The Thoracodorsal Perforator Flap: Clinical Experience and Anatomic Study with Emphasis on Harvest Techniques

Aldo Benjamin Guerra, M.D., Stephen Eric Metzinger, M.D., Kiersten Maria Lund, M.D., Michelle Maria Cooper, M.D., Robert Johnson Allen, M.D., and Charles Louis Dupin, M.D. New Orleans, La.

The thoracodorsal artery perforator flap is a relatively dorsi perforator-based flap.3,4 This nomencla- new flap that has yet to find its niche in reconstructive ture is confusing and incorrect. Because the surgery. At the authors’ institution it has been used for limb salvage, head and neck reconstruction, and trunk flap derives its blood supply from the perforat- reconstruction in cases related to trauma, burns, and ma- ing vessels that originate from the lateral or lignancy. The authors have found the flap to be advan- medial branch of the thoracodorsal artery, its tageous for cranial base reconstruction and for resurfac- proper name is the thoracodorsal artery perfo- ing the face and oral cavity. The flap has been used 5 successfully for reconstruction of traumatic upper and rator flap. The flap can be further classified as 6,7 lower extremity defects, and it can be used as a pedicled an indirect muscular perforator-type flap. flap or as a free tissue transfer. The perforating branches Like other perforator-based flaps, it can be of the thoracodorsal artery offer a robust blood supply to ϫ raised with maximal preservation of donor-site a skin–soft-tissue paddle of 10 to 12 cm 25 cm, overlying structures.1–4 Unlike perforator flaps from the the . The average pedicle length is 8,9 20 cm (range, 16 to 23 cm), which allows for a safe anas- buttocks and abdomen, which are bulky, this tomosis outside the zone of injury in traumatized extrem- flap provides a thin and pliable skin–soft-tissue ities; the flap can be made sensate by neurorrhaphy with paddle, which can be used to resurface shal- sensory branches of the intercostal nerves. Vascularized lower defects.3 Its pliability is advantageous, as bone can be transferred with this flap by taking advantage of the inherent vascular anatomy of the subscapular ar- it allows for greater manipulation and contour- tery. A total of 30 pedicled and free flap transfers were ing in reconstruction of complex structures. performed at the authors’ institution with an overall com- An anatomic study of the thoracodorsal ar- plication rate of 23 percent and an overall flap survival rate tery perforator flap focusing on bony and soft- of 97 percent. Major complications, such as vascular thrombosis, return to the operating room, fistula forma- tissue landmarks that aid the surgeon in dissec- tion, recurrence of tumor, and flap loss, occurred in 17 tion of this flap was performed. Our dissections percent of the patients. Despite these drawbacks, the au- focused on the topographical anatomy of the thors have found the thoracodorsal artery perforator flap latissimus dorsi muscle, the anatomy of the to be a safe and extremely versatile flap that offers signif- icant advantages in acute and delayed reconstruction main vascular tree, and the perforating vessels. cases. (Plast. Reconstr. Surg. 114: 32, 2004.) The study spotlights the lateral branch of the thoracodorsal artery, which is known to have the largest and most reliable perforating ves- Initially described in 1995,1 the thoracodor- sels. The arc of rotation of the flap was also sal artery perforator flap is based on at least demonstrated. one perforating vessel from the thoracodorsal Our clinical experience with the thoracodor- artery.2–4 It was originally called the latissimus sal artery perforator flap in reconstruction of dorsi musculocutaneous flap without muscle,1 traumatic and postoncologic defects at the and others refer to it as the thin latissimus same institution is described. The location of

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, and the Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center. Received for publication June 11, 2002; revised August 15, 2003. DOI: 10.1097/01.PRS.0000129071.03842.C5 32 Vol. 114, No. 1 / THORACODORSAL ARTERY PERFORATOR FLAP 33 defects has been variable and includes the oral continued into the axilla. Measurements of the cavity, mandible, anterior and lateral cranial perforators and arc of rotation were carried base, trunk, and upper and lower extremities. out. Our overall experience consists of 30 cases since 1992. Results Seventeen of 20 cadavers (85 percent) were ANATOMIC STUDY found to have at least one perforator from the lateral branch of the thoracodorsal artery, Methods and Materials which supplied the skin–soft-tissue paddle. The Twenty cadavers were dissected for this ana- first perforator was always the largest from this tomic study. A flap measuring 10 cm in width vessel system, measuring between 0.5 and 0.6 by 30 cm in