Case 2 - 2025: Reconstruction of an extensive foot defect using a combined sensory split latissimus dorsi and serratus anterior muscle flap
Dr. med. Luisa Lotter1, PD1
- 1Kantonsspital St. Gallen, Switzerland
Abstract
Keywords: Lower extremity; Flap; Reconstruction; Soft tissue; Trauma; Microsurgery; Foot; Latissimus Dorsi ; Authors: Dr. med. Luisa Lotter, Dr. med. Ilja Käch, PD Dr. med. Volker Schmidt. Institution: Kantonsspital St. Gallen, Switzerland Abstract A 67-year-old male patient sustained a complex foot injury with an open Lisfranc dislocation of the medial cuneiform bone and shaft fractures of the 2nd to 4th metatarsals in July 2024, as a result of a crush trauma. After initial osteosynthetic treatment, a pronounced necrosis developed in the area of the hindfoot and forefoot over time and an implant-associated wound infection. The patient was then transferred to our tertiary care hospital for specialized defect reconstruction. At first radical necrosectomy was performed, resulting in a 10 x 12 cm soft-tissue defect in the heel area, which extended medially and laterally. In the area of the forefoot, there was also a full-thickness wound measuring 4 x 3 cm with exposed osteosynthetic material, bone, and tendon. Patient medical history The patient has no pre-existing conditions. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg. Before and After Patient examination Upon admission to our hospital, on assessment, the 67-year-old male patient was in good general health with a slim nutritional status. On the heel area of the right foot was a 10 x 12 cm soft-tissue defect, which extended medially and laterally. In the area of the forefoot, there was also a full-thickness wound measuring 4 x 3 cm with exposed osteosynthetic material, bone, and tendon. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg. Pre-operative considerations The reconstruction of complex soft tissue injuries with exp
BeforeAfterThe patient has no pre-existing conditions. Blood tests on admission showed a blood glucose level and HbA1c value within the normal range. An angiography was performed, revealing a regular three-vessel supply to the affected lower right leg.
The wound bed was prepared by debriding non-viable tissue and taking precise measurements of the skin and soft tissue defect. Exposed functional structures were identified and measured. A 3 cm section of the osteosynthesis material, as well as the tendon of the extensor hallucis longus muscle, were exposed. Additionally, there was only a very thin soft tissue covering over the heel.
Before the defect was covered by a free microsurgical flap, the osteosynthesis material was replaced by the orthopaedic team due to a preceding implant-associated infection. The posterior tibial artery and the saphenous nerve were exposed up to 5 cm.
2
For the defect coverage, a combined microsurgical flap procedure consisting of the lateral portion of the latissimus dorsi and the distal three slips of the serratus anterior muscle was planned. At the beginning, the vascular supply of the M. latissimus dorsi, including the thoracodorsal nerve, long thoracic nerve, and serratus arcade, is visualized. It is particularly important that the dorsal branch of the thoracodorsal nerve is preserved, as it is essential for the motor function of the medial portion of the latissimus muscle, which will be left in situ.
3
This is followed by mobilization of the latissimus dorsi muscle and detachment of the lateral portion, as well as the distal three slips of the serratus anterior muscle. The common vascular pedicle is followed up to the origin of the circumflex scapular artery, and the flap is then detached along with the thoracodorsal nerve. The medial part of the latissimus dorsi muscle is preserved (marked in green).
4
Microsurgical anastomoses of the perforator: arterial anastomose to the posterior tibial artery were established in an end-to-side fashion using Dafilon 8-0. The vein was anastomosed end to end to the concomitant veins of the posterior tibial artery using a 2.5 mm coupler. The branch of the thoracodorsal nerve was connected to the sensory branch of the saphenous nerve epineurally using a 3 cm nerve allograft and Dafilon 9-0.
5
The flaps were accurately modelled to meet the defect configuration and two Charrier Redon drains were inserted. The skin was removed, and the entire flap was covered with mesh graft from the ipsilateral thigh.
