Journal of the American Academy of Orthopaedic Surgeons 324 Soft-tissue defects of the shoulder, upper arm, and elbow may result from trauma, tumor, infection, or irradiation. Exposed bone, tendon, and joint require proper coverage to prevent infection and desicca- tion and to expedite functional recovery. 1 Similarly, loss of upper- extremity function, including shoulder abduction, elbow flexion, and elbow extension, may result from conditions such as brachial plexus injury and poliomyelitis, as well as from trauma. The latissimus dorsi muscle is large and has a long vascular pedi- cle that allows a significant arc of rotation around the origin of the thoracodorsal artery, vein, and nerve in the axilla. It is expendable, with only minimal morbidity asso- ciated with its loss, and it is easily dissected. 2,3 It can be transferred with an overlying skin paddle that allows not only postoperative mon- itoring but also replacement of skin and subcutaneous tissue. Because of its position along the lateral tho- rax and back, it is infrequently in- jured as a result of trauma to the upper extremity. Although free tissue transfer is frequently required to treat a muti- lating injury to an upper extremity and shoulder, the advantages of a pedicled flap are compelling. A microvascular anastomosis and operative microscope are unneces- sary, and innervation is not sacri- ficed. It must be remembered, however, that care is required to safely elevate and rotate the muscle without injuring the pedicle and to accomplish subcutaneous passage of the muscle so as to reach the shoulder, upper arm, or elbow; it is quite easy to twist, stretch, or com- press the vascular pedicle, which may result in vascular compromise. Postoperative monitoring is also important, hence the attraction of raising the muscle with an associ- ated skin paddle to facilitate assess- ment of capillary refill and venous outflow. Anatomy In Latin, latissimus dorsi means “widest of the back”; this accurately reflects the size of this large trian- gular muscle, which averages 180 cm 2 in surface area. It originates from the lower six thoracic verte- brae, the thoracolumbar fascia, and the iliac crest (Fig. 1). From this extensive origin, the muscle fibers converge into a tendon that wraps around the lower border of the teres major and inserts into the floor of the bicipital groove of the humerus. The latissimus dorsi and teres major muscles form the poste- rior axillary fold. Dr. Pierce is Upper Extremity Surgeon, Bone and Joint Center, Bismarck, ND. Dr. Tomaino is Hand and Upper Extremity Surgeon and Associate Professor, University of Pittsburgh Medical Center, Pittsburgh, Pa. Reprint requests: Dr. Tomaino, Suite 1010, Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213. Copyright 2000 by the American Academy of Orthopaedic Surgeons. Abstract Tissue with a blood supply derived from a single constant vascular pedicle may be raised as a flap and rotated within the reach of its blood supply to cover and reconstruct a variety of complex wounds. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilization, and expendability. It can be rotated, with or without overlying skin, to cover soft-tissue defects involving the shoulder, arm, and elbow, or it can be transferred as an innervated muscle to improve shoulder abduction as well as elbow flexion and extension. The major clinical applications of the pedi- cled latissimus dorsi muscle flap for upper-extremity reconstruction include use as a bipolar transfer to improve elbow flexion after trauma or brachial plexus injury and as a nonfunctioning myocutaneous transfer for coverage of nerves, bones, and joints after soft-tissue loss due to trauma, tumors, infection, or irra- diation. J Am Acad Orthop Surg 2000;8:324-331 Use of the Pedicled Latissimus Muscle Flap for Upper-Extremity Reconstruction Troy D. Pierce, MD, MS, and Matthew M. Tomaino, MD Troy D. Pierce, MD, MS, and Matthew M. Tomaino, MD Vol 8, No 5, September/October 2000 325 The latissimus muscle has a dom- inant vascular pedicle and multiple secondary segmental pedicles. The primary blood supply is from the thoracodorsal artery, which (along with the circumflex scapular artery) is one of the terminal branches of the subscapular artery. The subscapular artery is typically very short and originates from the axillary artery. The secondary blood supply comes from perforating vessels through the posterior thoracolumbar fascia. The muscle can survive on its supply from either