length was diagrammed on each mm in diameter, originating 2 to 4 cm distal to cadaver and was centered over a point 8 cm the bifurcation of the thoracodorsal artery, and below the posterior axillary fold and 2 cm be- measuring 4 to 6 cm in length. Twelve cadavers hind the anterior border of the latissimus dorsi had a second perforator about 2 to 6 cm distal muscle. It included skin that draped 2 cm an- to the main perforating vessel. A third perfo- terior and 6 cm posterior to the anterior edge rator was found in only 10 cadavers. All perfo- of the muscle. Based on previous anatomic rating vessels were found within 8 cm of the studies, this flap would include perforators aris- vascular hilus. The perforators were observed ing from the lateral branch of the thoracodor- to penetrate the dorsal thoracic fascia and sal system.1,5,10 A second reference point was travel for a distance of 2 to 6 cm. The direction chosen 2 cm behind the anterior border of the was quite variable. Importantly, the average muscle and 4 cm below the tip of the scapula. distance from the to the hilus According to Heitmann et al.,5 this is the loca- was found to be 12 cm in length, making the tion of the thoracodorsal hilus where the vessel average total length of the pedicle 20 cm. bifurcates into the lateral and medial branches. A line of cleavage where the perforator ves- Skin incisions were opened from the axilla to sels ascend to the flap could be identified on the posterior-lateral torso, leaving the flap un- all 20 latissimus dorsi muscles. Perforating ves- dissected. The skin was elevated, thereby pre- sels from the lateral branch were found on a serving the underlying latissimus dorsi muscle. line that begins 2 cm posterior to the anterior This muscle is organized into large muscular border of the latissimus dorsi muscle and trav- bundles. It was noted that large perforating els along the muscle’s anterior long axis. Iden- vessels would rise to the skin between and not tification of the cleavage plane that carries the through the muscle bundles. In the cadaver, neurovascular structures is facilitated by early the muscle bundles are thin and appear wasted identification of the thoracodorsal nerve in the compared with the live specimen, making it distal portion of the latissimus dorsi muscle. easier to separate them. At the distal end of the The arc of rotation for the thoracodorsal thoracodorsal artery perforator flap, we identi- artery perforator was defined (Fig. 1, above, fied a cleavage plane between muscle bundles left). The flap offers an arc of 90 degrees clock- on the anterior-lateral portion of the latissimus wise and counterclockwise. The flap was trans- dorsi muscle, where the lateral branch of the posed onto the breast anterolateral and pos- thoracodorsal artery was recognized. terolateral chest wall (Fig. 1, above, right). This The inferior portion of the flap was elevated is not the extensive transposition seen with the first, and then the flap was approached from musculocutaneous flap, because the radius of medial and lateral directions. Dissection halted the thoracodorsal artery perforator arc is when a perforator was encountered. We ob- smaller. Rotation through 180 degrees clock- served perforating vessels capable of feeding wise to the head and neck was performed. The the flap ascending from the lateral branch of flap comfortably reaches the clavicle area (Fig. the thoracodorsal artery in this muscle cleav- 1, below, left). Arc of rotation to the is age plane. All perforators greater than 0.5 mm accomplished with counterclockwise rotation ascended to the skin–soft-tissue flap via separa- 90 degrees (Fig. 1, below, right). In addition, the tions between muscle bundles. Spreading the flap can be transposed easily to the axilla. With muscle apart allowed dissection below the more extensive dissection, some flaps reached main body of the latissimus dorsi muscle be- just beyond the elbow and the base of the neck. tween two large muscle bellies. Dissection was Further efforts to advance the flaps higher on 34 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2004

FIG.1.(Above, left) The arc of rotation for the thoracodorsal artery perforator flap. (Above, right) The thoracodorsal artery perforator flap offers an arc of 90 degrees clockwise and counterclockwise. The flap was transposed onto the breast anterolateral and posterolateral chest wall. This is not the extensive transposition seen with the musculocutaneous flap, because the radius of the thoracodorsal artery perforator arc is smaller. (Below, left) Rotation through 180 degrees clockwise to the head and neck was performed. The flap comfortably reaches the clavicle area. (Below, right) Arc of rotation to the arm is accomplished with counterclockwise rotation of 90 degrees. The flap covers the upper arm comfortably.

