Operative Technique in Plastic Surgery – Kevin C.Chung

3
CHAPTER
Rectus Abdominis Flap for
Thoracic Reconstruction
Maureen Beederman and David H. Song
DEFINITION
■ Chest wall defects can involve the skin, subcutaneous tissue, muscle, rib, and
underlying thoracic viscera.
■ The rectus abdominis muscle flap (with or without overlying skin) can be used
for chest wall defects and is especially useful for anterior, lower sternal, and
parasternal defects.1
■ A vertical rectus abdominis myocutaneous (VRAM) flap contains both rectus
abdominis muscle and overlying skin and subcutaneous tissue, supplied by a
pedicle and its musculocutaneous perforators, with skin paddle oriented in a
vertical direction.
■ A transverse rectus abdominis myocutaneous (TRAM) flap contains both
rectus abdominis muscle and overlying skin and subcutaneous tissue,
supplied by a pedicle and its musculocutaneous perforators, with skin paddle
oriented in a horizontal direction.
■ Rectus abdominis flaps can be used to fill a large amount of dead space or to
cover prosthetic materials used for chest wall stabilization, such as methyl
methacrylate, mesh, or titanium plates.
ANATOMY
■ The rectus abdominis muscle is a Mathes-Nahai type III muscle with two
dominant vascular pedicles: the superior epigastric artery and inferior
epigastric artery.
■ The superior epigastric artery is a continuation of the distal portion of the
internal mammary artery (IMA), which originally arises from the subclavian
artery.

■ The inferior epigastric artery arises from the external iliac artery.
■ The rectus abdominis muscle has a predictable blood supply, making it a
dependable option for reconstruction.
■ Secondary blood supply also arises from intercostal arteries.
■ Rectus abdominis muscle consists of two muscle bellies separated by the linea
alba.
■ Each muscle is enclosed in fascia, which is formed from the aponeurosis of
the external oblique, internal oblique, and transversus abdominis muscles.
■ Rectus abdominis muscle origin: xiphoid and 5th to 8th costal cartilages
■ Rectus abdominis muscle insertion: pubic symphysis
■ The rectus abdominis muscle is thick, bulky, and durable and is good for
filling dead space.
■ One can raise the muscle in a vertical (VRAM) or transverse (TRAM) manner,
depending on the size and orientation of the defect.
PATHOGENESIS
■ Chest wall defects can occur as a result of trauma, tumor resection, infection,
congenital disorders, or radiation-induced necrosis.
■ Infectious sources include empyema, bronchopleural fistula, or mediastinitis
after cardiothoracic surgery.
■ Sternal wound infection risk factors include obesity, diabetes, COPD, and
bilateral harvest of IMAs during prior cardiothoracic surgery (compromising
blood supply to the sternum and overlying tissues).2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history is important to consider when planning for chest wall
reconstruction, as it will affect the reconstructive decision-making and options.
■ Consider previous attempts at chest wall closure and reconstruction,
specifically if other local flaps have been used, including latissimus dorsi,
pectoralis major, or omental flap.
■ Significant prior abdominal surgery, including autologous breast
reconstruction or abdominoplasty, which could affect blood supply to the
rectus abdominis muscle
■ One or both IMAs may have been harvested for prior cardiac surgery, which
may adversely affect the superior epigastric artery blood supply to rectus
abdominis musculature and need to be closely examined. However, owing to
extensive intercostal collaterals, mostly a superiorly based flap is viable.

■ The presence of an ostomy or urostomy can potentially affect utility of rectus
abdominis muscle.
■ A history of diabetes or history of smoking can affect small vessels and
compromise blood supply to the skin of VRAM/TRAM flaps.
■ Other risk factors that can compromise reconstruction include obesity,
malnutrition, older age, steroid use, and other comorbidities.
■ Discussion of future treatment planning with thoracic surgeon
■ Determine whether the patient has had or will need to undergo future
radiation therapy, as this will affect local tissue quality and flap options.
■ Physical examination
■ Assess chest wall space requiring reconstruction, including the presence of
mediastinitis or other localized infections, bronchopleural fistula, and
exposure of vital organs.
■ Determine whether bony reconstruction is required.
• Skeletal support is most often required for lateral and posterolateral wall
defects.1
• Number of ribs removed and history of chest wall radiation can affect the
need for structural support.
IMAGING
■ Imaging may not be required for all patients.
■ CT of the chest and abdomen may be done to assess extent of tumor, invasion
of surrounding structures, amount of dead space, and possible fluid collections
or infection.
■ Assess abdominal wall integrity, including the presence of any hernias.
NONOPERATIVE MANAGEMENT
■ If no exposure of underlying vital structures, consider using negative pressure
wound therapy (NPWT) to manage wound initially.
■ Should be used only in clean wounds; if infection is present, will require
appropriate debridement of all infected tissues prior to use of NPWT.
SURGICAL MANAGEMENT
■ Coverage of chest wall defects can either be immediate, commonly following
tumor resection, or delayed, commonly following mediastinitis or other chest
wall infections.

PREOPERATIVE PLANNING
■ Must consider whether skeletal stabilization is required, especially if ribs are
resected.
■ Skeletal chest wall reconstruction is outside the scope of this chapter but an
important consideration when planning reconstruction and deciding the best
reconstructive option.
■ If more than four or five ribs are resected or if total sternotomy is performed,
skeletal reconstruction is most often needed to prevent flail chest and maximize
pulmonary function and to protect underlying vital organs.
■ For pedicled rectus abdominis reconstruction, consider whether IMA (one or
both) has been sacrificed during previous cardiac surgery and check for
viability when raising flap. Typically, due to a rich network of collaterals from
the 8th intercostal network, the flap should be suitable.
■ If IMA has been harvested, determine if enough time has passed for
intercostal collaterals to form; consider basing flap superiorly off intercostal
collaterals.3
■ If rectus abdominis flap is being used for filling of dead space after infection,
ensure that all devitalized and infected components of the wound have been
thoroughly debrided prior to flap insetting.
POSITIONING
■ For harvesting the rectus abdominis flap, supine positioning is optimal, with
arms abducted on arm boards.
■ Depending on the location of the defect, the patient may also be in lateral
decubitus positioning, which still allows harvest of the rectus muscle.
APPROACH
■ Based on the size and shape of the defect, consider whether muscle only or
musculocutaneous flap is required.
T E C H N I Q U E S
■ Rectus Abdominis Musculocutaneous Flap
■ Create a template to design your flap based on the proposed defect size.

■ Design the flap either vertically (VRAM) or transversely (TRAM),
depending on the location and size of defect (TECH FIG 1A).
■ The flap should be designed to capture periumbilical perforators (TECH
FIG 1B).
■ Handheld Doppler can be used preoperatively to locate possible perforators
prior to starting flap elevation.
■ Make an incision just lateral to the midline on the side of the muscle to be
harvested.
■ If a sternotomy incision is already present, simply extend this incision
inferiorly.
■ Make incision through skin and subcutaneous tissue and dissect to the
medial and lateral perforators in order to spare as much anterior sheath fascia
as possible.
■ Incise fascia longitudinally, just lateral and medial to the perforators.
■ Dissect laterally, superiorly, and inferiorly, until desired size is reached.
Ensure that all suitable musculocutaneous perforators are identified and
protected during flap elevation.
■ Identify both the superior epigastric artery and the deep inferior epigastric
artery.
■ Once the deep inferior epigastric artery has been identified, ligate it close to
its origin at the pubic symphysis.
■ Divide the rectus abdominis muscle from its insertion on the pubic
symphysis or more superior to the pubic symphysis if not using the entire
muscle.
■ Interpolate rectus abdominis myocutaneous flap into defect space (TECH
FIG 1C,D).
■ Flap can either be tunneled below an existing skin bridge or interpolated
into defect.
■ Close anterior rectus sheath primarily in a figure-of-eight fashion.
■ If donor-site defect is too large, mesh may have to be used to prevent
hernia formation.
■ Inset the flap in a layered fashion, ensuring that there is no tension on the
vascular supply.
■ Place closed suction drains in both the donor and recipient sites.
Pedicled Rectus Abdominis Muscle-Only Flap

■ Harvesting a muscle-only rectus abdominis flap is similar to the
VRAM/TRAM harvest, with a few key distinctions.
■ Consider using a rectus abdominis flap if there is enough local chest wall
skin for coverage or if planning to harvest a split-thickness skin graft for
coverage.
■ Make a midline incision through the skin and subcutaneous tissue down to
the anterior rectus fascia.
■ Incise rectus fascia longitudinally, just lateral to the midline.
■ Dissect laterally and inferiorly according to your template defect size until
desired size is reached.
■ The entirety of the rectus abdominis muscle or just a portion may be used.