system alone, and the vascular anatomy is fairly consis- tent. The thoracodorsal artery most commonly branches from the sub- scapular artery (in 94% of cases in one study 4 ), but may originate directly from the axillary artery (in 5% of cases in that same study). The average length of the thoracodorsal artery is 8.4 cm. Its external diame- ter is approximately 2.0 to 2.5 mm. The neurovascular pedicle typically enters the undersurface of the latis- simus muscle 10 to 12 cm from the axilla. Within the muscle, the artery and vein each bifurcate into trans- verse and descending branches. The descending branch runs approxi- mately 2 cm from the anterior edge of the muscle. The latissimus muscle is inner- vated mainly by the C7 root via the thoracodorsal nerve, which arises from the posterior cord of the brachial plexus. This consistent neural anatomy permits harvesting of the latissimus on a long neural pedicle and allows its use as a func- tional muscle-tendon transfer, which can effectively provide shoul- der abduction, elbow flexion, or elbow extension. If a functional transfer is not required, division of the nerve will result in muscle atro- phy and less bulky contour at the recipient site. In its normal position, the latis- simus muscle functions to extend and internally rotate the humerus, adduct the arm, stabilize and ele- vate the ipsilateral pelvis, and hold the inferior angle of the scapula against the chest wall to aid in pre- venting scapular winging. Exam- ples of activities that involve the action of the latissimus are chop- ping wood, climbing, paddling a canoe, and swimming the crawl stroke. Its strength can be assessed on physical examination by asking the patient to adduct the arm (with the elbow flexed) against resis- tance. The posterior axillary fold, and specifically the latissimus, should be palpated and compared with the opposite side. Operative Technique The operative technique for harvest has been well described. 5 With the patient in the lateral decubitus position, the arm and hemithorax are prepared so as to allow full exposure of the shoulder, back, and chest distally to the iliac crest. Po- sitioning is facilitated by placing the abducted upper extremity on a well-padded Mayo stand. Hyper- abduction of the shoulder for long periods of time should be avoided, however, as this can potentially injure the brachial plexus. The muscle runs from the poste- rior axillary fold to the midpoint of the iliac crest. Its transverse portion extends cephalad to approximately three finger-breadths above the inferior angle of the scapula. The surgical incision should run from the palpable posterior axillary fold to the midpoint of the iliac crest. Elevation of skin flaps will allow exposure of the muscle. As subcu- taneous tissue is dissected, it should be remembered that the pedicle enters the muscle approximately 10 to 12 cm from the axilla; therefore, it is easiest to begin more distally. This allows initial identification of the longitudinally oriented lateral thoracic artery and vein, which supply the serratus anterior muscle. These vessels can be followed prox- imally to their origin from the tho- racodorsal pedicle (Fig. 2). The pedicle can be dissected before elevating the muscle off the thorax; alternatively, the muscle can be divided distally and lifted before exposing the pedicle. It is important to accurately plan the size of the muscle flap, to avoid finding that it is inadequate only after it has been tunneled through subcutaneous tissue. If a skin pad- dle is harvested with the latissimus muscle, its width should be limited to 10 cm; otherwise, primary clo- sure of the defect will not be possi- ble, and a split-thickness skin graft will be required. The donor wound should be ir- rigated, and hemostasis should be adequate; otherwise, closure may be complicated by postoperative hematoma. Wound closure is per- formed in two layers over large Figure 1 The fan-shaped latissimus dorsi muscle originates from the thoracolumbar fascia, the lower six thoracic vertebrae, and the iliac crest. It inserts into the medial lip of the bicipital groove on the proximal humerus. The superior border of the mus- cle overlaps and is attached to the inferior angle of the scapula. Circumflex scapular artery Subscapular artery Thoracodorsal artery Latissimus dorsi muscle Iliac crest Axillary artery Pedicled Latissimus Muscle Flap Journal of the American Academy of Orthopaedic Surgeons 326 suction drains, which are left in place for 5 to 7 days to minimize the risk of hematoma or seroma. The humeral insertion should be left in place until completion of the transfer to prevent potential injury to the pedicle. When the muscle is rotated to provide soft-tissue cover- age, subcutaneous passage is rec- ommended. However, at times, it is easiest and safest to avoid subcu- taneous tunnels and simply connect donor and recipient sites with open incisions. When the latissimus is transferred anteriorly to restore elbow flexion, it is usually passed beneath or deep to the pectoralis major tendon (Fig. 3). 