CME

Management of Posterior Trunk Defects

David W. Mathes, M.D.
James F. Thornton, M.D.
Rod J. Rohrich, M.D.
Dallas, Texas
Learning Objectives: After studying this article, the participant should be able
to: 1. Discuss nomenclature and anatomy associated with reconstruction of the
back. 2. Perform preoperative assessment, decision making, and counseling of
patients. 3. Describe current surgical planning, including careful analysis of the
defect and appropriate selection of tissue to provide coverage while maximizing
form and function.
Background: The plastic surgeon is called to reconstruct defects in the posterior
truck that involve an extensive zone of injury. Simple solutions, such as wide
undermining and primary closure, will not result in a stable closed wound.
Successful closure of these wounds depends on preoperative evaluation of tissue
needs and host defects, and selection of the most appropriate flap to close dead
space and provide vascularized tissue to the wound bed.
Methods: The authors examined the literature regarding the available treat-
ment options surrounding reconstruction of posterior back wounds. They re-
view the important details surrounding the use of each flap and present select
cases from their own experience regarding reconstruction of the back.
Results: The posterior trunk benefits from multiple flaps that can be used in
reconstruction of the back. The wound must be evaluated in terms of tissue
requirements and host issues, such as infection or previous radiation. Most
wounds can be closed in a single stage, after careful flap section based on the
wounds needs and anatomic location, with minimal postoperative complica-
tions. Early and aggressive treatment of these wounds improves patient out-
comes and can reduce the time spent in hospital.
Conclusions: Reconstruction of the posterior trunk depends on careful analysis
of the tissue defects, host issues, and application of functional anatomy. The
majority of wounds can be reconstructed after thorough debridement with a
vascularized muscle flap. (Plast. Reconstr. Surg. 118: 73e, 2006.)

R
econstruction of the back requires careful
analysis of the defect and appropriate se-
lection of the tissue that will provide cov-
erage while maximizing both form and function.
The plastic surgeon is called on to provide stable
coverage to complicated defects of the back that
present after radiation injury, chronic pressure
sores, spina bifida, dehiscence with exposure of
spinal stabilization devices, and postoperative
wound infections with or without dural leaks. As
has been clearly demonstrated in animal studies,
muscle flaps provide superior coverage when
compared with random flaps.1 This is due to
their ability to inhibit bacterial growth and to
promote wound healing via the improved deliv-
From the Department of Plastic Surgery, University of Texas
Southwestern Medical School.
Received for publication September 12, 2005; accepted No-
vember 29, 2005.
Copyright 2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000233130.93861.15
ery of antibiotics, immune cells, and oxygen.2,3
The transfer of vascularized musculoskeletal tis-
sue into the wound bed is the key to successful
healing and long-term coverage of the defect.4
Fortunately, the posterior back benefits from
the presence of multiple muscle groups that can
be harvested and transferred on their vascular
pedicle. To maximize the tissue coverage with
minimal donor-site morbidity, a systemic ap-
proach to the reconstruction of the back is or-
ganized in terms of regional options. The wound
should be first evaluated in terms of missing
tissue types, zone of injury, systemic host factors,
and donor tissues available. Once these factors
have been evaluated, the most appropriate flap
can be selected, based on anatomic and func-
tional considerations, and transferred. In those
rare situations that the local pedicled flaps are
not an option, a free tissue transfer can be per-
formed.
Regardless of the defect, in our experience,
many wounds can be closed with a single stage

