Versatility of the Latissimus Dorsi Flap in Head and Neck Surgery: Supporting Evidence from a Tertiary Oncology Center

Dear Sir,

We read with great interest the article by Shaya et al.,[1] “Free latissimus dorsi flaps in head and neck reconstruction at a modern high-volume microsurgical centre.” The authors provide a valuable contribution by highlighting the latissimus dorsi (LD) flap as a versatile and dependable option, particularly in salvage scenarios or when traditional first-line flaps are unsuitable. We would like to commend the authors on their large series and share additional perspectives based on our own experience at a tertiary oncology center.

1. LD Flap as a Primary Option: While Shaya et al. emphasize its utility as a backup, we have successfully used the LD flap as a primary reconstructive option in selected patients.[2] This includes individuals with previous trauma or surgery to the thigh—rendering the anterolateral thigh flap unusable—and those with a pear-shaped body habitus where thigh bulk limits flap usability. In such cases, the LD flap offers superior anatomical suitability and ease of harvest.

2. Vascular Considerations in Comorbid Patients: As noted in the article, many head and neck cancer patients are elderly and smokers—populations prone to peripheral vascular disease. We have observed significant atherosclerosis in lower extremity vessels, compromising flap reliability.[3] In contrast, the LD flap's thoracodorsal pedicle is less commonly affected by such changes, offering a safer vascular profile.

3. Composite Reconstruction Possibilities: In complex cases such as segmental mandibulectomy with overlying soft tissue defects, we have employed a combined osteocutaneous parascapular and LD flap from a single donor site.[4] This approach yields adequate soft tissue, bone, and skin coverage while maintaining a concealed donor area, thereby optimizing both functional and aesthetic outcomes.

4. Efficiency in Secondary Reconstruction: Shaya et al. highlight their senior author's expertise. We add that in revision surgeries or postradiation necks, a pedicled LD flap tunneled to the neck can be advantageous. This approach avoids microsurgical anastomosis, reduces operative time, and limits the need for positional changes. It also offers a practical solution for junior microsurgeons working in technically challenging necks.

5. Infection Control and Dead Space Management: The LD muscle's bulk and vascularity contribute to lower rates of infection and seroma in our experience, effectively filling dead space and improving local wound healing.

6. Contour and Aesthetic Benefits: The flat, broad muscle of the LD flap facilitates smooth contouring in the cervical region and conforms well to the recipient site geometry, offering superior cosmetic outcomes.

7. Alternative Venous Outflow Options: In vessel-depleted necks, we have found the cephalic vein transposition (cephalic flip) to be a reliable and technically accessible venous outflow option, especially for junior microsurgeons.[5]

In summary, we applaud Shaya et al. for shedding light on the underutilized yet highly valuable role of the LD free flap in head and neck reconstruction. Our experience echoes their conclusions and further supports expanding its indications beyond the salvage setting.

Authors' Contributions

Concept, design, analysis, and interpretation of data; draft manuscript and final approval of the manuscript: V.S., S.K., S.A.P. (reconstructive surgeons).

Ethics Approval

The standard mode of treatment was opted.

Consent to Participate

Institutional consent with no reveal of identity disclosure.

Publication History

Received: 03 May 2025

Accepted: 31 May 2025

Accepted Manuscript online:
11 June 2025

Article published online:
08 July 2025

• References

• 1 Shyaka I, Su CL, Wei FC. Free latissimus dorsi flaps in head and neck reconstruction at a modern high-volume microsurgery center. J Reconstr Microsurg 2025; 41 (04) 361-368
• 2 Barton Jr FE, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myocutaneous flap: anatomic observations and report of 60 cases. Plast Reconstr Surg 1983; 71 (02) 199-204
• 3 Jaffar S, Jaiswal D, Shankhdhar VK. et al. Free thoracodorsal artery perforator flap for head and neck reconstruction: an Indian experience. Indian J Plast Surg 2023; 56 (06) 499-506
• 4 Janus JR, Carlson ML, Moore EJ. The scapular, parascapular, and latissimus dorsi flap as a single osteomyocutaneous flap for repair of complex oral defects. Clin Anat 2012; 25 (01) 120-128
• 5 Vasilakis V, Patel HD, Chen HC. Head and neck reconstruction using cephalic vein transposition in the vessel-depleted neck. Microsurgery 2009; 29 (08) 598-602