6 Restoration of Elbow Flexion Loss of elbow flexion due to trau- matic muscle loss, brachial plexus injury, or poliomyelitis is an inca- pacitating problem because it se- verely reduces hand use. Schott- staedt et al 7 first proposed the use of the latissimus muscle as a transfer to the anterior or posterior upper arm in order to restore flexion or exten- sion, respectively. The technique of functional transfer for elbow flexion, or “flexorplasty” (Fig. 4), was popu- larized by Zancolli et al 6 and subse- quently by many others. 8-10 Several key points must be re- membered when performing this procedure. First, the muscle must be completely mobilized to allow transfer on its neurovascular pedi- cle. When it is transferred anteriorly, care must be taken not to twist the pedicle. Finally, to provide the best mechanical advantage, the latis- simus should be transferred in a bi- polar fashion such that its humeral insertion is reattached to the cora- coid process and its muscular ori- gin is woven through the distal biceps tendon. 6 Restoration of functionally useful elbow flexion requires that the mus- cle be of normal strength preopera- tively. 9 If it is not, flexion greater than 90 degrees may not be possible. Most series report approximately 120 degrees of flexion, with small (20- to 30-degree) flexion contrac- tures occasionally resulting. 8-11 Strength is usually more than enough to overcome gravity but not enough to overcome an examiner’s resistance. The strength is usually sufficient to allow a 2- to 3-kg weight to be lifted with the elbow in more than 90 degrees of flexion. 8-11 Even though the most common cause of loss of elbow flexion is brachial plexus injury, results of flexorplasties performed for post- traumatic muscle loss and poliomy- elitis are comparable. At the very least, most patients are able to get the affected hand to the mouth and have enough flexion to carry out activities of daily living. In the set- ting of brachial plexus palsy, gleno- humeral arthrodesis may occasionally be necessary to improve the effec- tiveness of the transfer; however, shoulder arthrodesis may not al- ways be necessary, because the bipo- lar transfer runs anterior to the joint and may act as a stabilizer against anterior subluxation. 6,12 In describing proper muscle ten- sioning during free transfer of the innervated gracilis muscle to replace muscle loss in the forearm, Manktelow and co-workers 5,13 have underscored certain points that can be useful when performing pedi- cled latissimus transfer to restore elbow flexion and extension and have particularly recommended pretransfer and posttransfer muscle measurement to aid in setting the correct tension. A transferred mus- cle should be tensioned so that its excursion is within the most power- ful range of the length-tension curve of muscle contraction (Blix curve). 14 If a sense of normal ten- sion before transfer is not estab- Axillary artery Axillary vein Circumflex scapular vein Midpoint of iliac crest Circumflex scapular artery Subscapular vein Subscapular artery Thoracodorsal vein Thoracodorsal artery Motor nerve to latissimus dorsi Latissimus dorsi Serratus anterior artery Serratus anterior vein Figure 2 After the muscle has been separated from the chest wall, it can be lifted proxi- mally to provide exposure of the pedicle. The artery and vein to the serratus anterior mus- cle can be traced proximally to their origin from the thoracodorsal pedicle. Troy D. Pierce, MD, MS, and Matthew M. Tomaino, MD Vol 8, No 5, September/October 2000 327 lished, a muscle may be placed either too tightly or too loosely after transfer. After the latissimus has been mobilized, but with its origin and insertion still attached, it should be stretched to its physiologic maxi- mum by abduction, forward flex- ion, and external rotation of the arm. With the muscle in the stretched position, sutures can be placed every 5 cm on its surface as