TECH FIG 1 • A. Large right chest wall
chondrosarcoma to be resected, just inferior and
medial to right nipple, measuring more than 5 cm. B. A
contralateral vertical rectus abdominis
musculocutaneous flap is designed based on the
above defect. The flap is designed near the umbilicus

to capture the periumbilical perforators, which are
marked in red. C. Final defect was 13 × 8 cm with
exposed lung and diaphragm. The resected mass
involved two ribs and the parietal pleura. In this
specific case, Gore-Tex mesh was used to prevent
lung herniation prior to insetting of the rectus
abdominis flap. D. Postoperative picture showing
closure of the defect with the vertical rectus abdominis
musculocutaneous flap and midline closure of the
donor site. One Jackson-Pratt drain is seen in the
recipient site, as well as a nearby chest tube.
■ During dissection, identify the superior epigastric artery (which is the artery
the flap will be based on) and the deep inferior epigastric artery.
■ Ligate musculocutaneous perforators, if only harvesting muscle and not
overlying skin and subcutaneous tissue.
■ Once the deep inferior epigastric artery has been identified, ligate it close to
its origin at the pubic symphysis.
■ Interpolate rectus abdominis muscle into defect space, either tunneled below
a skin and subcutaneous tissue bridge or directly into the defect.
■ Close anterior rectus fascia primarily or using a piece of mesh if any
significant tension is present or for added support.
■ Inset rectus abdominis muscle flap into defect and close surrounding local
skin in layers over the muscle.
PEARLS AND PITFALLS
Supercharging
arterial supply
or venous
drainage
■ Consider performing microsurgical anastomosis to aid with
venous drainage or arterial supply if recipient vessels are
available by hooking up the divided deep inferior epigastric artery
and/or vein.
Placement of
■ It is important to place drains in the recipient site, and sometimes

Jackson-Pratt
drains
in the donor site, to prevent hematoma formation, which can lead
to flap compromise.
Prior chest
wall surgery
or radiation
therapy
■ Knowledge of prior reconstructive efforts and/or history of
radiation is important prior to making a decision on flap design
and elevation, as this could affect the blood supply and overall
soft tissue coverage of the defect.
Intercostal
artery–based
rectus
abdominis flap
■ If bilateral internal mammary arteries have previously been
utilized or damaged (often the case with cardiothoracic surgery),
consider harvesting rectus abdominis flap based on intercostal
artery perforators.
Identify and
protect key
blood vessels
■ For superiorly based pedicled flaps, ensure that the superior
epigastric artery is identified and protected.
■ It is also important to identify the deep inferior epigastric artery
prior to dividing it.
POSTOPERATIVE CARE
■ Jackson-Pratt drains are often placed in both the donor and recipient sites.
■ Abdominal drain (donor site) is typically placed oto wall suction.
■ Chest drain (recipient site) is typically placed oto bulb suction.
■ Discontinue drains once output is less than 30 cc for 2 consecutive 24-hour
periods.
■ Patient will often require a chest tube, if the pleural cavity is violated. This is
managed by the thoracic surgery team.
■ Flap monitoring, if possible
■ If skin paddle is present, monitor warmth, color, skin turgor, and capillary
refill.
■ Tight inset may lead to arterial compromise or venous congestion, so clinical
monitoring is important even though this is not a free flap.
■ Avoid heavy lifting during immediate postoperative period to avoid hernias.
OUTCOMES
■ Use of vascularized muscle flaps, including the rectus abdominis flap, has
decreased morbidity and mortality associated with chest wall infections and
tumor resection.
■ Rectus abdominis flaps have been shown to be superior to other flap options
(including pectoralis advancement flaps) for coverage of the inferior portion of

the central chest wall.4
COMPLICATIONS
■ Hematoma and seroma formation
■ Compromise of vascular pedicle
■ Partial or total flap lost
■ If flap is superiorly based, the prior harvest of IMA for cardiac surgery can
lead to distal tip necrosis, most commonly located at the superior portion of
the chest wall.
■ Hernia formation
■ Wound dehiscence of either the donor or recipient site
REFERENCES
1. Losken A, Thourani VH, Carlson GW, et al. A reconstructive algorithm for
plastic surgery following extensive chest wall resection. Br J Plast Surg.
2004;57(4):295-302.
2. Clemens MW, Evans KK, Mardini S, Arnold PG. Introduction to chest wall
reconstruction: anatomy and physiology of the chest and indications for chest
wall reconstruction. Semin Plast Surg. 2011;25(1):
5-15.
3. Nguyen DT, Aoki M, Hyakusoku H, Ogawa R. Chest wall reconstruction of
severe mediastinitis with intercostal artery-based pedicled vertical rectus
abdominis muscle flap with oblique-designed skin paddle. Ann Plast Surg.
2011;67(3):269-271.
4. Davison SP, Clemes MW, Armstrong D, et al. Sternotomy wounds: rectus flap
versus modified pectoral reconstruction. Plast Reconstr Surg.
2007;120(4):929-934.

4
CHAPTER
Omental Flap for Thoracic
Reconstruction
Amir Inbal and David H. Song
DEFINITION
■ The omentum is rich in vasculature, lymphatics, and fat and serves an
important immunologic function within the abdominal cavity.
■ The original anatomical term epiploic is derived from the Greek word
epipleein, which means to float on. It was so named to reflect how the
omentum “floated” anterior to the intestines.
■ The omental flap can be harvested as a pedicled or free flap and is commonly
used as a pedicled flap for thoracic reconstruction.
■ These flaps are historically used to revascularize the myocardium and cover
intra-aortic balloon pumps and ventricular assist devices.
■ Thoracic and chest well defects are attributable to congenital malformations or
acquired deformities and can cause significant physical and psychological
morbidity.
ANATOMY
■ The region of the thorax amenable to pedicled omental flap reconstruction
includes the central and lateral thorax and its contents, most commonly the
sternum, pericardium, pleural cavity, and at times the overlying skin. When
needed, the flap can extend to reach beyond the chest.
■ Thorax: Composed of the skin, muscles, bones, and internal organs/structures
located between the neck and the abdomen
■ Muscles include pectoralis major, pectoralis minor, serratus anterior, serratus
posterior, rectus abdominis, external oblique, intercostal muscles, latissimus
dorsi, and trapezius.
■ Thoracic skeleton