TABLE I the neck and distal elbow caused perforating Anatomy Studies of the Thoracodorsal Artery Perforating vessels to tear. Vessels Discussion First Second Third The reliability of the thoracodorsal artery Perforator Perforator Perforator perforator flap will depend on the presence Angrigiani et al.1 40/40 40/40 32/40 and size of the perforating vessels. Injection Van Landuyt et al.10 29/30 NA NA Heitmann et al.5 20/20 13/20 2/20 studies focussing on the vascular anatomy of This study 17/20 12/20 10/20 these vessels have been performed by other NA, not applicable. groups (Table I). Angrigiani et al.1 were able to find at least one perforating vessel capable of davers. This detailed study demonstrated the supplying the flap in their anatomic study of 40 presence of two or more perforating vessels per cadavers. His group used fresh cadavers with latissimus dorsi muscle. In accordance with our intravascular injection of colored latex, high- study, all the cutaneous perforators were lighting small vascular structures. A European within 8 cm of the hilus. Both the medial and study using similar methods found a reliable- lateral branches were observed to have perfo- size perforator in 29 of 30 cadaver dissections.10 rators greater than 0.5 mm, but the largest More recently, Heitmann et al.5 reported their vessels originated from the lateral branch of findings using injectable latex in 20 fresh ca- the thoracodorsal artery. In the same study, the Vol. 114, No. 1 / THORACODORSAL ARTERY PERFORATOR FLAP 35 lateral branch showed a 100 percent rate of muscle bundles and infrequently through the adequate perforators and averaged 1.8 perfo- bundles. Spinelli et al.11 described this row of rators per vessel examined.5 The cumulative perforating vessels located directly over the lat- results of these studies show that cutaneous eral branch of the thoracodorsal artery in six perforating vessels in close proximity to the fresh cadavers. Kim et al.12 observed similar hilus of the thoracodorsal artery are reliable in anatomy. This line is not imaginary, but occurs presence and size. as a cleft between muscle bundles that allows For our study, we did not have the advantage the underlying vessels to nourish the skin–soft- of using fresh cadavers, and this could have led tissue envelope. Moreover, the line appears to the lower number of vessels identified in our white because the lateral thoracodorsal pedicle dissections. Identification of the vascular struc- is accompanied by the thoracodorsal nerve, tures was important, but our focus was on ob- which was found in a superficial location rela- taining a greater understanding of the relation- tive to the vascular structures. We observed this ship between neurovascular pedicle and line in all 20 cadavers (100 percent). muscle topography as it relates to the harvest- The first effort to locate the perforators by ing of the flap. In addition, we wished to iden- using topographical landmarks was performed tify certain landmarks that may help with local- using the posterior axillary fold and the ante- ization of the perforators and flap elevation. rior border of the latissimus dorsi muscle. An- Furthermore, primary interest was placed on grigiani et al.1 first used these landmarks in the lateral branch of the thoracodorsal artery. their original description of the thoracodorsal We identified 17 of 20 cadavers (85 percent) artery perforator flap. In addition, as pointed with at least one perforator from the lateral 5 branch of the thoracodorsal artery capable of out by Heitmann et al., identification of the supplying the skin–soft-tissue paddle. In accor- hilus by using the anterior border of the latis- dance with other studies, the first perforator simus dorsi muscle and the lowest point of the was always the largest and most consistent. Sec- scapula is useful. Using this method placed us ond and third perforators were identified but within 2 cm or less of the actual hilus location were smaller and their presence was less con- in most cases. Identification of the line of cleav- sistent. Our failure to find more than 85 per- age adds a third topographic point. Using all cent of the perforators may have been derived three landmarks, we were able to triangulate from the lack of fresh cadavers or injectable on the location of the perforators. On the ca- materials for this study. Regardless, three other daver, transposition of the flap to the anterior studies using more sophisticated methods have chest wall, axilla, arm, and supraclavicular area demonstrated the consistency of the perforator was accomplished safely, establishing the arc of anatomy over the latissimus dorsi muscle. In rotation for this flap. addition, other investigators of the thoracodor- sal artery perforator flap have considered the CLINICAL SERIES perforator distribution over the entire latissi- mus dorsi muscle, while we focused only on the Patients and Materials lateral branch. According to Heitmann et al.,5 we would miss 44 percent of the perforators The medical records of 32 patients involved studying only the lateral branch of the thora- in this study were reviewed for demographic codorsal artery. The