markers. After the muscle has been transferred to its new loca- tion, the origin and insertion should be established such that maximum stretch of the muscle is restored (the 5-cm intervals be- tween suture markers should be reestablished). When the latis- simus is transferred to the anterior aspect of the upper arm, maximum stretch will occur with the elbow in extension; therefore, the muscle is tensioned with the elbow extended. It is usually easiest to anchor the muscle origin (latissimus tendon) to the coracoid or anterior acromion before stretching the muscle dis- tally. The elbow is then extended, the proper tension established, and the distal weave between latis- simus muscle and biceps tendon performed. After wound closure, the elbow is flexed approximately 90 degrees for 3 weeks. Poor functional outcome may be due to graft ischemia as a result of pedicle injury during transfer or as a result of weakness of the latis- simus secondary to involvement in the pathologic process preopera- tively. 9 Therefore, it is imperative to measure the strength of the mus- cle before undertaking the proce- dure. This can be done as part of the physical examination, by assess- ing the bulk of the posterior axillary fold as well as the strength of the latissimus during resisted ad- duction and internal rotation. Elec- tromyography may also be useful in evaluating for denervation. This can be assessed by looking for fi- brillation potentials or diminished amplitude. In some cases of upper brachial plexopathy, the thoraco- dorsal nerve may be involved only partially, which allows some recov- ery. In this situation, it is probably better to delay latissimus transfer until strength has normalized or to select an alternative donor, such as the pectoralis major muscle, which is supplied not only by the lateral pectoral nerve (lateral cord of the brachial plexus) but also by the medial pectoral nerve (medial cord of the brachial plexus). 12 Although Stern et al 11 reported that preopera- tive electrical evidence of mild de- nervation did not preclude success- ful function, Moneim and Omer 9 Figure 3 Operative technique for bipolar latissimus transfer to restore elbow flexion. A, The latissimus dorsi muscle is exposed through a standard posterolateral approach. B, The muscle, with or without a skin paddle, is mobilized on a neurovascular pedicle. (Transfer with a skin paddle facilitates postoperative monitoring and avoids potential problems with wound closure due to the bulk of the latissimus muscle.) C, The muscle is tunneled subcutaneously through the axilla, deep to the pectoralis major tendon. D, The tendinous portion of the muscle is attached to the coracoid or acromion, and the broad muscular origin is folded on itself and sutured to the biceps tendon. A B C D Figure 4 Patient who underwent bipolar latissimus muscle transfer to restore elbow flexion, which had been lost secondary to poliomyelitis. Six months after transfer, he could flex his elbow against gravity with a range of motion of 0 to 110 degrees. Pedicled Latissimus Muscle Flap Journal of the American Academy of Orthopaedic Surgeons 328 clearly demonstrated that if latis- simus strength was not normal before transfer, less than 90 degrees of elbow flexion resulted. Transfer of the pedicled, inner- vated latissimus muscle appears to restore adequate elbow flexion if the latissimus is of normal strength preoperatively, the elbow has full passive mobility, and the shoulder is stable. Nevertheless, Steindler’s flexor-pronator origin transfer, tri- ceps transfer, pectoralis major ten- don or muscle transfer, and sterno- cleidomastoid transfer are all options. 12 Restoration of Elbow Extension Loss of elbow extension is not as disabling as loss of flexion, because elbow extension can be obtained by means of gravity. Active elbow extension is essential, however, for patients who need to work over- head (e.g., carpenters, painters, and pilots) and for those who rely on their upper extremities for mobiliza- tion and transfers (e.g., tetraplegics). Elbow extension can be restored with use of the pedicled latissimus muscle transfer. Functional range of motion and strength result in most patients, so long as preopera- tive strength is normal. In addition, when there is an associated soft- tissue defect, good contour can be restored in the arm. Functional latissimus transfer for elbow extension, or “extensor- plasty,” is performed by attaching the humeral insertion of the latis- simus to the posterior acromion and its muscle origin into the tri- ceps tendon (Fig. 5). 