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 Plastic and Reconstructive Surgery September 1, 2006

after debridement with the proper anatomically
based selection of a muscle flap. Our approach is
one of systematic analysis, followed by appropri-
ate flap selection, and finally operative debride-
ment and closure of these complicated wounds.
PRINCIPLES OF RECONSTRUCTION
Regardless of the flap selected, certain prin-
ciples must be followed to ensure successful re-
construction with minimal postoperative morbid-
ity. These include the use of appropriate systemic
antibiotics to control infection. Local wound care
is paramount and includes extensive debridement
of all devitalized soft tissue, cartilage, and bone.
We recommend that the plastic surgeon perform
the debridement and that both wound and bone
cultures are sent before definitive closure of the
wound is performed. This may include the tem-
porary application of a vacuum-assisted closure
device if indicated to improve the wound bed.5
Application of the vacuum-assisted closure device
is not a substitute for proper wound debridement,
and the device should only be applied once the
wound is clean. Bone fixation should be main-
tained if the hardware is stable. Often the hard-
ware is infected and removed, and bone fixation
is maintained with an external fixator or left for
secondary reconstruction after the wound has
healed. Neural function must also be protected
and preserved. Once control of the wound is es-
tablished, the defect can then be reconstructed
with a flap that will obliterate all of the dead space
and bring vascularized tissue into the wound bed.
This process should be performed in a expeditious
time frame, as early definitive coverage of the de-
fect can minimize infective complications.6
FLAPS FOR POSTERIOR TRUNK
RECONSTRUCTION
The flaps used for reconstruction of the mid-
line and posterior trunk defects include three
pairs of posterior trunk muscles: trapezius, latis-
simus dorsi, and the gluteus maximus (Fig. 1). All
three muscles have large cutaneous territories that
allow them to be used as musculocutaneous flaps.
In addition, other options include the scapular
flap, parascapular flap, paraspinous muscle flap,
intercostal neurovascular flap, and, rarely, the tun-
neled pedicled omental flap.
Selection of the flap to ensure viable coverage
depends on a thorough understanding of the
anatomy of the flap and its arc of rotation, and
analysis of the size and location of each defect.
Latissimus Dorsi
The latissimus dorsi muscle is a flat, broad,
triangular muscle that measures 35 cm long and
20 cm wide. The muscle arises from the posterior

Fig. 1. (Left) The common flaps that can be used to reconstruct an upper thoracic cervical defect include the (A) trapezius muscle flap
and (B) the latissimus dorsi flap. (Center) The common flaps that can be used to reconstruct a midthoracic defect include the (A) trapezius
muscle flap, (B) latissimus dorsi flap, and (C) paraspinous turnover flap. (Right) Defects in the lower lumbar area can be reconstructed
with (A) a reversed latissimus dorsi flap with skin island, (B) a composite latissimus and gluteus maximus flap, or (C) a superiorly based
gluteus maximus flap.

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Volume 118, Number 3 Management of Posterior Trunk Defects