lateral branch has been information, operative time, operative tech- the nutrient source for the thoracodorsal ar- nique, blood loss, and complications. This tery perforator flap we have used at our insti- group included all thoracodorsal artery perfo- tution for the past 11 years, and it made sense rator flaps performed over an 11-year period, to direct attention to this important vessel. We from March of 1992 to March of 2003. Two have not attempted to raise a medial branch patients had the procedure aborted for lack of perforator-based flap. adequate perforators. Complications were di- The lateral branch was found descending vided into early and late. Early complications along a line at approximately 2.5 cm behind included vessel thrombosis, return to the oper- the anterior border of the latissimus dorsi mus- ating room, flap loss, early débridement, sero- cle edge. In order for this vessel to nourish the mas, and wound infections. Late complications skin, it must send perforators through the mus- included delayed wound healing, fat necrosis, cle. We found these vessels traveling between and unexpected revision surgery. 36 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2004 Results latissimus dorsi muscle and 4 cm inferior to the Thirty thoracodorsal artery perforator flap tip of the scapula is marked in an attempt to procedures were performed over an 11-year locate the hilus of the vessel. A point 8 cm period (Table II). Thirteen flaps were pedicled below the posterior axillary fold and centered and 17 were free tissue transfers. Twenty-nine 2 cm behind the anterior edge of the latissimus of 30 flaps survived. Major complications oc- dorsi muscle is mapped out with a hand-held curred in 17 percent of patients. One flap was Doppler (Koven, Inc., St. Louis, Mo.) device lost to arterial thrombosis. One venous throm- (Fig. 2). Surgery is performed with the patient bosis occurred, but the flap was salvaged. This in the lateral decubitus position under loupe salvaged flap experienced fat necrosis. Fat ne- magnification. The inferior portion of the flap crosis was seen in one pedicled breast flap and is raised first. The neurovascular bundle is in a free flap used to reconstruct a composite identified. Subsequently, the posterior-dorsal mandibular defect after a fistula developed re- edge of the flap is elevated. We begin dissec- quiring débridement. Both flaps survived. The tion above the dorsal thoracic fascia and de- same patient later developed recurrence of his scend below the fascia when we get within 2 cm primary tumor and subsequently died. Fewer of the perforating row of vessels. The surgeon complications were seen in the pedicled group. enters a bloodless plane, which facilitates dis- One donor-site wound-healing delay occurred section toward the anterior edge. Visualization and two donor scar revisions were performed. is maximized in this plane. Dissection should Only one flap was debulked with suction- be done carefully as one approaches the me- assisted lipectomy at a second stage. ridian of the flap, which is reached by dissect- ing parallel to the direction of the muscle bun- Operative Technique dles. Dissection continues by peeling the The patient is marked in the sitting position. perimysium off the muscle bundles until the An area 2 cm behind the anterior border of the perforator cleavage line is identified on the

TABLE II Thoracodorsal Artery Perforator Flaps at LSUHSC 1992–2003

Location Defect Etiology Outcome and Complications Pedicled TDAP flaps 1 Trunk Clavicle Gunshot blast Healed 2 Axilla Contracture Burn Healed 3 Axilla Contracture Burn Healed 4 Axilla Contracture Hydradenitis Healed 5 Axilla Hydradenitis Hydradenitis Skin graft donor site, revision 6 Axilla Hydradenitis Hydradenitis Healed 7 Breast Mastectomy Carcinoma Healed 8 Breast Mastectomy Carcinoma Fat necrosis 9 Breast Mastectomy Carcinoma Healed 10 Breast Mastectomy Carcinoma Healed 11 Breast Mastectomy Carcinoma Healed 12 Breast Mastectomy Carcinoma Healed 13 Breast Mastectomy Carcinoma Healed Free TDAP flaps 14 L. skull base Temporal Carcinoma Healed 15 L. skull base Temporal Carcinoma Healed 16 Orbital Exenteration Carcinoma Healed 17 Orbital Exenteration Carcinoma Healed 18 A. skull base Frontal MVA Healed 19 Maxilla Palate Carcinoma Healed 20 Maxilla Palate Carcinoma Fat necrosis 21 Mandible Multiple Carcinoma Fistula, partial flap necrosis, recurrent tumor 22 Elbow Dorsal MVA Healed 23 Forearm Volar Degloving Delayed site scar revision 25 Forearm Volar Degloving Healed 26 Leg Lateral Shotgun blast Arterial thrombosis, flap loss 27 Leg Medial Open tibia Venous thrombosis, flap salvage, fat necrosis 28 Leg Anterior Open tibia Healed 29 Leg Anterior Open tibia Healed 30 Foot Dorsal Degloving Healed LSUHSC, Louisiana State University Health Science Center; TDAP, thoracodorsal artery perforator; L., left; A., anterior; MVA, motor vehicle accident. Vol. 114, No. 1 / THORACODORSAL ARTERY PERFORATOR FLAP 37 cle. Dissection can usually proceed more rap- idly at this point and includes ligation of the major branches of the thoracodorsal and sub- scapular vessels until one reaches the axillary artery and vein.

