This case report describes a combined latissimus dorsi/serratus anterior muscle and fascia free flap used to reconstruct large soft-tissue defects following replantation of a hand and wrist. The patient was a 25 year-old male with a crush/avulsion injury and partial amputation through the distal forearm, completed at the scene to a complete amputation to extract the limb. Immediate treatment was with replantation and primary closure. The patient developed a deep wound infection and necrosis of palmar and dorsal skin at multiple levels. Debridement produced an 18x17 cm dorsal defect of the hand and an 8x6 cm palmar defect of the distal forearm. The two defects were covered with a single large combined latissimus/serratus flap, anastomosed to the radial artery and cephalic vein in an end-to-end fashion. Both flaps survived and provided stable coverage of the wounds with no further surgery. Function was characterized by 8mm two-point discrimination, limited finger flexion and extension, and poor intrinsic function.
The combined latissimus/serratus flap has been used for massive defects in the head and neck, lower extremity, and trunk. The authors describe an appropriate use of the flap for a very large, multi-site soft tissue defect in the upper extremity. The advantages of this flap are its great surface area, ability to cover separate defects with a single flap, the long pedicle which allows for anastomosis outside the zone of injury, and its flat, supple muscle contour which works well for extremity defects without unwanted bulk. The authors point out that the fascial component of the serratus provides an excellent gliding surface for tendon rehabilitation after repair, grafting, or transfer.
Journal of Reconstructive Microsurgery