third of the outer ridge of the iliac crest, from the

lumbar and sacral spinous processes (T7 to T12,
L1 to L5) and from the thoracolumbar fascia. It
inserts to the intertubercular groove of the hu-
merus, where it forms the posterior axillary line.
External landmarks also include the posterior
midline, posterior superior iliac crest, and the tip
of the scapular. The action of the muscle is ad-
duction and medial rotation of the humerus. The
muscle is innervated by the thoracodorsal nerve.
The latissimus dorsi muscle (type V muscle)
possesses a primary blood supply from the thora-
codorsal artery and a secondary segmental supply
from the perforating branches of the intercostal
and lumbar arteries. The thoracodorsal artery has
a mean length of 9 cm, and this length can be
increased to 11 cm by dissection of the vessel to the
subscapular artery. The large-diameter thora-
codorsal vessels are well suited for free tissue trans-
fer, and the pedicle lengthened with vein grafts
enables the muscles to reach the lumbosacral
area.7 Three large segmental vascular pedicles that
originate from the ninth, tenth, and eleventh in- Fig. 2. This illustration demonstrates the location of the lumbar
tercostal arteries form the vascular basis of the perforators that provide the vascular supply to the reverse latis-
reverse or medially based musculocutaneous simus dorsi flap. Reprinted from Stevenson, T. R., Rohrich, R. J.,
flap. These vessels are consistently found at points Pollock, R. A., Dingman, R. O., and Bostwick, J., III. More experience
5 cm from the midline (Fig. 2), and additional with the reverse latissimus dorsi musculocutaneous flap: Pre-
mobility can be gained by exposing more of the cise location of blood supply. Plast. Reconstr. Surg. 74: 237, 1984.
dorsal perforating vessels.8 Previous injury to the
pedicle from radiation and surgery or ligation of
the thoracodorsal pedicle is not an absolute con- the lateral third of the clavicle, the spine of the
traindication to use of the flap. It has been dem- scapula, and the acromion. The action of the muscle
onstrated that the muscle can receive its blood is to elevate and retract the scapular and shoulder.
supply in a retrograde manner from an intact ser- Loss of function leads to drooping of the shoulder.
ratus branch via the intercostal system. Provided The muscle is classified as a type II muscle, and
this vessel is open, the muscle can be safely used its blood supply consists of the ascending and de-
to reconstruct posterior defects. scending branches of the transverse cervical ar-
The flap can be medially or laterally based and tery, intercostal perforators, and branches of the
rotated, advanced, or reversed as a turnover occipital artery superiorly. The muscle is inner-
flap.8 11 The posterior arc of rotation includes the vated by the spinal accessory nerve and by the
neck, occiput, parietal skull, and thoracic verte- branches of C3 and C4.
brae T1 to T12. The anterior arc can reach the Transfer of the inferior portion of the trapezius
ipsilateral hemithorax and sternum, the middle based on the descending branch of the transverse
and lower third of the face, and the superior ab- cervical artery is analogous to the pectoralis major
domen. The extensive arc of rotation makes this transposition or turnover flap used in sternal
flap the workhorse flap for trunk reconstruction. wounds. The flap is elevated rapidly inferiorly to