• Ribs—form the rib cage by attaching to vertebral bodies posteriorly and
sternum anteriorly (variable)
• Sternum—long, flat bone in the center of the chest composed of the
manubrium, body, and xiphoid process
• Thoracic vertebrae
■ Internal organs/structures that should be addressed when reconstructing the
thorax include the lungs, heart, pericardium, pleura and pleural space,
esophagus, trachea and bronchus, superior vena cava, thymus gland,
diaphragm, liver, gallbladder, pancreas, duodenum, and pancreas.
■ Dominant blood supply provided by paired internal mammary arteries
(branch of subclavian artery)
• Run posterior to costal cartilage adjacent to sternum with one or two venae
comitantes.
• Interconnect with transverse cervical, thoracoacromial, lateral thoracic, and
posterior intercostal arteries.
• Cutaneous perforating vessels supply overlying tissues and skin
■ Omentum
■ The omental flap is based on the greater omentum found in the abdominal
cavity (FIG 1A).
■ It contains visceral peritoneum, fat, lymphatic tissue, a rich vascular arcade,
and macrophage collections (milky spots).
■ It is a nonneurotized flap.
■ It originates from the peritoneum of the greater curvature of the stomach.
From here, the two layers of the visceral peritoneum descend anterior to the
small intestines, folding backward upon itself at a variable level within the
abdominal or pelvic cavity to ascend and enclose the transverse colon before
attaching to the posterior abdominal wall. With the two layers of visceral
peritoneum folded upon itself, it effectively creates a four-layered structure.
■ The right border of the greater omentum may be attached to the second
portion of the duodenum.
■ The left border of the greater omentum is continuous with the gastrosplenic
ligament.
■ In a study of 200 cadavers and 100 patients who had abdominal surgery, the
average omental length was 25 cm for men (range, 14–36 cm) and 24 cm for
women (range, 14– 34 cm). The average omental width was 35 cm for men
(range, 23–46 cm) and 33 cm for women (range, 20–46 cm). Size of the

omental flap ranges from 300 to 1500 cm2.1
■ The greater omentum is supplied by the right and left gastroepiploic arteries,
which communicate with a rich vascular network within the two layers of the
greater omentum along the greater curve of the stomach (FIG 1B).
■ Vascular supply from the right: celiac trunk to common hepatic artery to
gastroduodenal artery to right gastroepiploic artery
■ Vascular supply from the left: celiac trunk to splenic artery to left
gastroepiploic artery
■ The short gastric arteries originating from the splenic artery, superior to the
left gastroepiploic artery, also serve as an additional source of blood supply to
the omentum by multiple collateral vessels.
■ The right gastroepiploic artery is usually the dominant vessel supplying the
omentum. It is usually 2 to 3 mm in size, and the vein is typically larger.
■ From the anastomoses of the right and left gastroepiploic arteries, the
accessory, right, middle, and left omental arteries descend within the greater
omentum. There is a rich connective arcade between these vessels within the
omentum.
■ Five anatomic variations of the arcade have been described:2,3

FIG 1 • A. Anatomy of the greater omentum within the
abdominal cavity. B. Vascular anatomy of the omental
flap.
• Type 1 (81.7%): middle omental artery bifurcation in the lower third, with

anastomoses to the right and left omental arteries
• Type 2 (11.0%): middle omental artery bifurcation in the middle third,
before anastomoses to the terminal branches of the right and left omental
arteries
• Type 3 (4.5%): middle omental artery bifurcation in the upper third into two
or three branches
• Type 4 (1.2%): middle omental artery absent and replaced by several short
omental arteries
• Type 5 (1.6%): Left omental artery does not join the left gastroepiploic
artery
■ A robust venous system accompanies the arterial arcade and drains into the
right and left gastroepiploic veins.
PATHOGENESIS
■ Full-thickness defects of the anterior thoracic cavity can arise from a variety of
causes:4
■ Infections
• Necrotizing soft tissue infections
• Mediastinitis
• Sternal osteomyelitis
■ Fistulae
• Bronchopleural
• Esophagopleural
■ Trauma
■ Iatrogenic
• Radiation injury
• Postsurgical wound breakdown
• Exposed hardware (eg, aortic grafts, breast implants, vertebral, sternal
plates, or ventricular assist devices)
■ Neoplastic
• Contour congenital defects of the chest wall
• Poland syndrome
• Other breast defects
■ Flail chest: paradoxical chest movement during respiration of a portion of the
rib cage after it loses continuity with the surrounding chest wall resulting in

inefficient ventilation.
■ Most often the result of trauma or oncologic resection of a significant portion
of the chest wall
■ May require reconstruction with soft and/or bony tissue
• Defects 5 cm in diameter or larger generally require skeletal fixation.
■ Risk factors for sternal dehiscence and infection include chronic obstructive
pulmonary disease, obesity, diabetes, and bilateral harvest of the internal
mammary vessels.
■ Radiation-induced injury may cause significant scarring and nonfunctional
tissue that will require debridement and reconstruction.
NATURAL HISTORY
■ Without adequate treatment, defects of the anterior thorax can lead to
devastating consequences including paradoxical breathing, osteomyelitis,
mediastinitis, and death.
■ The greater omentum can be harvested from the abdominal cavity without any
major loss of function.
■ Over time, the omental flap contracts slightly to “bed down” at the defect site.
■ The omental flap provides soft tissue coverage only. In cases in which the
chest wall is unstable due to loss of structural support, alternative methods such
as wires, plates, mesh, or bony reconstruction are required.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation for patients requiring thoracic reconstruction
includes a detailed assessment of the etiology of the defect, the patient’s
underlying medical and functional status, the state of the pleural cavity, the
extent of the soft tissue defect, and whether skeletal support is required and
reconstructive options available.
■ It is important to note whether the internal mammary vessels have been
previously injured or sacrificed.
■ The etiologic factors of the defect should be elicited in history taking, as well
as its suitability for reconstruction.
■ Dirty or actively infected wounds or those with residual tumor are not
amenable to reconstruction.
■ Bacterial cultures should be obtained and targeted antibiotic therapy started
as necessary.
■ A detailed medical history should be noted including cardiovascular problems,

lung pathology, smoking, immunocompromise, and nutritional status.
■ As much as possible, any underlying medical condition should be corrected
or optimized prior to undergoing definitive reconstruction.
■ Special attention should be addressed with regard to history of previous
abdominal surgery, trauma, and any other abdominal morbidity, as these may
cause to preclude the omentum flap as a reconstructive option.
■ Available reconstructive options or prior attempts at reconstruction should be
noted.
■ Physical examination
■ The skin is inspected for previous scarring, prior incisions, active infection,
or radiation changes.
■ Hernias are noted. Laparoscopic surgical port site scars should be carefully
searched. Any prior surgery in the abdominal cavity can lead to intra-
abdominal adhesions, increasing the difficulty of omental flap harvest.
■ Missing tissues are noted.
• Soft and/or hard tissue defects may be present.
■ Breathing mechanics are evaluated.
• Pulmonary function tests are useful for evaluation of baseline pulmonary
status.
■ Routine preoperative laboratory testing should be performed.
■ Obtain a baseline chest radiograph.
■ Computed tomography (CT) should be considered in cases of complex or
extensive defects.
■ The defect should be thoroughly examined again, if possible, under general
anesthesia. The location, size, depth, and extent of the defect must be noted.
Exposed vital structures such as the pericardium, major vessels, or hardware
require more emergent coverage. Active infection or tumor should be excluded.
■ Patients may present with postoperative sternal wounds after cardiac or
mediastinal surgery.
■ Pairolero and Arnold classified wounds based on timing of presentation of
infection:4
• Type I—Occur soon after surgery, may contain incisional breakdown with
serosanguineous discharge and/or sternal instability
• Type II—Occur weeks after surgery, and cellulitis, mediastinal purulence,
and positive cultures may be present

• Type III—Occur months to years after surgery and contain draining sinus
tracts and chronic osteomyelitis
■ Type II and III wounds often require operative reconstruction.
IMAGING
■ Thoracic imaging
■ Chest radiographs in the anteroposterior and lateral dimensions can aid in
assessment of the defect. Although lacking in sensitivity and specificity, they
can be helpful in raising suspicions for other cardiac or lung pathology.
■ CT scans of the thorax are useful in preoperative evaluation of the thoracic
structures, in delineating the extent of the defect, as well as in locating any
underlying tumor or abscess.
■ Compared with CT scans, magnetic resonance imaging (MRI) scans are more
sensitive at detecting osteomyelitis and evaluating the soft tissues. However,
they are seldom required.
■ Vascular studies such as CT angiography may be warranted if tumor
resection or trauma is thought to compromise the vascular anatomy or when
extent of vascular involvement is unknown. In addition, if a free flap is
planned, the vasculature anatomy can be assessed for recipient vessels.
■ Abdominal imaging
■ In general, no investigations are needed to assess the omentum. In cases of
previous abdominal surgery or trauma, where there may be significant
adhesions or damage to the omentum, use of the omental flap would be
avoided. An exception is previous laparoscopic surgery where no
complications and minimal manipulation of abdominal contents have been
confirmed.
■ CT of the abdominal wall may assist in evaluating patients with a history of
surgery or trauma to the area.
■ Vascular studies such as CT angiography may be warranted if compromised
vascular anatomy is suspected secondary to previous surgery or trauma.
■ Laparoscopic surgery enables a direct intraoperative “peak” at the omentum
and its vascularity facilitating decision-making regarding its use.
DIFFERENTIAL DIAGNOSIS
■ Other flaps that can be used to reconstruct defects of the anterior thoracic
cavity include:
■ Pedicled flaps