7,14-16 As with flexorplasty, maximum recruitment of latissimus muscle fiber is de- sired. This is achieved by rolling the large, flat muscle into a cylin- der with the vessels and nerve inside, thus recreating the shape of the triceps. Optimal power and excursion after muscle transfer also depend on proper tensioning in its new location. Surface markings are placed at 5-cm intervals with the muscle stretched before transfer and are then reestablished after transfer to the back of the arm while the elbow is fully flexed. It is easiest to anchor the latissimus ten- don to the posterior acromion first, followed by proper tensioning and connection to the triceps tendon distally. This is performed with the elbow in flexion. Functional latissimus transfer for elbow extension has been reported less frequently than flexorplasty. 14-16 Nevertheless, useful return of active elbow extension can be expected. There are no studies comparing la- tissimus transfer with other muscle transfers for restoration of elbow extension. The advantages of this procedure over other operations, such as posterior deltoid or biceps transfers, are that wound coverage and restoration of arm contour can be accomplished in one procedure and that the latissimus transfer obviates the sacrifice of an impor- tant extremity muscle. Restoration of Shoulder Abduction A variety of tendon transfers have been attempted to restore lost del- toid function. Bateman 17 popular- ized the trapezius transfer to restore shoulder abduction and flexion after deltoid paralysis. This and other muscle transfers have had variable success. Lai et al 18 were the first to re- port the use of a pedicled latissimus transfer to partially restore deltoid function. They included a skin pad- dle for simultaneous coverage of a large soft-tissue defect. Itoh et al 19 reported the largest series of latis- simus “deltoid-plasties” in patients with brachial plexus injuries. The success of their series encouraged Ferrier et al 20 to use the procedure to reconstruct the deltoid of a patient with an existing hemiarthroplasty. Overall, patients with deltoid dysfunction secondary to muscle loss have fared better after this pro- cedure than those with paralysis secondary to brachial plexus injury. Resultant flexion and abduction usually approximate 90 degrees. Preoperatively, latissimus muscle Figure 5 Functional transfer of the latissimus muscle (left) was performed on this 14-year- old boy to restore grade IV elbow extension (above), which had been lost after excision of a synovial cell sarcoma involving the radial nerve. A skin paddle was used to facilitate postoperative monitoring and avoid problems with wound closure. Troy D. Pierce, MD, MS, and Matthew M. Tomaino, MD Vol 8, No 5, September/October 2000 329 strength should be at least grade IV if antigravity strength is to be restored. According to Itoh et al, 19 patients in whom some strength exists in the rotator cuff and/or the long head of the biceps may be capable of more than 110 degrees of flexion. This most likely reflects a retained depressor function from the rotator cuff and biceps tendon, which results in a more efficient force couple at the glenohumeral joint and improved mechanical advantage for the latissimus itself. Soft-Tissue Coverage of the Shoulder and Upper Arm Soft-tissue loss about the shoulder and upper arm may be the result of trauma, tumor, irradiation, or infec- tion. The goals of reconstruction include debridement of all necrotic, contaminated, or infected bone and soft tissue and coverage with well- vascularized tissue. When tissue loss is substantial, replacement tis- sue must be borrowed from a dis- tant site, as skin grafting is not possi- ble and local flaps are not available. The pedicled latissimus muscle flap provides an excellent source of well-vascularized skin and muscle for convenient single-stage cover- age (Fig. 6). Early coverage of open fractures reduces the risk of infectious com- plications, including osteomyelitis. Patients with chronic infection require radical debridement and early coverage to eliminate bacterial contamination and tissue devascu- larization. In studies involving the use of this technique, chronic infec- tion was successfully eliminated in all patients treated with radical de- bridement and early pedicled latis- simus coverage. 