superiorly. Attachments are left to the scapula spine,
unless the flap needs to reach the upper cervical
Trapezius Muscle spine.
The trapezius muscle, triangular in configura- The trapezius muscle is useful for coverage of
tion, covers the midline of the back from the occiput defects in the high thoracic and cervical areas.6,12,13
to T12 (overall area, 34 18 cm). It arises from the Usually the inferior portion of the muscle is used
superior nuchal line, the external occipital protu- for cervical and upper thoracic reconstruction
berance at the nuchal ligament, the thoracic verte- (Fig. 3). The muscle can be used as a rotation,
brae, and the superspinous ligaments. It inserts on advancement, or turnover flap.1317

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 Plastic and Reconstructive Surgery September 1, 2006

Fig. 3. This diagram illustrates the design of a pedicled musculocutaneous flap

for coverage of a cervical defect.

Paraspinous Muscle Flap crease) and the vertebral column. The distal end
The paravertebral musculature is located in of the flap may extend to a point midway between
the paravertebral gutter and extends from the tho- the medial border of the scapula and the midline.
racic region to the lumbosacral region. The mus- The parascapular flap, based on the descend-
cles are segmental in nature and arise from the ing branch, is centered on a vertical line extending
lamina and transverse processes of the vertebrae. from the triangular space and posterior iliac spine.
They insert to the posterior ribs and the posterior
crest.
The blood supply is from the dorsal segmental
branches of the aorta. Mustarde demonstrated
that these muscles can be mobilized by fracturing
the transverse processes and using them as a os-
teomuscular flap.18 This is rarely done, and these
muscles are most often used as bipedicled or turn-
over flaps. However, the bipedicled design limits
flap excursion.
Wilhelmi et al. proposed a modification
based on microfil injections that demonstrated
the presence of longitudinal intramuscular ves-
sels feeding the distal parts of a superiorly based
unipedicled paraspinous muscle flap.19 The flap
should be mobilized from the thoracolumbar
fascia laterally, the posterosuperior iliac fascia
crest caudally, and the quadratus lumborum
muscle anteriorly (Fig. 4). The flap can be ele-
vated bilaterally up to T10 and can be trans-
posed easily, and if it used as an advancement
flap, it should reach the midline. Fig. 4. This cross-sectional drawing demonstrates the area of
fascia incision and the use of a paraspinous turnover flap. The
paraspinous muscles are harvested off the transverse spinous
Scapular and Parascapular Flap processes. Muscle flaps are advanced after the debridement of
The skin territory of the circumflex scapular all necrotic tissue, and the wound is closed in layers. To ad-
artery can be divided into two regions based on its vance the flap, the medial perforators are divided. Reprinted
transverse and descending branches. The scapular from Wilhelmi, B. J., Snyder, N., Colquhoun, T., Hadjipavlou, A.,
flap is based on the transverse branch and is cen- and Phillips, L. Bipedicle paraspinous muscle flaps for spinal
tered on a horizontal line extending from the wound closure: An anatomic and clinical study. Plast. Reconstr.
triangular space (2 cm above the posterior axillary Surg. 106: 1305, 2000.