6
Follow-up
7
How to cite this article
Dr. med. Luisa Lotter, PD. Case 2 - 2025: Reconstruction of an extensive foot defect using a combined sensory split latissimus dorsi and serratus anterior muscle flap. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
Open access. © 2025 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
Keep reading
Related cases
Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture
Jorge Jimenez Lopez, Anastasia Boptsi, Konstantinos Kalousis
Keywords: Hand surgery; wrist; carpectomy; scaphoid; lunate dislocation Authors: Jorge Jimenez Lopez, MD; Anastasia Boptsi, MD; Konstantinos Kalousis, MD Institution: Universitätsklinikum Schleswig-Holstein Lübeck Abstract Carpal dislocation fractures are uncommon injuries, most frequently associated with high-energy trauma. Combined carpal dislocations without associated bone fractures are even rarer. Delayed treatment can have serious consequences. The case presented here involves an 86-year-old man with dislocation of the scaphoid and lunate bones, as well as acute carpal tunnel syndrome resulting from the injury. PRC is mostly a salvage operation but given the severity of ligamentous disruption, the need to restore the patient's mobility and also the fact, that scaphoid was irreducible, a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). Patient medical history The 86-year-old patient crashed the car into the wall of his garage at a speed of 30 km/h. As a result, the patient presented a dislocation of the lunate bone and the scaphoid. The patient lived alone and was completely independent. Regarding other conditions, he suffered from arterial hypertension and prostate cancer. Before and After Patient examination There was a visible deformity at the right wrist with bruising, and swelling. Additionally, a positive Hoffman-Tinel sign was observed with paresthesia in the median nerve area. A radiological examination of the hand was then performed, which revealed a dislocation of the scaphoid and lunate bones. No bone fractures were detected. Pre-operative considerations Given the severity of ligamentous disruption and the need to restore the patient’s mobility a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). 1 Surgical Dorsal Exposure The surgical procedure involved exposing and splitting the 4th and 3rd extensor tendon compartments to facilitate access. The extensor pollicis longus (EPL) tend
Case 16: Utilizing the reverse radial forearm flap for burn wound management of the hypothenar part of hand
David Salim, MD, Msc
Keywords: Reverse radial forearm flap, Burn wound management, Hand surgery Authors: David Salim, MD and Taiba Alrasheed, MD, FRCSC, Msc. Institution: Department of Plastic- & Breast Surgery , Zealand University Hospital Roskilde, Denmark Abstract A 55-year-old man had sought and was admitted to the emergency department one week after sustaining a superficial second degree burn wound on the hypothenar region of the right hand after accidentally placing it on a hot stove. At first sight, the burn wound seemed quite superficial and conservative healing and bandaging was initially deemed sufficient with the aim of spontaneous healing. One week after the initial assessment in the emergency department, the patient was seen for a routine clinical control of the wound. At this consultation, the patient scored 4/4 positive Kanavel’s signs and flexor tenosynovitis was suspected. Afterwards immediate wound revision of the right hypothenar was conducted. During wound revision, considerable amounts pus was noted and furthermore the musculus abductor digiti minimi was avital and excised. Suitable wound dressing was applied, pus was sent for culture and sensitivity testing and the patient was gives appropriate peroral antibiotics. After numerous wound revisions and debridement, control of the infection at the orthopedic surgery department was achieved. The patient was then referred to the plastic surgery department for planning of soft tissue coverage with a reverse radial forearm flap. Patient medical history The patient was known to have substantial unregulated diabetes mellitus type two, but no other known medical comorbidities. Before and After Patient examination The patient was seen in an outpatient setting in the plastic surgery department for planning of surgery. The defect was located to the whole hypothenar region of the right hand. Substantial soft tissue loss was noted and the 3-5th flexor tendons were exposed. Pre-operative considerations A reverse radial forearm
Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face
Dr. Guillermo Alvarez-Sanchez, Ignacio Lugo-Beltran
Keywords: Cheek reconstruction, face, cheek, forearm, free flap, Neurorrhaphy , radial forearm flap Authors: Dr. Guillermo Alvarez-Sanchez, MD ; Ignacio Lugo-Beltran, MD, Chief, Dr. Haro-Cruz Jorge Said, MD. Institution: Plastic and Reconstructive Surgery Division of Microsurgery, Hospital Angeles Metropolitano, Cuauhtémoc, Mexico. Abstract A 52 year old female who presents to the emergency room after receiving a dog bite in her right face, the defect is managed with a free radial forearm flap. Patient medical history 52 year old female, without past medical history, presented to the emergency room, referring she was attacked by her dog at her house, suffering a bite on her right cheek, with bleeding and loss of skin Before and After 1 Before photo - Arrival at the ER Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups. Patient examination Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups. Pre-operative considerations Given the circumstance of tissue loss, active bleeding and section of the nerve branches, also being a contaminated wound, we decided to go to the operating room immediately Due to tissue loss dimensions, we planned a radial free flap for tissue coverage 2 Debridement and assessing damages we cleansed, remodeled the irregular borders and clos