Improving the Versatility of the Latissimus Dorsi Myocutaneous Flap Using a Simultaneously Pre-expanded Adjacent Flap for Primary Donor-Site Closure and Algorithm for Preoperative Decision-Making.

BACKGROUND: Harvesting a large latissimus dorsi myocutaneous flap (LDMF) is constrained by donor-site closure. When the skin paddle width exceeds 10 cm, direct closure is difficult. This report describes a novel technique using a simultaneously pre-expanded adjacent flap to achieve primary LDMF donor-site closure and reviews reported closure strategies. METHODS: Between 2011 and 2025, 16 patients underwent reconstruction with a pre-expanded LDMF combined with a simultaneously pre-expanded adjacent flap for donor-site closure. Demographic data, defect characteristics, flap dimensions, and outcomes were analyzed. Additionally, a literature review was conducted to evaluate LDMF donor-site closure strategies. RESULTS: The mean age of patients in this study was 14.5 (range 5-36) years. The etiologies associated with study inclusion included post-burn contracture, congenital melanocytic nevus, and hemangioma. Defect sizes ranged from 25 × 10 cm to 32 × 21 cm, and the pre-expanded LDMFs measured 25 × 12.5 cm to 35 × 23 cm. In all cases, the pre-expanded adjacent flap enabled tension-free primary LDMF donor-site closure. Complete flap survival was achieved in 15 patients, while one patient experienced distal LDMF necrosis. No donor-site complications were observed. A narrative review (51 studies, 512 LDMFs) demonstrated that selection of donor site closure method has depended on skin paddle width and recipient site characteristics, forming the basis of a literature-informed framework for preoperative planning. CONCLUSIONS: In selected patients requiring large LDMF harvest for staged defect reconstruction, simultaneous expansion of adjacent flap represents a feasible approach to achieve tension-free primary donor-site closure. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .