Anatomical Study of the Close Association between Latissimus Dorsi and Surrounding Muscles. How to Safely Harvest the Muscle?

Background We suggested an easy and effective harvesting technique to avoid injury to tissues adjacent to the latissimus dorsi (LD). Methods Between 2007 and 2017, breast reconstruction was performed with an LD flap using the "bottom-up" technique. Medical records were retrospectively reviewed. Data on postoperative complications, results, and follow-up were obtained. Nine cadaveric dissections were performed to assess positional relationships between LD and adjacent muscles based on the ribs where relevant muscles and LD attach. Overall, 78 LD flaps were harvested without complications. Results Average age was 45.4 years. The mean operation time was 260minutes. There were no abnormalities or injuries in the adjacent fascia and muscles during the flap harvest. Drains were removed at an average of 21.9 days postoperatively. In all cadavers, there was conjoined fascia between the thoracolumbar and LD fasciae. The average level of the merging point between the LD and external oblique muscle (EOM) was 8.9 to 11.1 ribs. The average level of the overlapping point between the LD and serratus posterior inferior (SPI) was 9.5 to 11.1 ribs. Conclusions There are three dangerous zones during LD flap harvesting. The first zone is where the conjoined fascia encompasses the LD and thoracolumbar fasciae. The second zone is where the LD merges with the EOM and the serratus anterior. The third zone is the lower part where the LD merges with the SPI and EOM. The "bottom-up" technique enables a more meticulous and atraumatic operation by beginner flap surgeons.