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Flap dimensions are highly variable but may reach
10 30 cm.
An additional variant of this flap is the infra-
mammary extended circumflex scapular, which
follows the gradual curve into the inframammary
crease. This leads to an improved donor-site scar.
This modification is based on the numerous radial
vessels from the descending branch of the circum-
flex scapular artery.
The triangular space is bordered by the teres
minor and subscapularis superiorly, the teres mi-
nor inferiorly, and the triceps (long head) later-
ally. This marks the exit of the circumflex sub-
scapular artery. The base of the arc of rotation of
these flaps is at the triangular space, and they can
reach the shoulder, axilla, and lateral thoracic
wall.
Gluteus Maximus Flap
The gluteus maximus is shaped like a paral-
lelogram. It originates from the lateral sacrum and
posterior superior iliac crest and inserts into the
greater trochanter of the femur and iliotibial tract.
The muscle is innervated by the inferior gluteal
nerve. This nerve, along with the inferior gluteal
artery, should be preserved to maintain vascularity
and allow preservation of function.
This is a type III muscle with two dominant
pedicles (superior and inferior gluteal arteries).
The muscle has four vessels that enter its deep
surface. The superior and inferior gluteal muscles
enter about 5 cm from the pelvic origin of the
muscle, and the medial circumflex and the first
perforating femoral artery enter the muscle close
to the femoral attachment. There are extensive
anastomoses between the gluteal system and the
lumbar perforators.
The lateral position and deep location of the
gluteal pedicles, in addition to robust collateral
circulation, allows safe use of the gluteus maximus
flap in cases of radiation necrosis in the sacral
region. The point of rotation is based on the su-
perior artery, and it can reach the ipsilateral is-
chium and sacrum. This is an excellent flap for
coverage of lower lumbar defects.20,21 These flaps
can be designed based on the superior gluteal
artery and include perforator flaps that are useful
as turnover flaps and will reach the lumbosacral
recess. Ambulatory patients do not appear to no-
tice the loss of the upper aspect of the gluteal
muscle, and the skin paddle can be located near
the trochanter.
Omental Flap
The greater omentum is an extensive fibro-
fatty apron that is attached to the greater curva-
ture of the stomach and to the transverse colon
from the hepatic to the splenic flexure. The vas-
cular supply is from the right and left gastroepi-
ploic vessels that arise from the celiac and superior
mesenteric arteries. The greater omentum can be
harvested based on either the right or left gastro-
epiploic vessel and dissected free from all of its
other attachments. The omentum is mobilized by
freeing it from the attachments along the tenia
omentalis of the transverse colon and the greater
curvature of the stomach. The gastroepiploic ar-
tery is preserved. The ascending colon is dissected
from its peritoneal attachments, and the kidney is
reflected medially. A plane is then developed be-
tween the psoas and the quadratus muscles, and a
tunnel is created from the peritoneal cavity to the
back defect. The omental flap can then be tun-
neled retroperitoneally though a defect in the
lumbar fascia to reach the posterior trunk.22
In 1994, Giordano et al. treated a patient using
an omental flap based on the left gastroepiploic
vessels to cover the lower back after a postopera-
tive infection following the treatment of Potts
disease via the open approach.23 Lantieri et al.
reported harvest of the omental flap endoscopi-
cally based on the left gastroepiploic pedicle to
cover a complicated back wound.24 Endoscopic
harvest of the left gastroepiploic is thought to be
easier than harvest of the right, with less risk of
iatrogenic splenic injury. Second, in both cases,
the omentum was passed the through the left ab-
dominal wall, which was thought to be easier when
compared with the right side, where one must pass
the flap just beneath the renal pedicle.
Intercostal Neurovascular Flap
The course of the intercostal artery is divided
into four segments: vertebral, costal groove, inter-
muscular, and rectus. The costal groove segment
possesses large perforators at intervals of 1 to 3 cm
apart. The artery also gives off a lateral cutaneous
branch at the midaxillary line that provides per-
forators to the skin. This surgical technique of
harvesting this muscle for use as a flap is based on
the original description by Kerrigan and Daniel.25
The cephalad rib is excised as far dorsally as
possibly to increase mobility and the arc of rota-
tion of the flap. The flap is then tunneled, and the
donor site is closed primarily. This flap is best used
in those situations where the back is scarred and
many of the flaps have already been used. It can
