Limb Repair Using the Extended Chimeric Fasciocutaneous Scapular and Latissimus Dorsi Muscle (ECS-LD) Flap: A Case Series

We present four reconstructive cases of large soft tissue extremity defects utilizing a modification of the classic scapular-latissimus dorsi chimeric flap, which we refer to as the extended chimeric scapular and latissimus dorsi muscle flap (ECS-LDF). A 57-year-old male presented with a right lower extremity Gustilo IIIB fracture and an open knee joint with associated soft tissue loss following a motorcycle accident. An ECS-LDF (397 cm²), based on the subscapular artery, was harvested for coverage. The scapular skin paddle was inset over the knee, while the latissimus dorsi muscle was placed inferiorly over the leg defect and covered with a split-thickness skin graft (STSG). A five-year-old girl sustained multiple left lower extremity fractures and circumferential degloving of the knee due to a crush injury sustained in an auto-pedestrian trauma. The scapular portion (144 cm²) of the ECS-LDF was used to resurface the popliteal fossa, while the latissimus dorsi muscle and overlying STSG (351 cm²) covered the anterior knee and lateral leg. A 61-year-old male presented with a Gustilo IIIB fracture with extensive, near-circumferential degloving and soft tissue loss of the lower third of the left lower extremity. The latissimus dorsi muscle and scapular skin paddle of the ECS-LDF (310 cm²) provided complete soft tissue coverage. A 30-year-old female sustained a traumatic right upper extremity injury involving avulsion of the extensor tendons, median and ulnar nerves, and open radius and ulna fractures with overlying soft tissue loss. She underwent an ECS-LDF (250 cm²) with vascularized scapular bone for composite bony and soft tissue reconstruction. This series demonstrates the unique flexibility of the ECS-LDF in the reconstruction of complex defects due to its large skin paddle and freedom to independently orient the skin and muscle flaps. Furthermore, it results in a single donor with primary closure and a single microsurgical anastomosis. We believe the ECS-LDF is an excellent addition to the reconstructive microsurgeon's armamentarium.