Application of modified latissimus dorsi musculocutaneous flap in repair of Gustilo-Anderson type <b>Ⅲ</b>B and <b>Ⅲ</b> C upper limb injuries with composite tissue defects_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Hui ¹ ,  ZHOU Zhengbing ¹ , LIU Manhua ² , LUO Shunhong ² , JIA Yachao ¹ , CHENG Yuan ¹ , YU Yaling ¹ , CHENG Dongdong ¹

1. Department of Orthopaedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China;
2. Department of Orthopaedics, General Hospital of Hunan University of Medicine, Huaihua Hunan, 418000, P. R. China;

Corresponding?author：

ZHOU Zhengbing, Email: zhouzhengbing@yeah.net

Keywords：

Modified latissimus dorsi musculocutaneous flap; composite tissue defects; upper limb; limb salvage; wound repair

DOI：

10.7507/1002-1892.202604027

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Objective To investigate the feasibility and effectiveness of using a modified latissimus dorsi musculocutaneous flap for the treatment of upper limb injuries with complex tissue defects classified as Gustilo-Anderson type ⅢB and ⅢC. Methods Between January 2021 and January 2024, 19 cases of upper limb injuries with complex tissue defects classified as Gustilo-Anderson type ⅢB and ⅢC were repaired with a modified latissimus dorsi musculocutaneous flap. There were 14 males and 5 females, with an average age of 33 years (range, 8-65 years). Among these cases, 12 involved injuries to the upper arm and elbow, while 7 involved injuries to the forearm. The disease duration ranged from 2 hours to 10 days (mean, 2.6 days). The patients underwent emergency internal fixation or external fixation for fractures, along with repair of neurovascular injuries. Subsequently, based on the type and extent of tissue defect, 11 cases were treated with pedicled flap transplantation, while 8 cases underwent free flap transplantation. The size of the muscular flaps ranged from 16.0 cm×10.0 cm to 24.0 cm×14.5 cm, while the size of skin flaps ranged from 12.0 cm×5.0 cm to 27.0 cm×7.5 cm. All incisions at donor sites were sutured. Results All 19 flaps survived completely, with primary wound healing in 17 cases and secondary healing with skin grafting on the muscular flap in 2 cases. The incisions at donor sites healed by first intention. All patients were followed up 10-41 months (mean, 21 months), and limb salvage was successful in all cases. All fractures healed with a healing time of 8-14 weeks. At last follow-up, according to the functional evaluation criteria for upper limb replantation established by the Hand Surgery Branch of Chinese Medical Association, 15 cases demonstrated excellent functional recovery, while 3 cases showed good functional outcomes, 1 case showed poor recovery. Conclusion The modified latissimus dorsi musculocutaneous flap, through partial separation of the latissimus dorsi muscle and musculocutaneous perforators combined with a staggered arrangement of the muscle and skin components, enables flexible reconstruction of defects at different tissue levels. This technique demonstrates advantages including a high flap survival rate, satisfactory limb salvage outcomes, favorable functional recovery, and relatively low donor site morbidity, making it an effective method for reconstruction of Gustilo-Anderson type ⅢB and ⅢC upper limb injuries with composite tissue defects.

Citation： LIU Hui, ZHOU Zhengbing, LIU Manhua, LUO Shunhong, JIA Yachao, CHENG Yuan, YU Yaling, CHENG Dongdong. Application of modified latissimus dorsi musculocutaneous flap in repair of Gustilo-Anderson type ⅢB and Ⅲ C upper limb injuries with composite tissue defects. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(9): 1359-1363. doi: 10.7507/1002-1892.202604027 Copy

1.	Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type Ⅲ (severe) open fractures: a new classification of type Ⅲ open fractures[J]. J Trauma, 1984, 24(8): 742-746.
2.	Ricci JA, Stranix JT, Lee ZH, et al. Comparing reconstructive outcomes in patients with Gustilo type ⅢB fractures and concomitant arterial injuries[J]. Plast Reconstr Surg, 2019, 143(5): 1522-1529.
3.	張子陽, 唐修俊, 魏在榮, 等. 腹部帶蒂皮瓣修復上肢大面積皮膚缺損[J]. 中國修復重建外科雜志, 2017, 31(9): 1102-1105.
4.	張樹新, 鄔慧萍, 許永先, 等. 游離股前外側皮瓣修復四肢GustiloⅢ型開放性骨折合并皮膚軟組織缺損[J]. 實用手外科雜志, 2022, 36(2): 176-178.
5.	周征兵, 唐舉玉, 吳攀峰, 等. 雙側旋股外側動脈降支穿支皮瓣組合移植修復下肢大面積軟組織缺損[J]. 中華顯微外科雜志, 2020, 43(6): 535-539.
6.	周征兵, 唐舉玉, 吳攀峰, 等. 雙側旋股外側動脈降支穿支皮瓣組合移植治療上肢大面積軟組織缺損[J]. 中華手外科雜志, 2019, 35(3): 183-185.
7.	He J, Guliyeva G, Wu P, et al. Reconstruction of large soft tissue defects in the distal lower extremity: free chain-linked bilateral anterolateral thigh perforator flaps versus extended latissimus dorsi musculocutaneous flaps[J/OL]. J Pers Med, 2022, 12(9): 1400. doi: 10.3390/jpm12091400.
8.	Dong S, Jiang J, Lan R, et al. Clinical application of the free anterolateral thigh chimeric muscle flap for reconstruction of composite tissue defects of the forearm and hand[J/OL]. Front Surg, 2026, 13: 1748013. doi: 10.3389/fsurg.2026.1748013.
9.	潘達德, 顧玉東, 侍德, 等. 中華醫學會手外科學會上肢部分功能評定試用標準[J]. 中華手外科雜志, 2000, 16(3): 130-135.
10.	阿不來提 · 阿不拉, 任鵬, 古麗阿依夏木 · 賽買提, 等. 游離背闊肌皮瓣移植聯合外固定治療膝關節周圍骨與軟組織缺損[J]. 中國修復重建外科雜志, 2025, 39(4): 488-494.
11.	Andresen-Lorca B, Thione A, García-García M, et al. S. W. A. T. flap in plastic surgery: The latissimus dorsi. In-depth overview of a classic weapon and systematic review of its reported uses[J]. JPRAS Open, 2025, 48: 269-280.
12.	Smith JD, Smith B, Rosko AJ, et al. Modern applications of the pedicled latissimus dorsi flap for complex head and neck reconstruction[J/OL]. Oral Oncol, 2024, 159: 107059. doi: 10.1016/j.oraloncology.2024.107059.
13.	Liu Y, Zang M, Wu L, et al. Improving the versatility of the latissimus dorsi myocutaneous flap using the perforator propeller flap concept[J]. Ann Plast Surg, 2020, 84(6): 689-696.
14.	García-García M, Andresen-Lorca B, Thione A, et al. Latissimus dorsi flap: a comprehensive systematic review of traditional and novel applications[J/OL]. Front Surg, 2026, 13: 1752461. doi: 10.3389/fsurg.2026.1752461.
15.	Chim H, Cohen-Shohet R, McLaughlin MM, et al. Function-sparing free split latissimus dorsi flap for lower-extremity reconstruction: five-year consecutive single-surgeon series[J]. J Bone Joint Surg (Am), 2020, 102(19): 1714-17232.
16.	Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap[J]. Plast Reconstr Surg, 1981, 67(5): 637-641.
17.	Gao Y, Yang E, Luo S, et al. Pre-expanded muscle-sparing latissimus dorsi flap in defect reconstruction and its application strategy[J/OL]. Burns Trauma, 2024, 12: tkae014. doi: 10.1093/burnst/tkae014.
18.	Ha Y, Lee BH, Park JA, et al. Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap[J]. Microsurgery, 2023, 43(7): 665-675.
19.	Ozaniak A, Hladik P, Lischke R. Successful restoration of elbow extension using the latissimus dorsi flap: case report[J/OL]. Plast Reconstr Surg Glob Open, 2022, 10(2): e4121. doi: 10.1097/GOX.0000000000004121.
20.	Choi JS, An JK, Park JA, et al. Strategy for resurfacing complex extremity defect with chimeric, linked flaps: A review with a 10-year experience at major trauma center[J]. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS, 2023, 80: 107-114.