CASE REPORTS Case 1 A 28-year-old man presented to our clinic 2 years after undergoing excision of hidradenitis suppurativa and skin grafting at the axilla. He developed a scar contracture that had been present for 13 months. He was unable to abduct the arm more than 85 degrees (Fig. 3, left). A thoracodorsal artery perforator flap was pedicled into the axillary defect after scar release, with restoration of joint motion (Fig. 3, right). The donor site required skin grafting for closure. Secondary scar revision was carried out 8 months later.

Case 2 A 39-year-old man was transferred to our service after several attempts at closure of an anterior skull defect over a FIG. 2. The patient is marked in the sitting position. An period of 18 months. Earlier he had sustained a crush injury area 2 cm behind the anterior border of the latissimus dorsi to the frontal sinus and anterior skull complicated by a sub- muscle and 4 cm inferior to the tip of the scapula is marked dural hematoma and skull flap infection. On presentation, in an attempt to locate the hilus of the vessel. A point 8 cm dural exposure was noted along with persistent deep bone below the posterior axillary fold and centered 2 cm behind infection (Fig. 4, above). The pedicle measured 23 cm, allow- the anterior edge of the latissimus dorsi muscle is mapped out ing an easier anastomosis (Fig. 4, center). Fourteen months with a hand-held Doppler device. after surgery, the patient had no evidence of recurrent in- fection and was fully healed (Fig. 4, below). muscle. This line appears white due to the presence of the lateral thoracodorsal nerve DISCUSSION and vascular bundle. The perforating vessels Perforator-based flaps have allowed surgeons will be found along this line as the dissection to provide vascularized tissue transfers while proceeds proximally. minimizing donor-site morbidity.13,14 The tho- Once a perforator vessel is visualized and racodorsal artery perforator flap allows for found to be adequate, the anterior-lateral edge preservation of the muscle unit and is advanta- of the flap can then be elevated in a similar geous for several reasons (Table III). Dissec- fashion toward the meridian. Dissection pro- tion through the muscle results in a much ceeds until all the perforators are identified. longer pedicle (Fig. 4, center). In traumatized The space between two large muscle bundles extremities, the long pedicle is advantageous, where the perforator vessels ascend toward the allowing for safe anastomosis outside the zone skin flap can be further dissected until the of injury. A flow-through vascular anastomosis underlying structures are identified. The tho- is an option with this flap.4 A lengthy pedicle is racodorsal nerve can be separated from the of great advantage in head and neck recon- vessels so that it can be preserved. The distal struction, as it allows for anastomosis to any end of the thoracodorsal vessels, close to the vessel in the neck without vein grafts. Postop- origin of the muscle, is ligated and dissected erative magnetic resonance imaging facilitates toward the axilla. cranial base oncologic follow-up, with T1- The most delicate part of the operation oc- weighted images demonstrating a distinct curs when the perforators are separated from plane between fat and any potential tumor the muscle as dissection descends toward the recurrence (Fig. 5). main pedicle. Care is used in order not to The sparing of innervated muscle minimizes damage the delicate venae comitantes that ac- functional loss in those who require trunk sta- company the perforating artery. Once the per- bilization or muscle use in the early postoper- forator is released, retractors are placed on the ative period. Thoracodorsal nerves were rou- proximal latissimus dorsi muscle to continue tinely spared in this series (Fig. 6). This dissection into and eventually under the mus- maintains the contour of the back unaltered. 38 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2004

FIG.3.(Left) A 28-year-old man with scar contracture of the axilla after failed reconstruction for hidradenitis suppurativa. (Right) At 3 months after surgery the patient had regained full use of the joint.

