Original Article WSRM Special Topic Issue—Flaps
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Another Option of Perforator Flap in the Lateral Thoracic Area: Lateral Thoracic Perforator Flap Jeong Tae Kim, MD, PhD1
Sang Wha Kim, MD2
1 Department of Plastic and Reconstructive Surgery, College of
Medicine, Hanyang University, Seoul, Korea 2 Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
Address for correspondence Sang Wha Kim, MD, Department of Plastic and Reconstructive Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, Catholic University of Korea, 271 Chenbo-ro, Uijeongbu-si, Gyeonggi-do, 480-717, Korea (e-mail: [email protected]).
Abstract
Keywords
► free tissue flaps ► perforator flap ► thoracic arteries
Background The lateral thoracic donor site provides two types of perforator flap; the latissimus dorsi perforator flap based on the musculocutaneous perforator, and the thoracodorsal perforator flap based on the septocutaneous perforators from the thoracodorsal artery. In this article, we introduce a direct cutaneous perforator derived from the lateral thoracic artery, which provides another option for harvesting a perforator flap from the lateral thoracic region. Patients and Methods Overall 17 patients underwent reconstructions using the lateral thoracic perforator flap for defects resulting from tumor-ablative surgery in the head and neck region, chronic osteomyelitis, and trauma or chronic wounds of the lower extremities. Results All flaps survived without major complications and six of the flaps were harvested in a chimeric pattern. Conclusion When the latissimus dorsi and thoracodorsal perforator flaps are not suitable, the lateral thoracic perforator flap provides another option from the lateral thoracic region that is useful for a variety of reconstructions. However, anatomic variation and the shorter and smaller pedicle compared with the thoracodorsal vessels are drawbacks of the lateral thoracic perforator flap that make it difficult to approach. The combination of the versatility of the previous two perforator flaps based on the thoracodorsal system and this additional type of lateral thoracic perforator flap makes the lateral thoracic region a universal donor site.
Perforator flaps are popular in every field of reconstructive surgery, with their advantages of low donor-site morbidity, thinness, and pliability, which makes them suitable for reconstruction of the head and neck as well as the extremities.1–5 A perforator is defined as a terminal cutaneous vessel that penetrates a muscle to reach the skin, and true perforator flaps are based on such skin vessels.6 Only musculocutaneous perforators are considered true perforators, and flaps based on other types of perforator are not regarded as perforator flaps. However, owing to advances in microsurgical techniques and anatomic studies of perforator angiosomes, it is
widely accepted that the inclusion of septocutaneous and direct cutaneous perforators is useful for providing a variety of flap options in conventional donor regions. Previously the lateral thoracic donor site provided two options for perforator flaps; the latissimus dorsi perforator (LDp) flap based on the musculocutaneous perforator, and the thoracodorsal perforator (TDp) flap based on the septocutaneous perforators from the thoracodorsal artery.7–10 These perforator flaps have been used in many reconstructive fields and can even be harvested in a supine position, which make a two-team approach feasible during head and neck operations and lower extremity reconstructions.11–15
received October 21, 2013 accepted after revision December 15, 2013 published online July 10, 2014
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DOI http://dx.doi.org/ 10.1055/s-0034-1370358. ISSN 0743-684X.
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J Reconstr Microsurg 2014;30:443–450.
Lateral Thoracic Perforator Flap
Kim, Kim
Table 1 Patients’ list Case number
Gender
Age (y)
Diagnosis
Flap size (cm2)
Flap pattern
1
M
31
Recurrent squamous cell carcinoma, neck
20 12
Thin flap for resurfacing
2
M
60
Recurrent buccal cancer
65
For controlled resurfacing
3
M
53
Hypophalangeal cancer
86
Sensate flap
4
M
37
Chronic wound with osteomyelitis of the right leg
7 3, 4 2
Chimeric flap (þ skin flap for multiple resurfacing)
5
M
73
Esophalgeal cancer
96
Double pedicled flap
6
M
39
Crushing injury, left foot
13 10, 12 7
Chimeric flap (þ skin flap for multiple resurfacing)
7
F
51
Chronic ulcer, left leg
12 7
Thin flap for resurfacing
8 (Case 1)
M
56
Tonsillar squamous cell carcinoma, right
10 7, 9 8
Chimeric flap (þ skin flap for inner lining þ muscle flap for dead space)
9
M
57
Hypopharyngeal cancer
14 9, 3 2
Chimeric flap (þ skin monitoring flap)
10
M
59
Laryngeal cancer
86
Thin folded flap for hemilaryngeal reconstruction
11
F
54
Arteriovenous malformation, right heel
12 5
Sensate flap
12
F
56
Parotid cancer, left
16 10
For thin resurfacing
13
F
73
Chronic osteomyelitis, skin and soft tissue defect, left
12 8
Chimeric flap (þ adiposal flap for implantable monitoring)
14
M
42
Parotid cancer, right
17 10
Double pedicled flap (þ thoacodorsal)
15 (Case 2)
M
14
Venous malformation, upper lip and cheek
53
Thin flap for lip reconstruction & prevention of recurrence
16
M
65
Skin and soft tissue defect, right hand dorsum
14 8
Chimeric flap (þ adiposal flap for implantable monitoring)
17
M
13
Posttraumatic contracture, wrist & forearm, right
15 7
Thin flap for resurfacing & contracture release
Abbreviations: F, female; M, male; y, years.
