The origin of the muscolocutaneous latissimus dorsi flap dates back to 1906 when Igino Tansini, an Italian surgeon, described a procedure to reconstruct the mastectomy defect. After a detailed study of Tansini's original description and drawings, new insights about the pedicle of its compound flap have been found, showing that it has the same pedicle of the scapular flap. In the end, Tansini's flap should be more correctly considered as a compound musculocutaneous scapular flap

Cigna E

Gerald Gl

Houseman N

Lombardi E

Parisi P

Ribuffo D

Scuderi N.

Seneviratne S

English

CIGNA, EMANUELE

Archivio della Ricerca - Università di Pisa

Abstract. – The origin of the muscolocuta-neous latissimus dorsi flap dates back to 1906when Igino Tansini, an Italian surgeon, de-scribed a procedure to reconstruct the mastec-tomy defect. After a detailed study of Tansini’soriginal description and drawings, new insightsabout the pedicle of its compound flap havebeen found, showing that it has the same pedi-cle of the scapular flap. In the end, Tansini’sflap should be more correctly considered as acompound musculocutaneous scapular flap.Key Words:Latissimus dorsi flap, Tansini flap, Breast reconstruc-tion, Breast surgery, Autologous breast reconstruction,Breast cancer, Scapular flap.IntroductionIn the 1970’s, surgeons from Germany andUSA claimed to discover the musculocutaneouslatissimus dorsi flap for breast reconstruction.However, in a beautiful paper, the renownedAmerican surgeon, Dr GP Maxwell, gave creditto Iginio Tansini, an eminent surgeon born in Mi-lan, Italy, in 1855 for the first original descriptionof this flap1. In the early 1980s, it was the firstpurely autogenous method of breast reconstruc-tion2 and in the 1990s it started to be used to filldefects following quadrantectomy or wide localexcision2.Iginio Tansini completed his medical trainingat the University of Pavia, an important Universi-ty in Northern Italy. His mentor was ProfessorEnrico Bottini, “…one of the most audacious andperfect surgeons of his time...” In 1882, Tansinibecame Chief Surgeon at the Greater Hospital inLodi, and then Professor of Surgery at the Uni-versities of Modena (1888), Palermo (1898), andfinally again at Pavia (1903), following the deathof Enrico Bottini. He is considered, with otherdistinguished surgeons like Sabattini, Sterzi,European Review for Medical and Pharmacological SciencesIginio Tansini revisitedD. RIBUFFO1, E. CIGNA1, G.L. GERALD1, N. HOUSEMAN2, S. SENEVIRATNE2,E. LOMBARDI3, P. PARISI1, N. SCUDERI11Department of Surgery “P. Valdoni”, Unit of Plastic Surgery, “Sapienza” University of Rome, Rome, Italy2Jack Brockhoff Reconstructive Plastic Surgery Research Unit, University of Melbourne, Melbourne,Australia3Private Practice, Taranto, ItalyCorresponding Author: Emanuele Cigna, MD; e-mail: emanuelecigna@msn.com 2477Pieri3, and more recently, Sanvenero Rosselli,one of the surgeons which improved and helpedthe development of plastic surgery in Italy4.Iginio Tansini was well aware of the impor-tance of anatomical dissections to surgeons. Inhis words: “...with exercises on cadavers we getthe most important concepts of surgical anatomy,which parallel and complete topographic anato-my. Dieffenbach was right when he said that thehistory of surgery is to the history of medicine,what the history of wars is to the history ofStates.In old war ferociousness and courage were es-sential to soldiers, but in modern war tactics dis-cipline is essential to power, so in modernsurgery the correct indication and science distin-guishes a great surgeon, and victory will be forthose who study and not just solely to those whoare audacious. Composure during surgery is theresult of knowledge.”5.As we know, Tansini’s surgical technique datesback to 1896, when he described his cutaneousflap harvested from the back, and used it to re-construct the wound after a mastectomy. In hisown words this flap was created: “…in order toachieve three goals: (1) to get a large flap for aquick repair; (2) to use thick and resistant skin,as far as possible from the breast region, and thatonly very rarely is involved in primary or sec-ondary recurrences; and (3) to avoid scarringand retraction in the axilla, as can happen afteran axillary lymphadenectomy, because very oftenwe see the scar adhering to the big vessels andnerves, limiting any arm movement, and some-times critically compressing the axillary vein…”.After experiencing regular necrosis of the distalthird of the skin flap, in association with the tran-section of vessels coming from the circumflexscapulae vessels, he described his musculocuta-neous flap in 1906, which avoided this complica-tion. While Tansini was proposing his musculo-2015; 19: 2477-2481Figure 1.Angiosomes of the latissimus dorsi.Figure 2. Cover of Tansini’s book collecting all his papers.Figure 3. Anatomical preparation of