• Pectoralis major muscle flaps
• Advancement based on the thoracoacromial blood supply
• Turnover based on the internal mammary blood supply
• Rectus abdominis flaps based on the superior epigastric artery
• Muscle only
• Myocutaneous
• Latissimus dorsi flaps (usually for more lateral defects of the anterior
thoracic cavity)
• Internal mammary artery perforator flap
■ Free flaps
NONOPERATIVE MANAGEMENT
■ When left long enough, any wound can heal without operative intervention.
However, healing time, exposure of vital mediastinal structures or hardware,
and the risk of intervening infection must be taken into consideration.
■ There are a variety of wound dressings that can be used, ranging from simple
wet-to-dry dressings to advanced silver-containing biomaterials, which are
beyond the scope of this chapter.
■ A useful bridge to reconstruction is the use of a negative pressure wound
therapy (NPWT) system, which can aid in wound bed preparation and allow
for patient and wound optimization prior to definitive wound coverage.
SURGICAL MANAGEMENT
Preoperative Planning
■ The omental flap can be harvested as a pedicled or free flap. For defects of the
thorax, it is commonly used as a pedicled flap.
■ The size of the omental flap is variable and dependent on individual patient
anatomy.1 The reach of the pedicled omental flap depends on its size.
■ Compared with muscle flaps, omental flaps allow better lining of the inferior
third of the mediastinum, provide more bulk, and conform to the deep recesses
of the mediastinum.5
■ The general indications for the use of thoracic defects requiring omental flap
reconstruction are6:
■ Full thickness in nature exposing the underlying bone, mesh (eg, ADM),
hardware, or mediastinal contents

■ Where dead space obliteration in the thorax is required
■ Considered a good option for radionecrotic chest wounds, with its theoretical
advantage of having immunogenic properties.
■ Foul-smelling, contaminated, or infected wounds
■ Provides a large surface area cover especially when extending the arc of
rotation. If used for skin and subcutaneous tissue coverage, the omental flap
can be skin grafted in the same sitting.
■ When covering a prosthetic material, musculocutaneous flaps are preferred to
omentum and skin graft owing to a better seal by the former.
■ Good source of bulk providing volume for pleural defects or any dead space
obliteration
■ Can plug and wrap around bronchopleural fistula.
■ Due to its donor-site morbidity risks by intra-abdominal incursion, the
omentum is considered a second option when other fasciocutaneous or
musculocutaneous options are unavailable and thus provides a secondary flap
source when other flap options are exhausted.
■ Risks of abdominal donor-site insult to the patient must be considered.
■ Relative contraindications include previous abdominal trauma, surgery, or
infection.
Preoperative Planning
■ The thoracic defect requiring reconstruction needs to be assessed and
optimized prior to definitive coverage. This may require multiple debridements
and the use of NPWT and antibiotic therapy.
■ We use the omental flap if there are no other pedicled flap options available to
meet the reconstructive demands. Most commonly, no preoperative imaging is
necessary for omental flap assessment.
■ The omental flap can generally reach most of the central thorax up to the
sternal notch and the lower parts of the pleural cavities (FIG 2). When
detached only from the colon, it can reach the nipple in 75% of cases.7

FIG 2 • Potential reach of the pedicled omental flap.
■ If planned as a free flap, recipient vessel choice and preparation are required.
■ Location and size of the defect are ideally identified prior to surgery to guide
decisions regarding flap dimension, harvest technique, and required vascular
pedicle length (ie, transposition or free flap).
■ Ideally, microbiological and histological examinations should be established
prior to flap harvest.
■ Arc of rotation considerations when considering a pedicled omental flap:
■ Can extend to reach “knees to neck.”
■ Arch includes the mediastinum and anterior, lateral, and posterior chest wall.8

■ A flap based on the left gastroepiploic pedicle has a greater arc of rotation
compared to the right gastroepiploic vessel, which is the dominant of the two.
■ Involved tissue types
■ Skin: identifying skin involvement is important for determining if a
musculocutaneous flap or omentum with a skin graft is required. The decision
to use omentum would be a very large surface area wound that requires skin
graft use. Skin graft should be meshed to allow fluid transudation through.
■ Muscle:
• Determine which muscles are involved and the level of functionality with
remaining muscles.
• If resection, radiation, or infection compromises a local musculocutaneous
flap that would otherwise be available, this is critical to know prior to
surgery as an omentum flap may be the best option for reconstruction.
■ Bony defects greater than 5 cm or involving more than 3 to 4 contiguous ribs
are likely to benefit from structural support in addition to soft tissue
coverage.
■ Wound age
■ Acute vs chronic wounds often influences the quality of localized tissue
vascularity, extent of fibrosis, and local wound healing capabilities as a result
of inflammation-dependent changes.
■ This may indicate the use of the more distally located omentum with its
known immunogenic properties.
■ Condition of the surrounding tissue. The presence of irradiated skin, previous
scars/contractures, localized infection or inflammation, and acute trauma
influences the regional tissue integrity and subsequently requires
consideration while determining the reconstructive approach and complexity.
■ Patient lifestyle, general health, and functional status guide flap selection for
those patients where preservation of muscular functionality is warranted.
■ Prognosis
■ Life expectancy and patient-specific goals must be considered when
determining complexity of reconstruction.
■ Abdominal morbidity must be considered in patients with poorer overall
prognoses especially if their diseases or conditions involve abdominal
morbidities.
■ Preoperative patient preparation
■ Two days prior to surgery, mechanical bowel preparation is performed.

■ Patient is placed on clear liquid diet.
■ Preoperative prophylactic antibiotic regimen is given as indicated for
laparotomy.
■ Intraoperative considerations
■ Nasogastric tube is inserted and kept in place for 2 postoperative days.
■ Chest tube is considered for chest wall defects involving the pleura.
■ Deep venous thrombosis (DVT) prophylaxis is considered in accordance with
major surgeries of the abdominal wall and thoracic surgery.
■ Two-team approach is possible and should be considered.
Positioning
■ The patient is positioned supine for best exposure. This is done for both the
open and laparoscopic harvest technique.
■ Sterile preparation of the operative field should include the entire abdomen
extending to the thorax where the defect is located.
■ Intraoperatively, the defect and donor site should be partitioned as much as
possible to prevent cross-
contamination.
■ If skin grafting of the omental flap is required, the planned donor site should
be prepared.
■ The patient may be placed in partial or complete lateral decubitus position for
posterior defects. For this approach, the laparoscopic approach can be
considered.
Approach
■ Laparotomy (open approach)
■ Partial upper midline (epigastric) incision is the most commonly used. It can
be performed in a longitudinal or transverse fashion.
■ A complete midline incision is considered when a previous surgical scar can
be used or in those cases demanding better exposure.
■ We use the open technique when the thoracic defect is already
communicating with the upper part of the abdominal cavity.
■ Laparoscopic9,10
■ Considered in selected patients, especially if there is no communication
between the thoracic wound and the abdominal cavity
■ Can assist in pedicle or free flap harvest with minimal size incisions

■ This technique has the advantages of reduced postoperative pain, shorter
postoperative bed rest, lower rate of respiratory and wound complications,
and earlier resumption of oral nutrition.11
■ After laparoscopic harvest, the pedicled omental flap can be delivered into
the thoracic cavity in two ways:
• Via a limited incision in the diaphragm
• If harvested as a free flap, the omentum can be delivered via an extension of
the infraumbilical laparoscopic access port.
■ There is a learning curve, and the surgeon must be competent at handling
laparoscopic equipment within the abdominal cavity, as well as being
equipped to handle any complications related to harvest, such as:
• Intra-abdominal bleeding
• Bowel perforation
• Other visceral injuries
■ The laparoscopic approach requires carbon dioxide insufflation within the
abdominal cavity. This can lead to increased cardiac afterload and decreased
cardiac output, and can be detrimental to and precipitate arrhythmias in
patients with significant cardiac disease, and should proceed with caution in
this patient population.12 Additional precautions can include:
• Preoperative echocardiogram assessment and optimization
• Intraoperative invasive hemodynamic monitoring
• Slower carbon dioxide insufflation of the abdominal cavity
■ Partial or total harvest of the omentum can be done based on reconstructive
requirement. Careful trimming of the omental flap can be done based on
knowledge of its vascular anatomy.
T E C H N I Q U E S
■ Open Harvest of the Omental Flap
■ After sterile preparation of the abdomen, incisions are made:
■ Upper epigastric incision is most commonly used and can be made in a
transverse or vertical fashion.
■ For better exposure, a complete midline laparotomy incision is considered.
This can be done via an extension of the existing thoracic defect or a

separate incision.
■ Previous scars are considered for reuse.
■ Dissection is continued, rectus fascia is divided, and once the parietal
peritoneum is breached, the stomach and greater omentum come into view
(TECH FIG 1A).
■ At times, adhesions may be present and should be released if in the way of
flap harvest.
■ Commonly, the omentum will be visualized immediately under the
peritoneum.
■ The greater curvature of the stomach is identified and traced bilaterally along
its gastric border.
■ Right and left gastroepiploic vessels are identified, as well as their major
descending branches to the omentum.
■ The omentum is delivered out of the abdominal cavity and flipped upward to
expose the posterior attachments of the transverse colon.
■ The omentum is separated from transverse colon and great curvature of the
stomach in the relatively avascular plane with the help of an assistant who
keeps gentle traction on the omentum.
■ Care must be taken to secure the ligature of the short gastric vessels as
coagulated vessels and insecure ligatures can dislodge postoperatively
when they become distended and cause significant bleeding.
■ Omental ligamentous attachments are freed, alongside meticulous collateral
gastroepiploic perforating vessel ligation.
■ Any lateral attachments to the duodenum or gastrosplenic ligament are
divided.
■ Care is taken to avoid any injury to the appendices epiploicae when
dissecting in the avascular plane adjacent to them.
■ Any possible colonic diverticula originating from the transverse colon must
be avoided.
■ Caution is taken to avoid injury to the middle colic vessels and the
transverse mesocolon.

Right gastroepiploic artery (flap pedicle) Greater omentum (free flap) Left gastroepiploic artery (ligated) 'Separation from the transverse colon

TECH FIG 1 • A. Open approach to omental flap
harvest. B. Harvest of omental flap and extension
technique.
■ Once the flap is isolated on its attachment to the stomach, a decision is made
whether to harvest the flap based on the right or left gastroepiploic arteries.
■ This depends on the location of the defect as well as the size of the pedicle
vessels, especially if it is being harvested as a free flap.
■ Skeletonization of the pedicle is often not required or advisable and some
perivascular tissue must be spared, to decrease the risk of vasospasm.
■ Pedicle can be based on the commonly dominant right gastroepiploic artery
originating from the gastroduodenal artery at the gastroduodenal junction.

■ Flap harvest based on the right gastroepiploic vessel is rapid because the
leaves of the omentum usually are not fused to the body and tail of the
pancreas and are easily dissected away.
■ Alternatively, the pedicle can be based on the left gastroepiploic artery or
short gastric arteries originating from the splenic artery.
■ The left gastroepiploic artery provides the greatest pedicle length and is
more commonly used for extended arch of rotation and flap reach.8
■ Elongation of the pedicle technique is performed by division of internal
arcades and basing the flap on the right, middle, or left omental branch that
arises from gastroepiploic system (TECH FIG 1B).
■ Closure of the abdomen should be done in layers including robust rectus
fascia closure.
■ A drain should be placed to detect any intra-abdominal hemorrhage.
■ Laparoscopic Harvest of the Omental Flap
■ After sterile preparation of the abdomen, the laparoscopic ports are placed
(TECH FIG 2).
■ A 10-mm post is placed through an infraumbilical incision, and
pneumoperitoneum is achieved.
■ A 30-degree angled telescopic camera is then placed through this port, and
three additional 2.5-mm ports are placed under direct vision.
■ One port is at the right hypochondrium, another at the right iliac fossa, and
the third at the left flank.

TECH FIG 2 • Laparoscopic approach to omental flap
harvest.
■ Although three ports are usually sufficient for instrumentation, additional
ports can be added as required.
■ The greater omentum is then identified. An instant look inside the abdominal
cavity to check if the omentum has sufficient bulk and size, prior to flap
harvest, is commenced.
■ Any pre-existing adhesions between the greater omentum and the parietal
peritoneum are released with ultrasonic dissection.
■ The omental flap is then dissected off the transverse colon.
■ A pair of atraumatic laparoscopic grasping forceps is placed through the
right hypochondrium port to pull the greater curve of the stomach cranially
toward the right, exposing the transverse colon.
■ The remaining ports facilitate the ultrasonic scalpel and additional
atraumatic grasping forceps to pull the transverse colon caudally while
dissecting the posterior attachments of the omentum off this structure.

■ Once the flap has been isolated on its attachments to the greater curvature of
the stomach, it is released from the left edge (for a flap harvested based on
the right gastroepiploic artery), carefully ligating the short gastric arteries
along the way.
■ For delivery of the flap into the thoracic cavity, a communicating
diaphragmatic incision measuring about 4 to 5 cm can be made either from
the thoracic defect or laparoscopically.
■ Care must be taken not to kink the pedicle when the flap is delivered into the
defect.
■ For external delivery as a free flap, the right gastroepiploic pedicle is
divided, and the flap is delivered through an extension of the infraumbilical
incision.
■ Closure of the port sites can be done in a simple interrupted fashion. A drain
should be placed to detect any postoperative intra-abdominal hemorrhage.
■ Transposition of the Omental Flap
Pedicle Transposition
■ For extended arc of rotation, a left gastroepiploic artery–based flap is
generally considered.8
■ When transposing the flap, avoid overt pedicle compression against
gastroduodenal area to prevent gastric outlet obstruction.
■ Transposition to the thorax is done in one of three ways:
■ Extracutaneous tunneling over the costal margin, in which the exposed flap
is skin grafted. This is associated with less risk of compression but with a
higher infection rate that is contiguous with the abdominal cavity (TECH
FIG 3).
■ Subcutaneous tunneling over the costal margin. This risks compression on
the pedicle, especially when edematous.
■ Through the rectus sheath, facilitated by the laparoscopic approach. Lower
hernia rates but risk of diaphragmatic hernia is increased. This is performed
either through the diaphragm cruciate ligament on the right, where the liver
buttresses the area, or to the left of the falciform ligament.13
■ A small tacking suture may be placed where the omentum enters the chest
wall to prevent pull or extrusion on the pedicle.

TECH FIG 3 • Pedicled omental flap harvest. Thoracic
reconstruction for major resection involving all layers
of the right thoracic cage. Resection included pleural
cavity breach indicating ADM use for structural
support. A pedicled omental flap was harvested based
on the right gastroepiploic artery.
■ Adequate pedicle length is ensured to avoid excessive tension on the pedicle
during transposition and insetting.
Free Flap Transposition
■ The omental flap has a relatively long ischemia time due to its low metabolic
demand.
■ The dominant right gastroepiploic artery is commonly used.
■ Adequate preparation of the defect site and recipient vessels should be done
prior to dividing the omental flap pedicle.
■ Recipient vessels may include neck, thoracic, aortic, and vertebral arteries
and their braches.
■ Omentum is transferred and vascular anastomosis is commenced at the
recipient site.