Muscle origins are left undisturbed, producing ble III). Multiple flaps have been raised from less pain and no dead space. Seroma forma- the subscapular system, including bone, mus- tion, a frequent complication of the latissimus cle, musculocutaneous, and osteocutaneous dorsi muscle flap,15,16 was avoided in our series flaps. This makes the subscapular territory one (Table III). Bulky muscle flaps frequently have of the most versatile in plastic surgery.20 The to be thinned out at a second stage, whereas thoracodorsal artery perforator flap is an ex- the thoracodorsal artery perforator is a thin tension of this vascular pedicle that minimizes flap that is good for resurfacing and can donor-site morbidity and can be safely com- achieve reconstruction of shallow defects in a bined with the above-mentioned tissues to cre- more elegant manner.3 We debulked only one ate a variety of composite flaps. flap at a second stage. Disadvantages with this flap have been en- The thoracodorsal artery perforator flap has countered (Table IV). Patient positioning and a reliable blood supply and can be made as dissection of the perforator can increase oper- large as 10 ϫ 25 cm.1,4,5,10 If one requires a flap ative time. The learning curve for this flap is larger than this, a different donor site should steep. Careful planning and patient markings be used. The thoracodorsal artery perforator’s are required in order not to place the flap arc of rotation allows for coverage of wounds outside the realm of adequate perforators, and on the anterior chest wall, clavicle, axilla, and this takes experience and skill. Early in our proximal arm. A small radius on the arc of series using Angrigiani et al.’s1 marking rotation limits the reach of the flap, although method, we failed to find vessels adequate to the arc itself is comparable to that of the latis- carry the flap for two cases. Marking the pa- simus dorsi musculocutaneous flap.17 Care tient while sitting and operating in the decub- should be taken not to exceed the reach of the itus position, with the arm elevated, shifts the flap, as this may lead to rupture of the delicate location and direction of the perforators, an perforating vessels and the flap failure that experience that other groups have shared.18 In other groups have experienced.18 Thicker flaps the first case, presurgical markings were made in obese patients provide excellent tissue bulk too low to include the major perforating vessel for breast reconstruction.19 Surgeons are al- from the lateral branch of the thoracodorsal ready familiar with the vasculature that nour- artery. In the second case, two small perfora- ishes the latissimus dorsi muscle. Large vessel tors were identified during the dissection of diameter is an advantage in microsurgery (Ta- the flap. These were judged to be inadequate Vol. 114, No. 1 / THORACODORSAL ARTERY PERFORATOR FLAP 39

TABLE III Advantages of the Thoracodorsal Artery Perforator Flap

Aesthetic Improved aesthetic appearance with intact muscle Musculature Preservation of function aids with rehabilitation Vasculature Possibility of flow-through anastomosis Anastomosis Reliable, wide diameter and vein Follow-up T1-weighted magnetic resonance images facilitate postoncologic follow-up Pedicle Average 20-cm pedicle (range, 16–23 cm); anastomosis out of zone of injury or radiation damage increases safety and patency Sensation Neurorrhaphy for sensation with intercostal nerves Seroma No dead space; incidence of seroma is zero

FIG. 5. Postoperative magnetic resonance imaging facili- tates cranial base oncologic follow-up, with T1-weighted im- ages demonstrating a distinct plane between fat and any potential tumor recurrence. for flap transfer. Since then, we have noted that these perforators experience prolonged vasospasm as they are dissected. Patience is needed to allow the vasospasm to resolve. In retrospect, these perforators would likely have performed well. These events early in our ex- perience were critical steps in the learning curve of this procedure. However, if the sur- geon encounters similar situations, he or she should keep in mind the multiple flaps that can be based on the subscapular artery, such as the scapular, parascapular, latissimus dorsi, FIG.4.(Above) A 39-year-old man with exposed dura and and flaps, to salvage deep bone infection of the frontal skull after multiple at- tempts at closure of the anterior skull defect over a period of the reconstruction. 