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 Plastic and Reconstructive Surgery September 1, 2006
provide healthy tissue from outside a zone of in-
jury in many patients. Its main advantage is that it
can also serve as an innervated flap as it brings
along a nerve. The perforators can supply a hearty
flap, with the largest reported size being 18 12.5
cm.26
SYSTEMATIC APPROACH TO
POSTERIOR TRUNK
RECONSTRUCTION
The wound is evaluated and treated according
to the specific needs of the wound and its ana-
tomic location. The location of the wound will
often dictate the choice of flap (Table 1). Our
approach utilizes the trapezius, latissimus dorsi,
paraspinous, or gluteus maximus alone or in com-
bination to achieve wound closure without tension
or residual dead space.
Cervical Defects
The majority of these defects can be recon-
structed with a trapezius muscle flap based on the
descending branch of the transversal cervical ar-
tery. Chun et al. reported on the use of the vertical
trapezius musculoskeletal flap.16 Using this flap,
they reconstructed five patients with a history of
previous irradiation to the upper back with ex-
posed hardware. They reported no flap loss,
wound dehiscence, or evidence of postoperative
dehiscence. The authors limited the extension of
their skin paddle to no further than 1 cm beyond
the muscular margin of the flap. This was based on
reports that extension beyond that point is asso-
ciated with a higher incidence of skin loss at tip of
the flap (23 percent of the flaps with an extended
skin paddle).13 Three patients had seromas that
required drainage. The authors concluded that
Table 1. Regional Reconstruction of Midline Back
Wound Location
Cervical
High thoracic
Small defect
Large defect
Thoracic
Small defect
Large defect
Thoracolumbar and low lumbar
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this flap design is a reliable method of reconstruc-
tion for this region.
In a similar retrospective review of compli-
cated posterior wounds, Disa et al. described the
management of radiated reoperative wounds in
the cervicothoracic spine with a trapezius turn-
over flap.15 In this study, six patients were op-
erated on in an 18-month period using unilat-
eral trapezius turnover flaps based on the
transverse cervical artery. All flaps survived and
wounds were healed. The authors concluded
that the trapezius turnover flap is an excellent
choice for the cervical spine wound when pri-
mary closure is not possible or in the setting of
infection or exposed hardware. The ease of the
harvest and minimal donor-site morbidity make
it a useful, single-stage reconstructive option for
these difficult wounds.
Therefore, based on our own experience and
a review of the literature, we recommend that
cervical defects be reconstructed with a trapezius
flap. This is demonstrated in the featured case,
where a wound was easily reconstructed with a
trapezius flap (Fig. 5). However, in certain cases,
a latissimus dorsi flap can be used when the tra-
pezius has previously been sacrificed.
Upper Thoracic Defects
Small upper thoracic defects can be recon-
structed with a trapezius muscle flap. An equally
viable option is a latissimus dorsi advancement
flap. In our hands, we have noted that the latissi-
mus dorsi with a skin paddle over the proximal
two-thirds of the muscle is more reliable. These
two flaps can be combined for wounds that also
have a deep component. The trapezius muscle can
be transposed to close the dead space, while the
Muscle Flap
Trapezius muscle flap
Latissimus dorsi flap
Trapezius muscle with split-thickness skin graft
Latissimus with skin island
Trapezius muscle (deep layer)
Latissimus advancement flap
Reverse latissimus dorsi flap
Paraspinous turnover flap
Latissimus dorsi with skin island
Latissimus dorsi with skin island
Unipedicled latissimus
Composite latissimus and gluteus maximus
Paraspinous turnover flap
Free flaps
Volume 118, Number 3 Management of Posterior Trunk Defects
Fig. 5. Cervical defects are best treated with the trapezius flap based on the transverse cervical artery. (Left) The wound from a
previous tumor resection. (Center) The flap is designed with a skin paddle to cover the defect. (Right) Four-week postoperative view
after flap transfer.
latissimus dorsi is advanced to close the wound.
However, most of the wounds encountered in the
upper thoracic back can be closed with a single
muscle flap.
Midthoracic Defects
Midthoracic defects are best closed with the
lower portion of the latissimus dorsi or a reversed
latissimus dorsi flap. It can also be closed with the
lower portion of the trapezius muscle flap. When the
wound is deep, the paraspinous muscles with the
thoracocolumnar fascia can be used to fill dead
space. In certain situations, some authors have sug-
gested using the paraspinous muscle (unipedicled
or bipedicled) flaps alone. This is demonstrated in
the reconstruction of a midthoracic back wound
after tumor resection using a latissimus dorsi muscle
