A rib-latissimus dorsi osteomusculocutaneous flap supplied by perforators of the posterior intercostal arteries and loose connective tissue for skull, scalp and chest wall reconstructions

The authors describe a new rib-latissimus dorsi osteomusculocutaneous flap that contains no intercostal vessels that they have developed for use in skull and scalp reconstructions, as well as for reconstructions of the chest wall. To nourish this flap, the blood supply to the ribs does not depend on a direct nutrient artery from the posterior intercostal artery but on the perforators of the posterior intercostal arteries and loose connective tissue between the periosteum of the ribs and the latissimus dorsi. The 8th to the 11th posterior intercostal arteries send off identical perforators to the latissimus dorsi, which are continuous to the periosteal vascular network of the ribs. Further, these perforators, with lengths that range from 4 to 8 cm, are able to provide the torsion required during surgery. The loose connective tissue about these perforators also reinforces the connection of vascularity between the periosteum of the ribs and the latissimus dorsi. Thus, elevation of a rib-latissimus dorsi composite flap is possible without any intercostal neurovascular bundles, as is required for conventional rib-latissimus dorsi flaps. Clinically, the rib blood flow was confirmed by bleeding from the cut edge and a postoperative bone scintiscan. Unlike conventional rib-latissimus dorsi flaps, this flap has the following advantages: 1 the choice of ribs that can be attached to the flap is extended; 2 a firmer, more mobile connection of ribs and muscle is achieved; 3 the need of a donor site thoracotomy is lessened; and, 4 postoperative pain due to intercostal nerve damage is reduced. Given these features, this flap provides a useful alternative osteomusculocutaneous flap option.