flap is. Okay hopefully that's not it. See we're getting very close to that point. Yep. See I may have brought up a slip of serratus here, you see? Mm hmm. Okay, so how close are we to getting - reaching that goal? Are we close? Close, yep. We need a little bit more don't we? Yes. Her latissimus is very thin. Mm hmm. If you see any branches going into the muscle let me know. I think I'm starting to see them now, see this? The vessels going in here? So I have to be careful I don't knock off the thoracodorsal. Mm hmm, there's one right there too. Whew - okay, see this right here? Uh huh. Warning sign. Okay.

See this right here? See this - here's another one over here. (mumbles). (mumbles). All right, so we can see… We can see these blood vessels coming down here. They look like a crow's foot coming down like the toes of the crow, coming down. These are the branches of the serratus. When you see those, you know those branches come from the thoracodorsal. That's a warning sign that you've got to be really careful, and maybe it's time to go to the bipolar. And I think that we can already see here, right here - this could be the thoracodorsal right here, going into the muscle. So we've got to be very careful here now that I don't make a mistake. Very careful. I know I'm okay. Oh, we're getting some big blood vessels coming up here. See how big that is? That's really big, okay? See that, see that? See that right there? Yep. So if we don't have to go up there and isolate the pedicle, I'm going to be very happy. I tried to set it up so that I wouldn't have to do that. So let's go up here, and we'll take - some of this down. And hold it up. Richardson. Look at that - see, I only see the hole - look at this - okay, do you see that? See that? See my hand here? Coming out through where the breast used to be.

CHAPTER 4

Okay, so let's see if it’ll reach. Okay. I think it will reach, right? Okay, so normally - now - Okay, so normally I would make - I'd go through here and I make a tunnel. But I've already made one for you. But the general surgeons have already made it for me, because they were planning ahead. It's one of the basic principles of plastic surgery is always plan ahead. Right? Always plan ahead. Pretty amazing, huh? that we're able to do that. All right, so now it's important that you make sure there's no bleeding back here because these tissues tend to get a seroma. Okay. Underneath them, and there's lots of ways to stop that, but we don't have them here. Okay. But we got to make sure we don't get a hematoma. Okay. Under our flap, so let's look around here. You start on your side. Then I'm going to get this side, and you're going to come over to my side. Okay. Just make sure there's no bleeders anywhere of any consequence. Okay, I don't see anything, I think we did a good job, don't you? Okay and… And... Do we still need this? No, just get rid of that.

So we're looking for capillary refill. Just the outline of the hemostat here. See that? And the blood comes back. Slowly. If it's instantaneous, that's a sign of venous congestion. That means you have a venous problem. Okay. Okay, in this case, it's nice and slow, we have good capillary refill. We're probably alive in spite of the fact that I have this flap so distally. Now we must make sure we have nothing bleeding underneath here, do we? We do. Oh, okay. Do you think bleeding here? All right, I think we're good. Okay. We're good, we're good, we're good. Okay, I think it's pretty good. All right, it's kind of juicy over here. I think you're pretty good. Okay so I think we should put a drain under both the anterior and posterior. Do we have two Hemovacs that we can do that with? We have one, but I'll get another one. Yeah, so you guys - through a separate stab wound, you guys - The patient will probably be - is being allowed to lie on their back, so I usually put them out - you know, like - like some - like a - so they're not lying on the flap, bring it out through the anterior part of the incision. Kind of like chest tubes? With a stab-through stab wound. Okay. Okay, so now I'll take that silk. Forceps. Okay, so if you would grab a tonsil clamp or something through the - through the breast, or the vicinity thereof. Okay, you're going to grab this. Okay, and then I'm going to feed this through here. You pull your suture. All right. Are you watching that come through? Watch that come through. Here we go - like on the movies - light over there, please, thank you. Here we go - boom, boom, boom, boom, boom. Is it big enough? Oh, phew. Okay, all right, good. Yep.

CHAPTER 5

Okay, on the donor site, they're going to bring, you know, bring this together. Okay, bring this together. And then you'll sew it to this, okay? Okay. Bring that - the "T" together - inverted-T - boom, boom. As I say, normally in a breast reconstruction or something in which there's more aesthetic surgery, I will not make this incision. I will just lift that up and do all the dissection with big retractors, which we don't have. Okay. Okay? All right. All right, that's how you do it. You guys close this. Okay. You're in charge. Okay, so what we're doing now is we're closing the donor site and the recipient site simultaneously. Push together.