the muscles involvedin Tansini’s musculocutaneous flap of 1906. The dotted lineoutlines the borders of the flap. (1) Infraspinatus muscle, (2)Teres minor, (3) Teres major, (4) Latissimus dorsi.D. Ribuffo, E. Cigna, G.L. Gerald, N. Houseman, S. Seneviratne, E. Lombardi, P. Parisi, N. ScuderiNew FindingsThe latissimus dorsi musculocutaneous flap isan excellent source of well vascularized autolo-gous tissue for use in breast reconstruction with acomplication rate of around 9%11,12.cutaneous flap other surgeons during this timewere proposing a pedicled median transfer fromthe opposite breast to gain enough tissue for therequired reconstruction.Tansini’s technique had great clinical successuntil the 1930’s, but was later abandoned, proba-bly due to oncological issues. There are reportsthat this flap was used extensively throughoutItaly and Europe by: Campari from Lecco; Cig-nozzi from Grosseto; Crosti from Milan; D’Estefrom Treviglio; Ajello from Palermo; Uffreduzzifrom Turin; Thevenard from Paris; and Guibèfrom Caen, who was published in the PresseMedicale in 19151. Then in the 1970’s, Olivari,Schneider, Muhlbauer, and Bostwick rediscov-ered the Latissimus Dorsi musculocutaneousflap. They modified the design and technique andthen published papers that resulted in the popu-larity of this muscle flap as a highly successfulworkhorse flap for breast reconstruction fordecades to follow6-10.Nevertheless, it is still commonly thought thatTansini had some misconceptions about the vas-cularization of the latissimus dorsi flap. In GPMaxwell’s words: “…he was wrong only inthinking that the scapular circumflex artery wasmore important than the subscapular and thora-codorsal arteries in supplying the flap…”1.2478Figure 4. Anterior view. (1) Latissimus dorsi tendon, (2)Teres major, (3) Subscapular muscle, (4) Transected tendonof coracobrachialis muscle, (5) Pectoralis minor, (6) Serra-tus anterior muscle.Figure 5. Anatomical preparation of the subcutaneouslevel of the scapular region and of the cranial part of theinfrascapular region. The vessels shown actually constitutethe pedicle of the scapular and parascapular free flaps. InTansini’s own words, “…there are usually three vesselscoming off the circumflex scapulae (they might be two oreven one, but they are always there). They arise from thetriangular space, delimited by teres minor, teres major andthe long head of the triceps muscle, or might even comeover the superomedial margin of the teres minor or be-tween this muscle…”According to the classification of Mathes andNahai13, the latissimus dorsi muscle has a type Vblood supply, predominantly supplied by the tho-racodorsal artery, which is a continuation of thesubscapular artery that arises from the third por-tion of the axillary artery. Mathes and Nahai alsorecognized a segmental minor blood supply fromthe intercostal and lumbar arteries, which formedthe basis for the turnover back flap13.It has now been demonstrated that the latis-simus dorsi muscle has no less than six separateblood supplies or angiosomes: the transverse cer-vical – superficial branch; the transverse cervical– deep branch (also known as dorsal scapularartery – DSA); the posterior intercostal vessels;the suprascapular artery (SS); the occipitalartery; and of course, the thoracodorsal14 (Figures1 and 2).The circumflex scapular artery arises from thesubscapular artery, at approximately 3 or 4 cmfrom its origin at the axillary artery15. The arterypasses posteriorly through the triangular spacegiving off:1. The infrascapular branch, which enters thesubscapular fossa deep to the subscapularis.2. Three muscular branches to teres major, teresminor and latissimus dorsi.3. The descending branch, which goes back as itscontinuation and emerges posteriorly from thetriangular space, and divides into two cuta-neous branches, the cutaneous scapular andparascapular branches.4. Several small penetrating branches that supplythe lateral border of the scapula.The circumflex scapular artery supplies thelatissimus muscle via direct anastomoses withthe DSA and SS vessels. This vascular contribu-2479Iginio Tansini revisitedD. Ribuffo, E. Cigna, G.L. Gerald, N. Houseman, S. Seneviratne, E. Lombardi, P. Parisi, N. Scuderiture Nobel Prize recipient Camillo Golgi inPavia. He was then Professor of Anatomy at theUniversity of Ferrara, and finally in 1900 he re-turned to the world-renowned University ofPavia, as Professor of Anatomy.We can finally say, after a thorough re-exami-nation of Tansini’s published anatomical andclinical work that Tansini’s flap is not a latis-simus dorsi musculocutaneous flap, but morecorrectly, a compound musculocutaneous scapu-lar flap, and its blood supply was correctly quot-ed.–––––––––––––––––––AcknowledgementsAll authors declare no commercial associations or financialinterest that might pose or create a conflict with all informa-tion presented in the submitted manuscript.