10,21 Contrary to traditional teaching, delay in defin- itive wound closure is unnecessary when meticulous, aggressive de- bridement precedes acute muscle coverage. The pedicled latissimus muscle flap is particularly useful for prob- lems secondary to radiation dam- age. Involved tissue is often too fibrotic to support skin grafts, local flaps, or primary wound closure after excision. 22,23 Mendelson and Masson 24 reported successful cov- erage of the shoulder in three pa- tients with chronic radiation injury. Although the pedicled latissimus transfer is an excellent option, these series had a combined complication rate of 27%. Fortunately, most com- plications involved the donor site and did not affect long-term out- come. The rate of complications due to donor-site seroma or hematoma averaged 10% to 11%. Large suc- tion drains should be maintained in place for 5 to 7 days to prevent this complication. Soft-Tissue Coverage of the Elbow Trauma to the upper extremity commonly results in soft-tissue loss about the elbow. The pedi- cled latissimus muscle can reach this level, but transfer with an associated skin paddle is risky because cutaneous perforators diminish at this distal level. Mobi- lization of the pedicle to the origin of the thoracodorsal artery helps to increase the distance that the muscle can be transposed distal- ly. 25-29 Even though an orthograde (proximal-to-distal) radial forearm flap or a reverse-lateral arm flap can be used to cover the elbow as well, their use is often contraindicated when a high-energy wound has re- sulted in a wide zone of injury. Jutte et al 27 demonstrated in cadavers that the latissimus muscle could easily reach the olecranon and beyond in all specimens exam- ined. Nevertheless, reliable single- stage coverage of the elbow and proximal forearm requires harvest of the entire length of the latis- simus. 25-29 An adequate subcuta- neous tunnel created along the pos- terior aspect of the upper extremity is required to transfer the muscle without placing pressure on the pedicle (Fig. 7). Before these cases Figure 6 A, This 22-year-old woman sustained an open fracture of the midportion of her humerus, which was associated with a large soft-tissue defect. Her biceps muscle was retained. B, A myocutaneous-pedicle latissimus transfer was performed to provide soft- tissue coverage after internal fixation of the fracture. The thoracodorsal nerve was divided to allow muscle atrophy, so that the transferred muscle would not be too bulky. A B Pedicled Latissimus Muscle Flap Journal of the American Academy of Orthopaedic Surgeons 330 References 1. Katsaros J: Indications for free soft-tis- sue flap transfer to the upper limb and the role of alternative procedures. Hand Clin 1992;8:479-507. 2. Hui KCW, Zhang F, Sutkin H, Wu P, Tingley S, Lineaweaver WC: Functional assessment of the shoulder following latissimus dorsi muscle donation in the handicapped. J Reconstr Microsurg 1999;15:101-103. 3. Russell RC, Pribaz J, Zook EG, Leigh- ton WD, Eriksson E, Smith CJ: Func- tional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 1986;78: 336-344. 4. Bartlett SP, May JW Jr, Yaremchuk MJ: The latissimus dorsi muscle: A fresh cadaver study of the primary neuro- vascular pedicle. Plast Reconstr Surg 1981;67:631-636. 5. Manktelow RT: Microvascular Recon- struction: Anatomy, Applications and Surgical Technique. Berlin: Springer- Verlag, 1986, pp 151-164. 6. Zancolli E, Mitre H: Latissimus dorsi transfer to restore elbow flexion: An appraisal of eight cases. J Bone Joint Surg Am 1973;55:1265-1275. 7. Schottstaedt ER, Larsen LJ, Bost FC: Complete muscle transposition. J Bone Joint Surg Am 1955;37:897-919. 8. Chuang DCC, Epstein MD, Yeh MC, Wei FC: Functional restoration of elbow flexion in brachial plexus in- juries: Results in 167 patients (ex- cluding obstetric brachial plexus injury). J Hand Surg [Am] 1993;18: 285-291. 9. Moneim MS, Omer GE: Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus dis- ruption. J Hand Surg [Am] 1986;11: 135-139. 10. Hirayama T, Tada H, Katsuki M, Yoshida E: The pedicle latissimus dorsi transfer for reconstruction of the plexus brachialis and brachium. Clin Orthop 1994;309:201-207. 11. Stern PJ, Neale HW, Gregory RO, Kreilein JG: Latissimus dorsi muscu- locutaneous flap for elbow flexion. J Hand Surg [Am] 1982;7:25-30. 