■ Flap Inset
■ Attention is paid to pedicle positioning to avoid compression, kinking, or
twisting, which may compromise blood flow to the flap immediately or early
in the postoperative period (TECH FIG 4A).
■ For the mediastinum and other external chest defects, the omentum can
provide volume as well as a large surface area covered by a skin graft (TECH
FIG 4B).
■ Can be folded to fill dead space commonly present in the deep pleural cavity
■ Can wrap around vessels or plug bronchopleural fistulas
■ Multiple tucking or stay sutures are used to keep the flap in its place and
prevent gliding or sliding.
■ Drains are recommended for serous fluid accumulation, commonly
associated with the omentum flap, and for early recognition of bleeding.
TECH FIG 4 • A. Pedicled omental flap inset. The
omental flap covered the entire ADM. The flap was
sutured all around for water seal closure. B. Skin
grafting of the omental flap for complete cover.
PEARLS AND PITFALLS
Preoperative
assessment
■ Past medical history of abdominal or pelvic surgery should
prompt further investigation, and the omentum flap option

should be reconsidered.
■ Adequate workup and precautions should be taken in patients
with significant cardiac disease.
Port placement
(for
laparoscopic
harvest)
■ First port to be placed should be the 10-mm camera port to
allow pneumoperitoneum and placement of subsequent ports
under direct vision.
Harvest
technique
■ Special attention should be given to effective debridement of
infected or necrotic nonviable bone and cartilage tissues (eg,
sternum, ribs).
■ Laparoscopy allows a “peek” to assess the feasibility and
dimension of the omentum flap.
■ Use of nontraumatic grasping forceps.
■ Keep the omentum flap wet at all times to prevent its
desiccation.
■ Transillumination of the omentum allows visualization of its
vascularity.
■ Minimal manipulation of bowel.
Hemostasis
■ Use of hemostatic ultrasonic scalpel for laparoscopic harvest.
■ Avoid cautery use for vessels. Rather, ligate as you go to
decrease the risk of bleeding, hematoma, and injury to vessels
of the omental arcade.
■ An intra-abdominal drain should be placed to detect
postoperative hemorrhage.
■ Sustained postoperative seroma should be anticipated and
drains removed in time.
Delivery and
inset of flap
■ An incision in the diaphragm can be used for pedicle
transposition but should be wide enough to avoid compression.
■ Prior to ligating the main gastroepiploic vessel, the right and
left arteries can be temporarily clamped alternatively to
determine omental arch flow.
■ Subcutaneous tunneling should be wide enough (4 fingers’
wide or more) so that postoperative edema will not facilitate
compression and venous congestion.
■ Ensure that the pedicle is not kinked or compressed in the
process of flap delivery and inset.
■ If used for external coverage, the omental flap can be skin
grafted.
■ Sliding of flap postoperatively is a common difficulty and
avoided by multiple tucking sutures.

■ Gastric outlet obstruction should be thought of when the
pedicle is transposed over the gastroduodenal area.
■ Be alert for abdominal morbidities following surgery,
especially infection and peritonitis.
POSTOPERATIVE CARE
■ Immediate postoperative care should include flap care, monitoring, and
postabdominal and thoracic surgery precautions.
■ A meshed skin graft is advised for externally placed flaps to avoid transudate
under the skin graft. A dressing need not be applied to avoid flap
compression.
■ Clinical monitoring of the omental flap is difficult. Changes within the flap
are difficult to see until it is too late.
■ If used as a free flap, standard free flap protocols should be instituted
including regular flap checks, nothing by mouth (NPO) for the first 24 hours,
and bed rest.
■ As with any other flap, the 24- to 72-hour postoperative window requires
particularly attentive flap monitoring in the form of clinical and/or US
Doppler evaluations to identify any signs of pending flap failure.
■ Monitoring options include the following:
■ An implantable Doppler for free flap monitoring.
■ Temperature probe placement.
■ A skin-grafted window directly over the omentum facilitates pedicled as well
as free flap monitoring for direct flow signal monitoring with the use of a
pencil Doppler.
■ Postabdominal surgery precautions should include the following:
■ NPO followed by gradual clear fluids working up to normal diet over the first
few postoperative days. Commonly, a nasogastric tube is left in place until
postoperative day 2 or 3.
■ Monitoring of drain output for early detection of intra-abdominal
hemorrhage. The drain can be removed once output is less than 30 mL/d for 2
consecutive days.
■ Adequate pain control. The laparoscopic approach is associated with
decreased postoperative pain.
■ Early mobilization of the patient on the first postoperative day is
recommended, unless there are other factors preventing this.

■ Postoperative antibiotics are given in accordance with abdominal surgery and
laparotomy.
■ Chest tube with an underwater seal may be indicated for deep thoracic
defects involving the pleura. Chest tubes are removed following thoracic
surgeon consultation.
OUTCOMES
■ Remarkably very few complications are encountered in regard to donor-site
morbidities and flap inset.
■ Most complications are minor and are addressed conservatively.
■ FIG 3 shows an outcome in one patient after pedicled omental flap for
thoracic reconstruction.
■ In 135 patients undergoing use of the omental flap for extraperitoneal
reconstruction (64 pedicled and 71 free flaps), there were 25 donor-site
complications (18.5%).1 All but one omental flap was harvested via an open
technique.
FIG 3 • A. Postoperative anterior view of the
reconstructed thoracic defect. B. Postoperative lateral
view of the reconstructed thoracic defect. C.
Postoperative posterior view of the reconstructed
thoracic defect.
■ Twenty-six of 53 patients who had undergone previous abdominal surgery
required extensive adhesiolysis, with 4 patients sustaining enterotomies.
■ Eleven patients (8.1%) had partial flap loss and three patients (2.2%) had
total flap loss.

■ Factors associated with increased donor-site complications included:
• Use of pedicled flaps
• Mediastinitis
• Advanced age
• Pulmonary failure
■ In a series of nine laparoscopically harvested pedicled omental flaps for chest
wall and intrathoracic reconstruction, there were no major intra-abdominal
complications postoperatively.14
■ One patient required conversion to a free omental flap due to the detachment
of the pedicle, and another patient required conversion to an open harvest
technique due to severe abdominal adhesions. One patient had a small
transdiaphragmatic hernia treated laparoscopically.
■ In a head-to-head comparison of omental flaps vs pectoralis major flaps in the
treatment of 33 patients with sternal osteomyelitis, the sepsis-related mortality
rate was higher in the pectoralis group (28%) than in the omentum group (0%).
The authors concluded that the omental flap conferred greater immunologic
advantage as compared with pectoralis major flap.15
■ The open pedicled omental flap harvest technique was used successfully in 27
patients with deep sternal wound infections that had failed previous treatment
including pectoralis major flap coverage. There was 1 abdominal wall hernia
and 1 persistent fistula in this series.16
COMPLICATIONS
■ In general, postoperative complications associated with chest wall
reconstruction include hematoma, seroma formation (fluid transduction),
infection, and pneumothorax.
■ Skin graft nontake or separation could occur but is mostly only partial and
self-resolving.
■ If reconstructive plates are used for chest wall stabilization, foreign body
reaction, extrusion, and infection can result. This occurs more commonly if the
hardware is placed in a radiated field and insufficient soft tissue coverage is the
case.
■ Donor-site morbidity may include laparotomy-related complications. These
include but are not limited to
■ Bowel obstruction
■ Gastric outlet obstruction

