Outcomes of Calvarial and Soft Tissue Reconstruction

with Latissimus Dorsi Rib Osteomyocutaneous Free Flap

Abigail Meyers, BS;1 Bahar Bassiri Gharb, MD, PhD;1 Majid Rezaei, DDS, MD;1 Brian Figueroa, MD;1 Michael Annunziata, MD;1 Sean Nagel, MD;2 Mark Bain, MD;2 Sudish Murthy, MD, PhD;3 Francis Papay, MD1; Antonio Rampazzo, MD, PhD1

Large composite scalp and cranial defects are challenging to

reconstruct

The method of choice is mainly based on the size of the defect and

quality of the soft tissue envelope

Large cranial defects can also lead to complications such as herniation

of the cortex, subdural effusion, seizure, and syndrome of the

trephined

First described by Gottleib, the LD-rib flap (LDRF) was used for

successful reconstruction of full thickness skin and calvarial defects

Inclusion of the rib is not only for structure or aesthetics, but may also

play an important role for function

We aimed to present the outcomes of composite scalp and calvarial

defect reconstruction using the LDRF and conducted anatomical

cadaver dissections to study feasibility, perforator patterns, and to

define optimal flap design

An anatomical study was conducted to evaluate the connecting perforators between

thoracodorsal vessels (LD branch) and lateral branch of posterior intercostal vessels

Perforators were identified and exposed from the 12th rib to the 7th rib

An IRB-approved retrospective review of ten patients who underwent LDRF and one or two

ribs for treatment of cranial defects was conducted

Patient-reported outcomes regarding quality of life, neurological and functional status were

evaluated using validated surveys

Series illustrating superficial-todeep

dissection of the dorsal region.

(A) Removal of the skin and fascial

panniculus to display the underlying

epimysium of the trapezius (TZ) and

latissimus dorsi (LD) muscles. (B) The

epimysium of the LD has been

removed to display the underlying

muscles; infraspinatus (INF). (C) The

perforators.

The 10th rib (4.65± 2.01)

followed by 9th rib

(3.7±1.63) had the highest

number of perforators

A combination of the 9th

and 11th ribs exhibited

maximal perforator

number and pedicle

length

The minimum clinically important difference (MCID) was surpassed,

demonstrating improvement of function for 71% of patients on the

Barthel Index and 63% on the Selective Functional Movement

Assessment test (SFMA). *Only 6 pts filled out PDQ functional, 5

psychosocial precluding statistical comparison.

Median clinical follow-up was 48 [34-70] months postoperatively

All patients ultimately had stable LDRF reconstructions

Reconstruction of the calvarium with 1-2

ribs, and scalp with the overlying muscle

and skin paddle, is both anatomically

feasible and clinically sufficient to achieve

stability with soft tissue healing

Based on both cadaver dissections and

clinical experience, a combination of the 8th

and 10th or 9th and 11th ribs were

preferable for maximal perforator number

and pedicle length

Patient-reported outcomes align with

clinical improvement after LDRF

Reconstruction of composite scalp and skull

defects is important for not only restoration

of calvarial contour, but also for recovery of

cognitive function and prevention of further

decline