–––––––––––––––––-–––Conflict of InterestThe Authors declare that they have no conflict of interests.References1) MAXWELL GP. Iginio Tansini and the origin of thelatissimus dorsi musculocutaneous flap. Plast Re-constr Surg 1980; 65: 686-692.2) DIXON JM, VENIZELOS B, CHAN P. Latissimus dorsimini-flap: a technique for extending breast con-servation. Breast 2002; 11: 58-65.3) MICALI G, SCUDERI N, RIBUFFO D, TERRACINA FS. Thelegacy of Capt. Gino Pieri: a forgotten Italian con-tribution to the study of cutaneous blood supplyduring World War I. Plast Reconstr Surg 2003;112: 1066-1070.4) MICALI G. The Italian contribution to plasticsurgery. Ann Plast Surg 1993; 31: 566-571.5) TANSINI I, ED. Scritti medici. Italy, Milan: Wasser-man, 1935.6) OLIVARI N. The latissimus flap. Br J Plast Surg1976; 29: 126-128.7) SCHNEIDER WJ, HILL HL JR, BROWN RG. Latissimusdorsi myocutaneous flap for breast reconstruction.Br J Plast Surg 1977; 30: 277-281.8) MUHLBAUER W, OLBRISCH R. The latissimus dorsi my-ocutaneous flap for breast reconstruction. ChirPlast 1977; 4: 27.9) BOSTWICK J 3RD, VASCONEZ LO, JURKIEWICZ MJ. Breastreconstruction after a radical mastectomy. PlastReconstr Surg 1978; 61: 682-693.10) OLIVARI N. Use of thirty latissimus dorsi flaps. PlastReconstr Surg 1979; 64: 654-661.tion is well documented in old texts of anatomy,as in Testut’s “Topographic Anatomy”. It basi-cally involves the proximal third of themuscle16. Recently a case was published that de-scribed a latissimus dorsi flap that survivedbased on the lateral thoracic artery as both thethoracodorsal and serratus branch had been di-vided in previous surgery17. It is probably nothighlighted in modern textbooks because it is ofscarce importance in rotating flaps based on thelatissimus muscle.Based on the original book of Tansini’s pa-pers4 (Figure 3), published in 1935, at the timeof his retirement, we can now put new light in-to this old and fascinating topic, and requalifythe Tansini flap from an anatomical point ofview.As shown in Figures 4 to 5, Tansini actuallyproposes the harvest of a compound musculocu-taneous flap different from the classical latis-simus dorsi. In fact, he includes the infraspina-tus, a part of teres minor, the teres major, andonly the medial and most cranial part of thelatissimus dorsi muscle. The skin island, as wecan see, is much more cranial and medially lo-cated than the classic latissimus dorsi skin is-land. Tansini was well aware that his flap had adual blood supply, one for the skin and teresmuscles (coming off the circumflex scapulae),and one for the latissimus muscle (coming offthe subscapular artery via the thoracodorsalartery). In his own words, also quoted byMaxwell: “…by this method we not only pre-serve the flow of blood to the skin that stemsfrom the scapular circumflex, but also thatwhich arrives there by way of the latissimusdorsi muscle through the inferior scapulae (i.e.,the subscapular artery)…”Furthermore, it is utmostly interesting to no-tice which vessels he transected in his skin flap(1896), and then preserved in his musculocu-tanous flap ten years later (Figure 4). With ourcurrent knowledge, we can easily recognize theparascapular and scapular vessels, those thatsupply the parascapular and scapular free flaps.These vessels come from the circumflex scapularartery, after passing through the triangular space,which is delimited by the teres major, teres mi-nor, and the long head of the triceps muscle.Tansini highlights this, after several dissectionswith an eminent anatomist from Pavia, ProfessorSala, who graduated from Turin University andworked in Palermo between 1887 and 1889. In1890 Professor Sala became assistant to the fu-248011) SZYCHTA P, BUTTERWORTH M, DIXON M, KULKARNI D,STEWART K, RAINE C. Breast reconstruction with thedenervated latissimus dorsi musculocutaneousflap. Breast 2013; 22: 667-672.12) AGAOGLU G, EROL OO. Delayed breast reconstruc-tion with latissimus dorsi flap. Aesthetic PlastSurg 2009; 33: 413-420.13) MATHES SJ, NAHAI F, ED. Reconstructive surgery:principles, anatomy, & technique. New York:Churchill Livingstone; 1997.14) SENEVIRATNE S, DUONG C, TAYLOR GI. The angularbranch of the thoracodorsal artery and its bloodsupply to the inferior angle of the scapula: ananatomical study. Plast Reconstr Surg 1999; 104:85-88.15) STRAUCH B, YU, ED. Atlas of microvascular surgery.NewYork: Thieme Medical Publishers, 1993.16) TESTUT L, JACOB O, EDS. Anatomia topografica. Utet,1960.17) HARTMANN C, BRANDFORD O, MALHOTRA A, CHANA J.Survival of a pedicled latissimus dorsi flap inbreast reconstruction without a thoracodoral pedi-cle. J Plast Reconstr Aesthet Surg 2013; 66: 996-998.2481Iginio Tansini revisited

Iginio Tansini revisited

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Iginio Tansini revisited

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