Muscle-Sparing Latissimus Dorsi Flap with a Longitudinal Muscle Cuff: A Practical Strategy for Reliable Harvest of...

Background/Objectives: Reconstruction of elongated soft-tissue defects requires flaps that provide sufficient longitudinal reach without excessive width or donor-site morbidity. We describe a modified latissimus dorsi (LD) flap in which a narrow, longitudinally oriented muscle cuff is incorporated along the long axis of the skin paddle to act as a vascular carrier, and evaluate its clinical feasibility and reliability. Methods: This retrospective case series included consecutive patients who underwent soft-tissue reconstruction with an LD flap incorporating a longitudinal muscle component beneath an elongated skin paddle at a single tertiary center between March 2020 and August 2025. The same longitudinal muscle-cuff concept was applied across a spectrum of muscle harvest: most flaps were muscle-sparing LD (msLD; limited longitudinal muscle segment with preservation of the horizontal thoracodorsal nerve branch), while a wider cuff requiring sacrifice of both nerve branches resulted when the cuff extended proximal to the thoracodorsal bifurcation and was designated musculocutaneous LD (mcLD). Outcomes included flap survival, partial skin-paddle necrosis, operative time, donor-site closure method, and donor-site morbidity. In an exploratory subgroup analysis, the cohort was divided at a skin-paddle length-to-width ratio of 2.5 and compared using Welch's t-test and Fisher's exact test. Results: Twenty-five flaps were analyzed (21 msLD, 84.0%; 4 mcLD, 16.0%). The mean patient age was 54.0 ± 19.9 years, and scar contracture was the most common etiology (56.0%), with the lower leg the most common defect site (44.0%). The mean skin-paddle dimensions were 26.8 ± 3.2 × 11.4 ± 1.8 cm (mean area, 305.3 ± 63.8 cm²), and the mean operative time was 154.8 ± 49.7 minutes. No total flap loss occurred, and partial necrosis of limited extent developed in two patients (8.0%). Primary donor-site closure was achieved in 14 patients (56.0%). Because long-axis length was comparable between groups, the ≥2.5 group had a narrower skin paddle (10.0 ± 0.4 vs. 12.9 ± 1.5 cm) and smaller flap area (273.5 ± 43.7 vs. 339.7 ± 65.6 cm²) as an arithmetic consequence of the group definition; primary donor-site closure was more frequent in this group (76.9% vs. 33.3%, p = 0.047, unadjusted), and partial necrosis did not differ (7.7% vs. 8.3%, p = 1.00). No clinically significant donor-site functional complaints were documented in the medical records over a mean follow-up of 15.0 ± 8.8 months, and the mean QuickDASH score was 2.82 ± 3.10 (range, 0-11.36), although the questionnaire was administered postoperatively only and no objective strength or range-of-motion testing was performed. Conclusions: Harvest of long, relatively narrow LD skin paddles using a longitudinally oriented muscle cuff was feasible and was associated with favorable flap survival in this series, with no total flap loss and a low rate of limited partial necrosis. Because the design retains most of the muscle and, in the msLD configuration, its horizontal motor innervation while avoiding extensive intramuscular perforator dissection, it may represent a practical option for elongated soft-tissue defects; the absence of a control group and of objective perfusion or shoulder-function assessment precludes conclusions about mechanism or superiority.