18 months. (Center) The pedicle length of 23 cm is highly Our anatomic study was completed in an advantageous in head and neck and extremity reconstruc- effort to overcome these challenges. The addi- tion. (Below) Fourteen months after surgery, the patient is tion of a second topographic reference point without evidence of recurrent infection and is fully healed. has helped tremendously. This reference point suggests the location of the thoracodorsal hi- 40 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2004 are extremely variable.10 Schwabegger et al.18 stated that relying solely on ultrasound images of the vessels can lead to failure when planning for these flaps. Visual confirmation of the per- forators before finalizing the skin incisions is mandatory. However, use of topographic land- marks with identification of the line of cleavage in the muscle will help pinpoint where the perforating vessels are arising out of the mus- cle with accuracy, making expensive ultra- sound studies obsolete. Alternative donor sites, such as the antero- lateral thigh flap and radial forearm, can pro- vide tissue with similar characteristics that can be harvested in the supine position.22 These FIG. 6. The preservation of the thoracodorsal nerve is flaps have proven to be reliable and can be straightforward and can be accomplished while minimizing easier to dissect than the thoracodorsal artery functional loss. All 27 thoracodorsal nerves were spared in perforator flap.22 However, both of these flaps this series. suffer from having donor sites in areas of high TABLE IV visibility.23 In addition, tendon exposure can be Disadvantages of the Thoracodorsal Artery Perforator Flap problematic with the radial forearm flap donor site. Donor-site problems with the thoracodor- Size Limited to 10–12 cm ϫ 25–30 cm sal artery perforator flap can occur. Tight clo- Perforators Variability of perforators sure can be problematic with wide flaps.18 Experience Steep learning curve There is more tension on the skin at closure Positioning Requires lateral decubitus position for harvest because the latissimus dorsi muscle remains in Timing Because of positioning requirements may not place. This led to delayed healing in one of our be able to have two teams working at the patients. Widening scars led to revision surgery same time Neurorrhaphy Interposition nerve grafts frequently required in a second patient. However, the donor site remains well hidden in the posterior axillary fold. lus, a key landmark, as the first perforating vessel will be 2 to 4 cm from this location and all perforators are within an 8-cm radius of this CONCLUSIONS point.5 In addition, by elevating the inferior The thoracodorsal artery perforator flap is portion of the flap early and identifying the not a well-known flap. Recent publications line of cleavage in the muscle, the surgeon is have outlined the anatomy and experience able to use a third topographic landmark and with this flap, but these accounts are limited in thus can triangulate the location of the perfo- number. Over the past 11 years, we have ob- rators with reliability. Since the addition of tained a relatively large amount of experience multiple topographic landmarks, we have had using this flap as a free or pedicled transfer. We a 100 percent success rate in harvesting the have found the vascular anatomy of the perfo- thoracodorsal artery perforator flap. rator vessels to be dependable. The reliability Other groups have identified preoperative of the thoracodorsal artery perforator flap may Doppler studies as being helpful in planning have been tainted by the inconstant presence this flap.3,18 We do not believe preoperative of a direct cutaneous branch arising from the Doppler ultrasound modalities to be helpful. thoracodorsal artery and traveling anterior to Blondeel et al.21 found the sensitivity and pos- the muscle edge.24,25 This vessel is the basis for itive predictive value of unidirectional Doppler the thoracodorsal axillary flap described by Ca- flowmetry too low to be of any value in plan- banie et al.,24 but it is not a perforator because ning the thoracodorsal artery perforator flap. it does not travel through the latissimus dorsi This is due to the basic anatomy of the flap.1,5,10 muscle. The thoracodorsal artery perforator After the perforators penetrate the muscle, flap receives its blood supply from indirect they will likely travel on top of the fascia for 2 muscular perforators, has an arc of rotation to 6 cm, but the actual distance and direction similar to that of the latissimus dorsi musculo- Vol. 114, No. 1 / THORACODORSAL ARTERY PERFORATOR FLAP 