flap and skin graft (Figs. 6 and 7).
The use of a bipedicled paraspinous flap was
described recently in an article by Wilhelmi et al.19
The authors reported on 10 patients who were
referred to their plastic surgery service for recon-
struction. They also performed cadaveric studies
to confirm that the paraspinous muscles possess a
dual segmental arterial supply through both me-
dial and lateral perforators. The division of these
medial perforators can allow for medial advance-
ment of the muscle (Fig. 3). Eight of the patients
were reconstructed with paraspinous muscle flaps
alone. One patient underwent a latissimus dorsi
flap procedure and another received a trapezius
muscle flap to close the wound. The authors con-
cluded that the bipedicled paraspinous flap is a
good choice for reconstruction of middle spine
defects.
Coverage with the paraspinous muscle flap was
also reviewed by Manstein et al,27 who reviewed 12
patients whose wounds were reconstructed using
paraspinous flaps. Five of the 12 wounds were in
the upper thoracic region; the authors used a la-
tissimus dorsi flap for superficial coverage, and a
laterally based paraspinous muscle flap for deep
coverage. The other seven patients had wounds
located in the lower midline region and were re-
constructed with the paraspinous muscle alone.
Eleven of the 12 patients healed without difficulty.
The only failure was thought to be due to a per-
sistent dural leak. In a separate study, however,
Saint-Cyr et al. discussed the effective use of the
paraspinous muscle in eight patients to treat and
prevent of cerebrospinal fluid fistulas and to pro-
vide durable coverage of complex spinal wounds.28
Finally, a medially based turnover paraspinous
muscle flap described by Casas and Lewis is an
option, as long as those perforators have not been
sacrificed during the original spinal operation.6
Use of the reverse latissimus flap has been
demonstrated in patients with complex back
wounds. In a retrospective study, Meiners re-
viewed 14 patients who presented with a combi-
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 Plastic and Reconstructive Surgery September 1, 2006
Fig. 6. (Above) This defect was encountered after resection of a
sarcoma and included exposed bone and resection of the medial
pedicle to the paraspinous muscles. (Below) The defect was re-
constructed with a pedicled latissimus dorsi flap, as shown.
nation of spinal cord injury and complex back
wounds. They chose to reconstruct the defect with
a reverse latissimus flap. Eleven of the patients had
a stable wound after the single reconstructive pro-
cedure, but three of the patients required a sec-
ond operation due to complications that included
skin necrosis (two patients) and significant hema-
toma (one patient). In addition, the reverse latis-
simus is not always a viable option in the postop-
erative spine patient, because the spinal
perforators may have been divided for exposure
and hardware placement. The presence of these
perforators should be confirmed preoperatively
with a Doppler device before the harvest of such
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Fig. 7. Same patient as in Figure 6. Reconstruction at completion
of the case, after placement of a split-thickness skin graft.
a flap is undertaken. The use of a reverse latissimus
flap is demonstrated in the reconstruction of this
lower wound (Figs. 8 and 9).
Thoracolumbar and Lumbar Defects
Thoracolumbar and lumbar defects are best
reconstructed with flaps based on the latissimus
dorsi muscle, depending on the size of the defect.
Options for closure include musculoskeletal ad-
vancement flaps, a latissimus musculocutaneous
flap with a thoracocolumnar extension, and, for
large defects, a composite latissimus dorsi and glu-
teus maximus musculocutaneous flap. In certain
situations, the intercostal flap is a good option for
those patients who are deficient in local muscle.
Finally, in select cases, the omentum can be tun-
neled and used to cover the lumbar region when
no other flap is available for reconstruction.
The latissimus dorsi flap with a thoracolumbar
fasciocutaneous extension maintains a random ex-
tension over the fascia. To raise this flap, the most
distal origins of the muscle need to be freed from
the iliac and the oblique muscles. The donor site
will require coverage with a skin graft.
The composite latissimus dorsi and gluteus
maximus musculocutaneous flap has been used to
close defects such as those encountered with me-
ningomyelocele defects. The skin between the two
muscles is supplied by the perforators from the
anastomosis of the thoracodorsal and superior
gluteal arteries. The mobilization of this flap often
requires a lateral relaxing incision.
The intercostal flap can be employed in those
patients who present with lumbar defects and have
limited local options because of previous surgery.
Volume 118, Number 3 Management of Posterior Trunk Defects