1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type Ⅲ (severe) open fractures: a new classification of type Ⅲ open fractures[J]. J Trauma, 1984, 24(8): 742-746.
2. Ricci JA, Stranix JT, Lee ZH, et al. Comparing reconstructive outcomes in patients with Gustilo type ⅢB fractures and concomitant arterial injuries[J]. Plast Reconstr Surg, 2019, 143(5): 1522-1529.
3. 張子陽, 唐修俊, 魏在榮, 等. 腹部帶蒂皮瓣修復上肢大面積皮膚缺損[J]. 中國修復重建外科雜志, 2017, 31(9): 1102-1105.
4. 張樹新, 鄔慧萍, 許永先, 等. 游離股前外側皮瓣修復四肢GustiloⅢ型開放性骨折合并皮膚軟組織缺損[J]. 實用手外科雜志, 2022, 36(2): 176-178.
5. 周征兵, 唐舉玉, 吳攀峰, 等. 雙側旋股外側動脈降支穿支皮瓣組合移植修復下肢大面積軟組織缺損[J]. 中華顯微外科雜志, 2020, 43(6): 535-539.
6. 周征兵, 唐舉玉, 吳攀峰, 等. 雙側旋股外側動脈降支穿支皮瓣組合移植治療上肢大面積軟組織缺損[J]. 中華手外科雜志, 2019, 35(3): 183-185.
7. He J, Guliyeva G, Wu P, et al. Reconstruction of large soft tissue defects in the distal lower extremity: free chain-linked bilateral anterolateral thigh perforator flaps versus extended latissimus dorsi musculocutaneous flaps[J/OL]. J Pers Med, 2022, 12(9): 1400. doi: 10.3390/jpm12091400.
8. Dong S, Jiang J, Lan R, et al. Clinical application of the free anterolateral thigh chimeric muscle flap for reconstruction of composite tissue defects of the forearm and hand[J/OL]. Front Surg, 2026, 13: 1748013. doi: 10.3389/fsurg.2026.1748013.
9. 潘達德, 顧玉東, 侍德, 等. 中華醫學會手外科學會上肢部分功能評定試用標準[J]. 中華手外科雜志, 2000, 16(3): 130-135.
10. 阿不來提 · 阿不拉, 任鵬, 古麗阿依夏木 · 賽買提, 等. 游離背闊肌皮瓣移植聯合外固定治療膝關節周圍骨與軟組織缺損[J]. 中國修復重建外科雜志, 2025, 39(4): 488-494.
11. Andresen-Lorca B, Thione A, García-García M, et al. S. W. A. T. flap in plastic surgery: The latissimus dorsi. In-depth overview of a classic weapon and systematic review of its reported uses[J]. JPRAS Open, 2025, 48: 269-280.
12. Smith JD, Smith B, Rosko AJ, et al. Modern applications of the pedicled latissimus dorsi flap for complex head and neck reconstruction[J/OL]. Oral Oncol, 2024, 159: 107059. doi: 10.1016/j.oraloncology.2024.107059.
13. Liu Y, Zang M, Wu L, et al. Improving the versatility of the latissimus dorsi myocutaneous flap using the perforator propeller flap concept[J]. Ann Plast Surg, 2020, 84(6): 689-696.
14. García-García M, Andresen-Lorca B, Thione A, et al. Latissimus dorsi flap: a comprehensive systematic review of traditional and novel applications[J/OL]. Front Surg, 2026, 13: 1752461. doi: 10.3389/fsurg.2026.1752461.
15. Chim H, Cohen-Shohet R, McLaughlin MM, et al. Function-sparing free split latissimus dorsi flap for lower-extremity reconstruction: five-year consecutive single-surgeon series[J]. J Bone Joint Surg (Am), 2020, 102(19): 1714-17232.
16. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap[J]. Plast Reconstr Surg, 1981, 67(5): 637-641.
17. Gao Y, Yang E, Luo S, et al. Pre-expanded muscle-sparing latissimus dorsi flap in defect reconstruction and its application strategy[J/OL]. Burns Trauma, 2024, 12: tkae014. doi: 10.1093/burnst/tkae014.
18. Ha Y, Lee BH, Park JA, et al. Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap[J]. Microsurgery, 2023, 43(7): 665-675.
19. Ozaniak A, Hladik P, Lischke R. Successful restoration of elbow extension using the latissimus dorsi flap: case report[J/OL]. Plast Reconstr Surg Glob Open, 2022, 10(2): e4121. doi: 10.1097/GOX.0000000000004121.
20. Choi JS, An JK, Park JA, et al. Strategy for resurfacing complex extremity defect with chimeric, linked flaps: A review with a 10-year experience at major trauma center[J]. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS, 2023, 80: 107-114.

Chinese Journal of Reparative and Reconstructive Surgery

Application of modified latissimus dorsi musculocutaneous flap in repair of Gustilo-Anderson type ⅢB and Ⅲ C upper limb injuries with composite tissue defects

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