41 cutaneous flap, and has proven to be very ver- thoracodorsal perforator-based cutaneous island flap. satile with a relatively low rate of complications. Ann. Plast. Surg. 44: 181, 2000. Aldo Benjamin Guerra, M.D. 13. Blondeel, P. N., Vanderstraeten, G. G., Monstrey, S. J., et al. The donor site morbidity of free DIEP flaps and Department of Surgery free TRAM flaps for breast reconstruction. Br. J. Plast. Division of Plastic and Reconstructive Surgery Surg. 53: 322, 1997. Louisiana State University Health Sciences Cent 14. Kroll, S. S., Sharma, S., Koutz, C., et al. Postoperative 1542 Tulane Avenue, Room 701 morphine requirement of free TRAM and DIEP flaps. New Orleans, La. 70112 Plast. Reconstr. Surg. 107: 338, 2001. 15. Schwabegger, A., Ninkovic, M., Brenner, F., and Anderl, REFERENCES H. Seroma as a common donor site morbidity after 1. Angrigiani, C., Grilli, D., and Siebert, J. W. Latissimus harvesting the latissimus dorsi flap: Observations on dorsi musculocutaneous flap without muscle. Plast. cause and prevention. Ann. Plast. Surg. 38: 594, 1997. Reconstr. Surg. 96: 1608, 1995. 16. Titley, O. G., Spyrou, G. E., and Fatah, M. F. Preventing 2. Khoobehi, K., Allen, R. J., and Montegut, W. J. Thora- seroma in the latissimus dorsi flap donor site. Br. J. codorsal artery perforator flap for reconstruction (Ab- Plast. Surg. 50: 106, 1997. stract). South. Med. J. 89 (Suppl.): S110, 1996. 17. Dinner, M. I., and Peters, C. R. The arc of rotation of 3. Kim, J. T., Koo, B. S., and Kim, S. K. The thin latissimus the latissimus dorsi myocutaneous flap. Ann. Plast. dorsi perforator-based free flap for resurfacing. Plast. Surg. 3: 425, 1979. Reconstr. Surg. 107: 374, 2001. 18. Schwabegger, A. H., Bodner, G., Ninkovic, M., and Piza- 4. Koshima, I., Saisho, H., Kawada, S., Hamanaka, T., Katzer, H. Thoracodorsal artery perforator (TAP) Umeda, N., and Moriguchi, T. Flow-through thin flap: Report of our experience and review of the lit- latissimus dorsi perforator flap for repair of soft-tissue erature. Br. J. Plast. Surg. 55: 390, 2002. defects in the legs. Plast. Reconstr. Surg. 103: 1483, 19. Allen, R. J. Perforator flaps in breast reconstruction. In 1999. S. L. Spear, J. W. Little, M. E. Lippman, and W. C. 5. Heitmann, C., Guerra, A., Metzinger, S. W., Levin, S. L., Woods (Eds.), Surgery of the Breast: Principles and Art. and Allen, R. J. The thoracodorsal artery perforator Philadelphia: Lippincott-Raven, 1998. flap: Anatomical basis and clinical application. Ann. 20. Germann, G., Bickert, B., Steinau, H. U., Wagner, H., and Plast. Surg. 51: 23, 2003. Sauerbier, M. Versatility and reliability of combined 6. Hallock, G. G. Direct and indirect perforator flaps: The flaps of the subscapular system. Plast. Reconstr. Surg. history and the controversy. Plast. Reconstr. Surg. 111: 103: 1386, 1999. 855, 2003. 21. Blondeel, P. N., Beyens, G., Verhaeghe, R., et al. Dopp- 7. Wei, F. C., Jain, V., Suominem, S., and Chen, H. C. Con- ler flowmetry in the planning of perforator flaps. Br. J. fusion among perforator flaps: What is a true perfo- Plast. Surg. 51: 202, 1998. rator flap? Plast. Reconstr. Surg. 107: 874, 2001. 22. Wei, F. C., Jain, V., Celik, N., Chen, H. C., Chuang, D. C., 8. Allen, R. J., and Treece, P. Deep inferior epigastric and Lin, C. H. Have we found the ideal soft-tissue perforator flap for breast reconstruction. Ann. Plast. flap? An experience with 672 anterolateral thigh flaps. Surg. 32: 32, 1994. 9. Allen, R., and Tucker, C., Jr. Superior gluteal artery Plast. Reconstr. Surg. 111: 2481, 2003. perforator free flap for breast reconstruction. Plast. 23. Kimata, Y., Uchiyama, K., Ebihara, S., et al. Anterolat- Reconstr. Surg. 95: 1207, 1995. eral thigh flap donor-site complications and morbid- 10. Van Landuyt, K. Experience with the thoracodorsal ar- ity. Plast. Reconstr. Surg. 106: 584, 2000. tery perforator (TAP) flap. Presented at the Second 24. Cabanie, H., Garbe, J., and Guimberteau, J. C. Anatom- International Course on Perforator Flaps, New Or- ical bases of the thoracodorsal axillary flap with re- leans, La., November 5-7, 1998. spect to its transfer by means of microvascular surgery. 11. Spinelli, H. M., Fink, J. A., and Muzaffar, A. R. The Anat. Clin. 2: 65, 1980. latissimus dorsi perforator-based fasciocutaneous flap. 25. Rowsell, A. R., Eisenberg, D. N., and Taylor, G. I. The Ann. Plast. Surg. 37: 500, 1996. anatomy of the subscapular-thoracodorsal arterial sys- 12. Kim, D. Y., Cho, S. Y., Kim, K. S. Lee, S. Y., and Cho, B. 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