Fig. 8. The latissimus dorsi can also be used as a reverse flap based on the lumbar perfo-
rators found 5 cm from the midline at T9 through T11. (Left) The defect and the design of
the flap is shown, with marking of the skin island and the location of the latissimus dorsi
muscle. (Right) The flap is then elevated based on the lumbar perforators.

Fig. 9. At postoperative week 3, the flap provides excellent wound coverage.

This flap can provide a good skin paddle. It can cations of this flap included a postoperative hernia
also be used to create a sensate flap. Wong et al. in one patient and a pneumothorax in a second
presented four patients who were successfully re- patient. All wounds healed and regained some
constructed using this technique.26 The compli- sensation over time.

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Microvascular Free Flaps for Trunk Defects
The majority of the defects encountered in the
posterior trunk can be reconstructed with local flaps.
In cases of irradiation of the spine, extensive trauma,
or significant debridement of surrounding tissue,
the patient may be left with poor local solutions for
providing vascularized tissue to the wound. In these
rare cases, free tissue transfer is used to provide
coverage.29 32 The location of a recipient vessel in
this area can be challenging, and one may utilize the
dorsal branch of the fourth lumbar artery located at
the lateral margin of the sacrospinalis muscle at the
level of the upper part of the fourth vertebra. This
vessel can serve as the recipient vessel for the free
transfer of a latissimus flap when local flaps are not
available. Park and Koh described the use of the
superior gluteal vessel, which is large in caliber, con-
stant, and relatively unaffected despite previous
radiation.31 This vessel and its corresponding vein
can be used as a recipient for the free tissue transfer
when the lumbosacral defect cannot be covered using
a conventional method. In the majority of cases, a ar-
teriovenous loop is used based on the saphenous vein.
Few et al. presented their experience with mi-
crovascular reconstruction to close defects in the
hostile back.7 The hostile back was defined in
this series as being greater than 200 cm with a
history of irradiation and multiple attempts at re-
construction. The group presented four patients
who met the above criteria and underwent suc-
cessful closure with a free flap based on an arte-
riovenous loop to provide inflow.
DISCUSSION
Traditional wound closure of back defects un-
der tension, with skin grafts or local random trans-
position flaps, is a poor choice for the patient with
a complicated posterior trunk wound. These treat-
ment options fail because of the poor tissue vas-
cularity and the presence of a significant zone of
injury that produced the wound breakdown in the
first place. These patients often have undergone
radiation treatment to the posterior trunk, and
the wounds are often complicated by infectious
processes such as osteomyelitis.
Application of a vacuum-assisted closure de-
vice after thorough debridement can help prepare
the wound bed for flap closure. Several studies
have demonstrated an increase of up to 63 percent
in the production of granulation tissue when com-
pared with normal saline-soaked gauze dressing
changes.3335 The vacuum-assisted closure device
uses an occlusive dressing that removes exudates
while keeping the wound environment moist. It
82e
also appears to increase blood flow almost four-
fold, and the negative pressure increases the cel-
lular mitotic index via upregulation of the cells.36
This dressing should not be used to close these
complicated wounds. Instead it should be seen as
a bridge to final wound closure. Also, it should
only be applied to wounds that have undergone
adequate debridement.
Reconstruction of these wounds requires ei-
ther a one- or two-layer muscle closure, depending
on the depth and size of the wound. The initial
procedure continues to be aggressive debride-
ment of all necrotic, infected, and fibrotic tissues.
In addition, in patients with malignant disease,
tumor-free margins must be obtained and con-
firmed by frozen or permanent section before de-
finitive treatment is completed. All patients with
osteomyelitis should be treated with intervenous
antibiotics for 6 weeks following reconstruction.37
Our approach continues to emphasize the im-
portance of flap selection based on anatomic lo-
cation. We depend on the trapezius, latissimus
dorsi, paraspinous, and gluteus maximus muscles
alone or in combination as advancement flaps,
rotation flaps, island flaps, unipedicled or bi-
pedicled flaps, or turnover flaps to achieve wound
closure. It is also possible to use fascial flaps in
certain cases where there is minimal dead space to
fill with the flap. Most reconstructions can be
achieved with a single layer of vascularized mus-
culoskeletal tissue, but deep wounds often require
a two-layer muscle flap closure. In the upper tho-
racic region, the trapezius can be used to obliter-
ate the dead space, whereas in the thoracolumbar
region, the paraspinous muscles with thoracoco-
lumnar fascia can be used as a turnover flap. These
deep wounds are then best covered by a latissimus
dorsi flap.
If the tenets described in this article are fol-
lowed closely, a high rate of successful wound clo-
sure should be expected. The surgeon must en-
sure adequate debridement of all devitalized
tissue, use the correct antibiotic regimen, utilize
drains when needed, and select the most appro-
priate vascularized muscle flap for the wound. Fail-
ure to do so will result in complications such as
partial flap loss, persistent dead space, lack of ad-
equate muscle bulk, and persistent infection.
Thus, flap selection should be anatomic based on
its arc of rotation, and the surgeon should ensure
the presence of a vascular pedicle outside of the
zone of injury. The flap should be mobilized to
allow the surgeon to obtain tension-free closure
with the elimination of all potential dead space.
Reliable reconstruction of these complicated
Volume 118, Number 3 Management of Posterior Trunk Defects
wounds continues to depend on a regionalized
selection of the correct vascularized tissues.
David W. Mathes, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical School
5323 Harry Hines Boulevard
Dallas, Texas 75390-9132
dwmathes@hotmail.com
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