12. Richards RR: Operative treatment for irreparable lesions of the brachial are finished, it is critical to assess the viability of the distalmost por- tion of the muscle, as this region may constitute a watershed area between the thoracolumbar perfo- rators and the thoracodorsal pedi- cle. If the muscle is not pink, it should be debrided, and alternative techniques for coverage selected. Even though abundant literature in support of use of the pedicled latissimus muscle flap for coverage of the elbow does not yet exist, it is a feasible, safe transfer with mini- mal donor-site morbidity. We have used it successfully without com- plications, initiating early range of motion of the elbow after 5 days. Summary The versatility of the pedicled latis- simus dorsi muscle flap for upper extremity reconstruction is unparal- leled. The long vascular pedicle allows transfer not only to the shoul- der but also as far distally as the elbow. Maintenance of innervation allows its use as a functional transfer to restore shoulder abduction and elbow flexion and extension. Even though microvascular anastomoses are not required, considerable care is necessary to avoid injury to the pedi- cle during flap dissection and trans- fer. Donor-site morbidity is mini- mal, and the resulting scar is easily hidden by conventional clothing. Figure 7 A massive soft-tissue defect of the posterior aspect of the right arm, elbow, and proximal forearm in a 32-year-old man. Left, The proximal forearm muscles could be skin-grafted, but a pedicled latissimus transfer had to be performed to provide distal soft-tissue coverage. Transfer of the muscle to the level of the elbow required mobilization of the thoracodorsal pedicle proximally to its origin from the subscapular artery. Right, The muscle was subsequently successfully skin-grafted to provide stable long-term soft-tissue coverage. Troy D. Pierce, MD, MS, and Matthew M. Tomaino, MD Vol 8, No 5, September/October 2000 331 plexus, in Gelberman RH (ed): Opera- tive Nerve Repair and Reconstruction. Philadelphia: JB Lippincott, 1991, vol 2, pp 1303-1325. 13. Manktelow RT, Zuker RM, McKee NH: Functioning free muscle transplanta- tion. J Hand Surg [Am] 1984;9:32-39. 14. du Toit GT, Levy SJ: Transposition of latissimus dorsi for paralysis of triceps brachii: Report of a case. J Bone Joint Surg Br 1967;49:135-137. 15. Harmon PH: Muscle transplantation for triceps palsy: The technique of uti- lizing the latissimus dorsi. J Bone Joint Surg Am 1949;31:409-412. 16. Landra AP: The latissimus dorsi mus- culocutaneous flap used to resurface a defect on the upper arm and restore extension to the elbow. Br J Plast Surg 1979;32:275-277. 17. Bateman JE: The Shoulder and Neck, 2nd ed. Philadelphia: WB Saunders, 1978, pp 606-608. 18. Lai MF, Milroy BC, Pennington DG: Shoulder defect cover with functional restoration using the latissimus dorsi myocutaneous flap: A case report. Br J Plast Surg 1982;35:140-143. 19. Itoh Y, Sasaki T, Ishiguro T, Uchinishi K, Yabe Y, Fukuda H: Transfer of latissimus dorsi to replace a paralysed anterior deltoid: A new technique using an inverted pedicle graft. J Bone Joint Surg Br 1987;69:647-651. 20. Ferrier JA, Owens T, Singer DI: Functional reconstruction of the shoul- der with a latissimus dorsi pedicle flap and a hemiarthroplasty: A case report. J Hand Surg [Am] 1995;20:284-287. 21. Stern PJ, Carey JP: The latissimus dorsi flap for reconstruction of the brachium and shoulder. J Bone Joint Surg Am 1988;70:526-535. 22. Dowden RV, McCraw JB: Muscle flap reconstruction of shoulder defects. J Hand Surg [Am] 1980;5:382-390. 23. Cohen BE: Shoulder defect correction with the island latissimus dorsi flap. Plast Reconstr Surg 1984;74:650-656. 24. Mendelson BC, Masson JK: Treatment of chronic radiation injury over the shoulder with a latissimus dorsi myocu- taneous flap. Plast Reconstr Surg 1977; 60:681-691. 25. Sadove RC, Vasconez HC, Arthur KR, Draud JW, Burgess RC: Immediate clo- sure of traumatic upper arm and fore- arm injuries with the latissimus dorsi island myocutaneous pedicle flap. Plast Reconstr Surg 1991;88:115-120. 26. Silverton JS, Nahai F, Jurkiewicz MJ: The latissimus dorsi myocutaneous flap to replace a defect on the upper arm. Br J Plast Surg 1978;31:29-31. 27. Jutte DL, Rees R, Nanney L, Bueno R, Lynch JB: Latissimus dorsi flap: A valuable resource in lower arm recon- struction. South Med J 1987;80:37-40. 28. Chang LD, Goldberg NH, Chang B, Spence R: Elbow defect coverage with a one-staged, tunneled latissimus dorsi transposition flap. Ann Plast Surg 1994;32:496-502. 29. MacKinnon SE, Weiland AJ, Godina M: Immediate forearm reconstruction with a functional latissimus dorsi island pedicle myocutaneous flap. Plast Reconstr Surg 1983;71:706-710.