■ Peritonitis and other infections (eg, abscess)
■ Intra-abdominal hemorrhage
■ Viscera injury (eg, splenic, liver, bowel perforation)
■ Volvulus
■ Fascial dehiscence and hernia (eg, epigastric, diaphragmatic)
■ Late complications including adhesions and postoperative ileus
■ In general, flap-related complications include flap loss secondary to vascular
twisting, kinking, excessive tension, and vasospasm, as well as bleeding and
infection.
■ Specific complications related to the omentum flap include seroma formation
(transudation), omental atrophy, flap sliding or migration, and avulsion.
ACKNOWLEDGMENTS
We thank Adrian S. H. Ooi, MBBS, MRCS, MMed, and Chad M. Teven, MD,
for their contributions to the preparation of this chapter.
REFERENCES
1. Das SK. The size of the human omentum and methods of lengthening it for
transplantation. Br J Plast Surg. 1976;29(2):170-44.
2. Alday ES, Goldsmith HS. Surgical technique for omental lengthening based
on arterial anatomy. Surg Gynecol Obstet. 1972;135(1):103-107.
3. Upton J, Mulliken JB, Hicks PD, Murray JE. Restoration of facial contour
using free vascularized omental transfer. Plast Reconstr Surg. 1980;66(4):560-
569.
4. Pairolero PC, Arnold PG. Thoracic wall defects: surgical management of 205
consecutive patients. Mayo Clin Proc. 1986;61(7):557-563.
5. Puma F, Fedeli C, Ottavi P, et al. Laparoscopic omental flap for the treatment
of major sternal wound infection after cardiac surgery. J Thorac Cardiovasc
Surg. 2003;126(6):1998-2002.
6. Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the
reconstruction of the chest wall. Ann Surg. 1977;185(5):
548-554.
7. Krabatsch T, Schmitt DV, Mohr FW, Hetzer R. Thoracic transposition of the
greater omentum as an adjunct in the treatment of mediastinitis: pros and cons
within the context of a randomised study. Eur J Surg Suppl. 1999;(584):45-48.
8. Alday ES, Goldsmith HS. Surgical qmy. Surg Gynecol Obstet. 1972;135:103.
9. Corral CJ, Prystowsky JB, Weidrich TA, Harris GD. Laparoscopic-assisted

bipedicle omental flap mobilization for reconstruction of a chest wall defect. J
Laparoendosc Surg. 1994;4(5):343-346.
10. Salameh JR, Chock DA, Gonzalez JJ, et al. Laparoscopic harvest of omental
flaps for reconstruction of complex mediastinal wounds. JSLS. 2003;7:317-
322.
11. Puma F, Vannucci J. Advantages of laparoscopic omental flap in the treatment
of deep sternal wound infection. Interact Cardiovasc Thorac Surg.
2011;13(2):188.
12. El-Muttardi N, Jabir S, Win TS. Pearls and pitfalls of laparoscopic harvest of
omental flap for sternal wound reconstruction in patients with significant
cardiac dysfunction. J Plast Reconstr Aesthet Surg. 2013;66(12):e394-e395.
13. Vyas RM, Prsic A, Orgill DP. Transdiaphragmatic omental harvest: a simple,
efficient method for sternal wound coverage. Plast Reconstr Surg.
2013;131:544-552.
14. Acarturk TO, Swartz WM, Luketich J, et al. Laparoscopically harvested
omental flap for chest wall and intrathoracic reconstruction. Ann Plast Surg.
2004;53(3):210-216.
15. López-Monjardin H, de-la-Peña-Salcedo A, Mendoza-Muñoz M, et al.
Omentum flap versus pectoralis major flap in the treatment of mediastinitis.
Plast Reconstr Surg. 1998;101(6):1481-1485.
16. Eifert S, Kronschnabl S, Kaczmarek I, et al. Omental flap for recurrent deep
sternal wound infection and mediastinitis after cardiac surgery. Thorac
Cardiovasc Surg. 2007;55(6):371-374.
SUGGESTED READING
Hultman CS, Carlson GW, Losken A, et al. Utility of the omentum in the
reconstruction of complex extraperitoneal wounds and defects: donor-site
complications in 135 patients from 1975 to 2000. Ann Surg. 2002;235(6):782-
795.

5
CHAPTER
Latissimus Dorsi Flap for
Chest Wall Defects
Essie Kueberuwa Yates and David H. Song
DEFINITION
■ Composite defects of the chest wall can arise secondary to oncological
extirpation, ablation due to infection, congenital defects, trauma, radiation, or
iatrogenic causes such as surgical access and hardware extrusion.
■ Methylmethacrylate (in a nonradiated wound bed), bioprosthetic mesh,
vascularized bone, local myocutaneous flaps, and free tissue transfer are all
routinely used in the reconstruction of chest wall defects.
■ The choice of technique is related to size, extent, and location of the defect
and the availability of donor site.
■ The latissimus dorsi flap (LDF) is a reliable flap with a robust and predictable
vascularity. The proximity of the flap to the chest wall makes it an ideal choice
for providing muscle, fat, and skin for use in reconstructing large chest wall
defects.
■ The thoracodorsal artery system nourishes the LDF and offers the possibility
for incorporating multiple tissue types of its single vascular pedicle (chimeric
flap).
ANATOMY
■ The LD muscle has multiple origins (FIG 1):
■ Spinous processes of T7-T12
■ Thoracolumbar fascia

FIG 1 • Latissimus dorsi muscle.
■ Posterior third of the iliac crest
■ Lowest six ribs
■ The LD muscle inserts into the intertubercular groove of the humerus.
■ It is a broad flat muscle, which is the most superficial back muscle overlying
the paraspinous muscles medially and serratus anterior laterally. It lies deep to
the trapezius superomedially.
■ The LD is a type V muscle, with the dominant vascular pedicle being the
thoracodorsal artery, a terminal branch of the subscapular artery, which arises
from the third portion of the axillary artery.
■ The thoracodorsal artery runs on the underside of the muscle, and the main
pedicle divides into two main branches: an upper horizontal branch that travels
medially along the superior border of the muscle and a descending oblique
branch that runs inferiorly, parallel to the anterior border of the muscle about

2.5 cm from the edge.
■ The bifurcation is predictably found 4 cm distal to the inferior scapular
border and 2.5 cm medial to the anterior border of the muscle.
■ Thoracodorsal artery perforators exit the muscle and perfuse the subcutaneous
tissue, one of these perforators is typically located 8 cm below the posterior
axillary fold and 2 cm behind the anterior border of the LD muscle.1
■ Secondary pedicles arise dorsally and mostly perfuse the distal part of the
muscle. They are typically found about 5 to 10 cm lateral to the spinous
processes and are arranged in a medial row (branches of the lumbar arteries)
and a lateral row (branches of the intercostal arteries).
■ The largest and most constant of these secondary blood supplies are the
branches of the 8th to 11th intercostal arteries. They are typically not useful for
large anterior chest wall reconstructions due to their location and short pedicle
length.
■ These branches can be used, however, when the LD has been previously
transected in a standard non–
muscle-sparing thoracotomy incision, as the distal portion of the muscle can
still be mobilized to provide coverage of limited posterior defects.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ When evaluating a chest wall defect, important considerations include the
following:
■ Viability and quality of the wound bed (radiated, inadequately debrided;
presence of contaminated hardware and large dead spaces result in poor
wound healing)
■ Effect of the wound on respiratory mechanics
■ Exposure of vital structures
■ Aesthetics and contour of the chest
■ Typically, defects larger than 5 cm or involving more than three ribs require
chest wall stabilization in addition to soft tissue coverage.
■ In the postirradiated chest wall, larger defects can be tolerated without fixation
due to the rigid scarring and fibrosis of tissue.
SURGICAL MANAGEMENT
■ The LDF is ideal for chest wall reconstruction because the axis and length of
the thoracodorsal pedicle afford this flap an excellent arc of rotation and
virtually any part of the ipsilateral chest wall can be reached.

