The Thoracodorsal Artery 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 latissimus dorsi muscle. 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 axillary artery 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 arm 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.