Historical Developments: The latissimus dorsi flap

4th August 2010

 

In 1970 as senior registrar at the University Clinic for Plastic Surgery in Cologne, I was engaged in the treatment of radiation ulcers following mastectomy and radiotherapy.

There had been an increased in the treatment of breast cancer by radiotherapy and the techniques were not as precise as now so radiation damaged was frequent.

There was a limited success in the traditional techniques for reconstructing and covering of radiation ulcers. Not only was the healing of split thickness skin grafts (STGS) in the irradiated area poor, but the use of local pedicle flaps was unsuccessful, as they displayed poor marginal perfusion, because of the irradiation, of the important distal third of the flap. Omental flaps, necessitate an additional laparatomy with inherent complications.

I searched the literature: (Gillies and Millard 1958; Converse 1964; Burian 1967; Lexer 1931; Battle 1964; Kirschner 1921; Sanvenero-Rosselli  1931; Gelbke 1963) and many others but was unable to find a safe method of closing the these radiation defects.

In 1974, I decided to raise a muscle flap including the overlying skin. With the assistance of Prof. Kummer from Institute of Anatomy I studied the anatomy of a flap incorporating latissimus dorsi muscle. On July 2, 1974 I operated on the first patient with this technique (Picture 1-4). We had a long waiting list of such patients so in a relatively short time I was able to operate successfully on a large number of such patients. All the flaps healed perfectly and this eased our problems of treating these radiation ulcers.

In April 1975, I visited the Plastic Surgery Unit in Salisbury as a registrar. I showed my results to John Barron, who was then President of British Association of Plastic Surgeons. He immediately recognised the importance of this new technique and asked me to present my technique and results at BAPS Winter Meeting in Royal College of Surgeons of England. I had the great honour to present "The Latissimus Dorsi Flap in Repair of Thoracic Defects" on December 4.1975.  I gave the name to this flap with the experience of 17 operations.

John Barron advised me to send a paper to Tom Gibson who was then the editor of British Journal of Plastic Surgery. Tom Gibson shortened my paper by about 50% and removed 4 pictures from original. Also he refused to accept the thoracodorsal artery in the paper "because such an artery does not exist in Gray's Anatomy". So I sent him a copy of Pernkopf Atlas of Anatomy with clear picture of thoracodorsal artery which supplies the latissimus dorsi muscle. Tom Gibson answered "There are obviously homo sapiens Germanicus with thoracodorsal artery and homo sapiens Britanicus without it". So in my paper in British Journal of Plastic surgery in January 1975 "The Latissimus Flap" you will unfortunately not find this important artery.

In 1976 we began to perform breast reconstruction with Latissimus flap and 1978 Marko Godina performed first free Latissimus flap for coverage of lower leg defects. The flap was used for coverage in the head and neck area, and the upper and lower extremity. Within 1 year the method was accepted worldwide.

I was of course very proud to have discovered this new and important technique which is so very helpful in such complicated problems. However in1979 I was invited to give a lecture about Latissimus Dorsi flap in Milan, Italy. After the lecture a friend of mine, Riccardo Mazzolla took me to the Sanvenero Rosseli collection which is the largest library for plastic surgery in the world. There he showed me a paper  in Italian by Ignatio Tanssini from 1906  "Sopra il mio nuovo processo di amputatione della mammella" in Riforma medica  12:752 (1906), Tanssini, who was professor of surgery in Padua, described exactly what we now call the Latissimus dorsi flap, which he used for closing defects after radical mastectomy. It is unbelievably that this brilliant technique was forgotten for over 70 years. Even in Converse's extensive 5 vol. 2400 p. book of plastic surgery from 1964, there is not a single word about this technique. Why is it that no plastic surgeon mentions this fantastic idea in more than 60 years?  It may be that Halstead's authoritative teaching that: every breast cancer must be treated by very radical surgery removing the, pectoralis major and minor muscle with axillary clearance followed by secondary wound healing or split skin graft. Any other techniques would appear to be an error.

If Tanssini's axial pattern flap and myocutaneous flap had not been overlooked maybe the tube pedicle would not have become so popular

BELOW: The first patient (J.H.)  with radiation ulcer. Operated on July 02. 1974

Clockwise from top left:  Radiation ulcer for 5 years; Radical debridement and mobilisation of the myocutaneous latissimus flap. Latissimus dorsi muscle is in the flap; Picture at the end of operation. Note the pink, well perfused flap; Six month postoperatively
This case was published in British Journal of Plastic surgery In January 1976 (29:126-128)

 

Back to list page
News and Views