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Latissimus Dorsi-rib Osteomyocutaneous Flap For Composite Cranial Defects: Report On 8 Cases And Anatomical Study
Michael J. Annunziata, BS, Majid Rezaei, DDS, MSc, Sean Nagel, MD, Mark Bain, MD, Sudish Murthy, MD, PhD, Richard L. Drake, PhD, Bahar Bassiri Gharb, MD, PhD, Antonio Rampazzo, MD, PhD.
Cleveland Clinic, Cleveland, OH, USA.

PURPOSE: Latissimus dorsi-rib osteomyocutaneous flaps (LDRFs) are versatile in reconstructing compromised composite defects of the cranium. The flap restores the contour of the skull, protects the brain, and improves neurologic status. There are benefits to using autologous rib instead of alloplastic material; however, rib viability and flap success rely on adequate blood supply. Our aim was to present the outcomes of 8 patients treated with LDRF and provide an anatomical basis for this flap.
METHODS: Eight patients with cranial defects treated with LDRF were evaluated retrospectively. Defect size, etiology, previous reconstructive attempts, outcomes, and complications were assessed. Patient reported outcomes were assessed with 36-Item Short Form Survey, Selective Functional Movement Assessment test, Karnofsky Performance Scale test, Functional Independence Measure test, Barthel test, University of Washington Quality of Life Questionnaire, Headache Disability Index, The Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and Pain Disability Questionnaire. Red latex was injected into the subscapular arterial system of 20 fresh cadaver sides. In the prone position, latissimus dorsi muscle was dissected from the ribs in a mediocaudal to superolateral direction to locate interconnecting vessels between the thoracodorsal and lateral posterior intercostal systems. The number, diameter and length of perforators, and distance from midline were measured. Statistical analysis was performed with SPSS 16.0, one-way ANOVA, and post-hoc Tukey’s tests.
RESULTS: All patients had a history of ≥2 previous failed reconstructions. Defects were secondary to gunshot injury, bone flap infection after cranioplasty performed for CVA and aneurism clipping, post-ablation irradiation, and post-frontal intracranial hemorrhage cranioplasty. Four defects were reconstructed using 2 ribs, whereas the remaining 4 patients received 1 rib. A prolene mesh was used to fill in the donor site defects in 6 patients. Average follow-up was 26 months (1-56 months). All patients had stable reconstructions. Headache resolved in 2 patients after reconstruction, and neurologic status improved in 3 patients. All patients showed some donor site morbidity with an increase in the Pain Disability Index. An average of 13.75 perforators could be localized in each cadaveric latissimus dorsi muscle. No perforator was found for the 7th rib. Not all cadaver sides contained perforating vessels for the 8th and 12th ribs. The distance from the midline to the first perforator was not different between the ribs (p = 0.499). Perforator diameter and pedicle length tended to decrease at more inferior rib levels. The 10th rib (4.65 ± 2.01) followed by 9th rib (3.7 ± 1.63) had the highest number of perforators. The 8th and 12th ribs contained the least perforators. The 8th rib had the longest perforators (4.26 ± 1.52 cm). The 8th and 9th had larger perforators than the 10th-11th-12th ribs (p = 0.021).
CONCLUSIONS: The LDRF can successfully address large composite cranial defects, provide support, and enhanced contour with acceptable donor-site morbidity. The 10th followed by the 9th rib has the best vascular supply for this flap. If 2 ribs are considered for the flap, the 9th and 11th are recommended. If only 1 rib is necessary for reconstruction, the 10th is ideal.


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