■ The most common uses of the LD in chest reconstruction are as a muscle-only
flap for intrathoracic obliteration of dead space or as a musculocutaneous flap
for coverage of large chest wall defects.2
Preoperative Planning
■ When planning chest wall reconstruction with an LD flap, the main
considerations are as follows:
■ Ensuring vascularity and availability of donor site. (On occasions, the muscle
is transected during thoracotomy.) Some syndromes (eg, Poland) are
associated with congenital absence of the pectoralis and LD muscle.
■ Assessing defect size: The thoracodorsal artery provides branches to the
serratus muscle, which can be taken in conjunction with the LDF if a larger
flap is necessary.
■ Assessment of the need for rigid fixation in addition to soft tissue coverage
for composite resections (involving more than three ribs). Vascularized bone
can be harvested in conjunction with the LD flap.
■ Appropriate preoperative counseling: The LD is an external rotator of the
shoulder, and patients should expect decreased strength and range of motion
postoperatively.
■ Preoperative markings: With the patient in the standing position, the borders of
the latissimus dorsi muscle are delineated (FIG 2).
■ Inferior tip of the scapula
■ Anterior border (with the arm elevated, the anterior border extends from the
posterior axillary line caudal to the iliac crest).
■ Upper border (with the arm elevated, the posterior border extends from the
axilla over the tip of the scapula to the midline of the back).
■ Lower border (curves from the lower midline of the back lumbar region) to
the anterior border of the muscle.

FIG 2 • Preoperative markings.
■ The inferior segment of the trapezius is also drawn out as it overlaps the
upper medial border of the latissimus as a reminder of this important
anatomic relationship.
■ Once the limits of the muscle have been identified, the location and orientation
of the skin island are planned.
■ The size of the skin island is a factor of the defect, and ability to close the
donor site primarily.
■ The skin island is precisely centered on a dominant perforator that is
identified using a handheld Doppler intraoperatively.
Positioning
■ The LDF is typically harvested in the lateral decubitus position with an
axillary support for respiration and with the arm prepped in and the shoulder
flexed to 90 degrees.
■ A beanbag with appropriate padding can be used, with a pillow placed
between the knees and abducted and elevated arm placed on a Mayo stand.

■ Lateral decubitus is the preferred positioning for a standard thoracotomy
allowing posterolateral and intrathoracic reconstructions to be performed
without position change.
■ Anterior defects do require harvest, delivery, and closure of donor site, before
inset performed when the patient position changes to supine.
T E C H N I Q U E S
■ Flap Elevation
■ The skin paddle is incised down through the thoracic fascia to the loose fatty
tissue overlying the LD muscle.
■ Caution is taken to bevel out circumferentially for a few centimeters to aid
closure without dog-ears and to maximize flap bulk.
■ Subcutaneous dissection is carried out inferiorly first, then superiorly
keeping a thin layer of loose areolar fat on the muscle until the limits of the
muscle are identified.
■ Care is taken to ensure the skin flaps are not too thin.
■ The aponeurosis of the trapezius and latissimus muscles is identified, and the
LD muscle is separated from underneath it.
■ Submuscular dissection is carried down on the medial underside of the LD
muscle from superior to inferior.
■ The fascial attachments to the paraspinous muscles are divided, and the
lumbar perforators are ligated when encountered.
■ Inferiorly, the muscle is divided through its attachments to the iliac crest.
■ The anterior border is separated next, again identifying and ligating
intercostal perforators and separating attachments from the serratus muscle.
■ At this point, the muscle is totally freed and can be flipped upward on its
pedicle. (The humeral insertion remains intact at this point.)
■ Any remaining attachments to teres minor or any other deep structures can
be identified and divided.
■ The vascular pedicle is visible entering the muscle approximately 10 cm
inferiorly from humeral attachment.

TECH FIG 1 • Chimeric thoracodorsal artery perforator
(TAP) flap based on the thoracodorsal system. LD,
latissimus dorsi muscle. (Courtesy of Lawrence J.
Gottlieb, MD.)
■ In the case of a chimeric flap, other options involve harvesting the tip of
the scapula (off angular branch), serratus muscle/fascia (off serratus
branch), and rib based on perforator connections from the LD muscle
(TECH FIG 1).
■ Division of the humeral insertion above the entry of the pedicle greatly
facilitates freedom of movement and ease of inset.
■ The thoracodorsal bundle is readily identifiable at this stage of the
procedure. Division of the nerve at this point minimizes dynamic movements
in the flap postoperatively.
■ Dissection of Axillary Tunnel
■ The tunnel facilitates the passage of the myocutaneous flap into the chest for

anterior defects.
■ Care should be taken to ensure the tunnel has adequate width.
■ The tunnel can be dissected from both the chest wall wound (recipient site)
and from the donor site (flap side).
■ Some surgeons like to predissect the tunnel prior to flap elevation.
■ If the humeral origin was divided during elevation, care must be taken not to
place tension on the pedicle as it passed through the tunnel.
■ The donor site should be closed in layers over closed suction drainage.
■ The flap is inset in layers over closed suction drainage
PEARLS AND PITFALLS
Minimizing
seroma risk
■ Consider quilting sutures for donor site.
■ Use at least two large-caliber drains.
■ Minimize excessive arm elevation in early postoperative period.
Flap elevation
pearl
■ If possible, leave the thoracodorsal branch to serratus intact. If
you have an injury to the TDA high in the axilla, the serratus
branch can nourish the flap via retrograde flow and intercostal
communications.
Minimizing
donor site
morbidity
■ If only a small flap is required, consider a TAP flap or
latissimus-sparing modification of the traditional procedure.
Stabilization of
the chest wall
■ Posterior ribs can be elevated with this flap and used in the
event when chest wall stabilization with autologous tissue is
desired.
Optimizing
success in
chronic chest
wall wounds
■ The LDF offers a good option for salvage in a chronic infected
wound. Adequate aggressive debridement prior to flap coverage
is essential to a successful outcome.

FIG 3 • A. This 53-year-old man had a history of
fungating primary adenocarcinoma of anterolateral
chest wall after radiation, with open draining wound and
osteoradionecrosis of the underlying rib. B. After
resection and reconstruction with LD flap. C,D.
Recipient and donor sites, respectively, 6 months
postoperatively.
POSTOPERATIVE CARE
■ Most patients have an uneventful postoperative course specifically related to
the LD flap.
■ Early ROM is encouraged to minimize arm and shoulder stiffness.
■ Excess elevation and abduction of the arm are discouraged, however, because
of significantly increased seroma formation risk.
■ Drains should stay in situ until <30 cc/24-h period is recorded for 2

consecutive days. Drains are often required for many weeks.
OUTCOMES
■ In the well-selected patient, the main outcomes for chest wall reconstruction
are readily achieved using LDF (FIG 3).
■ These flaps offer sufficient volume to fill the three-dimensional dead space,
buttressing repair of hollow visceral leaks, maintenance of chest wall stability,
restoration of aesthetic contour, covering of exposed prosthetic materials with
vascularized flaps, and retaining the “right of domain” of abdominal and chest
viscera while minimizing donor site functional deficits.3
COMPLICATIONS
■ The most common complication from LD flap harvest is donor site seroma
formation. Drains are often required for prolonged periods, on occasions up to
6 to 8 weeks.
■ In the event of seroma accumulation, repeat in-office aspiration may be
required. With time, fluid accumulation eventually stops, leaving behind an
empty bursa of varying dimensions.
■ Isolated arm strength can be diminished after flap transfer, although this is
rarely a significant finding, as the other muscles of the back compensate for the
absent muscle.
■ It takes 6 months to a year for the surrounding muscles to be fully
compensatory, and patients often describe easy fatigability in activities
requiring external rotation and elevation of the arm overhead (eg, swimming,
climbing, painting).3
■ The vascularity of the LD flap is robust, and vascular compromise or fat
necrosis is rare after LD transfer.
■ However, donor site marginal skin necrosis can occur particularly in smokers,
which might suggest avoiding excessive undermining.
REFERENCES
1. Bank J, Ledbetter K, Song D. Use of thoracodorsal artery perforator flaps to
enhance outcomes in alloplastic breast reconstruction. Plast Reconstr Surg
Glob Open. 2014;2(5):e140.
2. Bakri K, Mardini S, Evans K, et al. Workhorse flaps in chest wall
reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis
flaps. Semin Plast Surg. 2011;5(1):43-54.

3. Netscher D, Izaddoost S, Sandvall B. Complications, pitfalls, and outcomes
after chest wall reconstruction. Semin Plast Surg. 2011;25(1):
86-97.