In this article, we introduce a direct cutaneous perforator derived from the lateral thoracic artery, which provides another option for harvesting a perforator flap from the lateral thoracic region. With the versatility of the previous two perforator flaps based on the thoracodorsal system and the added option of the lateral thoracic perforator (LTp) flap, the lateral thoracic region could gain recognition as a universal donor site supplying three types of skin perforator flaps as well as muscle and bone flaps, together with various types of chimeric flap.
double-pedicled pattern for circumferential reconstruction of the esophagus and for resurfacing large areas. Patient data including gender, age, diagnosis, flap size, and flap patterns were reviewed retrospectively, and are summarized in ►Table 1.
Operation Technique (►Video 1)
Video 1
Patients and Methods We performed 17 reconstructive procedures with LTp flaps. In six cases, we used them for thin resurfacing or in a thin folding pattern. In six other cases, they were used along with other tissue components in a chimeric pattern. The LTp flaps were harvested with an intercostal nerve in a sensate pattern in two cases, and with supplementary perforators in a Journal of Reconstructive Microsurgery
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Harvesting a lateral thoracic perforator flap in the supine position in case 2. Online content including video sequences viewable at: www.thieme-connect.com/products/ejournals/html/ 10.1055/s-0034-1370358.
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Lateral Thoracic Perforator Flap
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Results Of the 17 patients who received lateral thoracic perforator flaps, 13 were male and 4 female and their mean age was 49 years (range, 13–73 years). The defects requiring reconstruction were caused by tumor-ablative surgery, chronic osteomyelitis, and trauma or chronic wounds of the lower extremities, etc. Flap dimensions ranged from 4 2 cm2 to 20 12 cm2 (►Table 1). No major complications such as flap failure or vascular compromise were found, and all the cases were uneventful during follow-up. There were no minor complications related to the flaps, such as hematomas, seromas, and infections apart from one patient who suffered mild wound dehiscence at the flap 2 weeks after the procedure, but this healed in response to conservative treatment. Another patient had hypertrophic scarring of the donor site wound. The mean follow-up period was approximately 11 months.
Case Reports Case 1 A 56-year-old male patient with squamous cell carcinoma of the right tonsil extending to the skin underwent wide resection of the tumor with radical neck dissection. The resulting defect required reconstruction with two components, one for the inner lining and the other for outer resurfacing. Thin flaps from the lateral thoracic region were planned. Two chimeric pattern flaps were designed preoperatively based on two perforators. After skin incision, reliable perforators were found at the anticipated positions. However, during dissection proximal to the main pedicle, the perforator was found to course to the lateral thoracic artery, which was the dominant artery of the lateral thoracic region in this patient. The flap was changed to the LTp flap, with a skin paddle of the same design. In addition, a muscular branch was encountered during dissection, and a small muscle flap of the pectoralis major was included as the third chimeric pattern component. The chimeric pattern flap was harvested with a 10 7 cm skin flap for the outer resurfacing, a 9 8 cm flap for the inner lining, and a small muscle flap for the dead space between pedicle and suction drain. The lateral thoracic artery and vein were anastomosed to facial vessels. Postoperative recovery was uneventful and the patient started radiation therapy and chemotherapy 3 weeks after surgery. There was no recurrence during a 13-month follow-up (►Fig. 1).
Case 2 A 14-year-old boy presented with a venous malformation on his upper lip and left cheek. Wide excision of the lesion was performed including the maxilla, alveolar bone, upper lip, and inner and outer soft tissue of the cheek area. A 5 3 cm thin perforator flap from the lateral thoracic area was designed for lip reconstruction. Although the skin incision was made in the right place and a reliable perforator was found at the expected location, the perforator was discovered during dissection to course aberrantly anteriorly to the lateral thoracic vessels. Since the venae comitantes of the lateral thoracic vessel was Journal of Reconstructive Microsurgery
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All these flaps were harvested with the patient in the supine position, with abduction of the arms. As surface landmarks, we marked the border of the pectoralis major and the anterior border of the latissimus dorsi (LD) muscle, which are the source boundaries of septocutaneous and direct cutaneous perforators in the lateral thoracic territory. A parallel incision was made over the midportion between the two borders of the muscles. After incision, both margins of the skin were pulled toward the surgeon with traction sutures to provide traction and countertraction and to avoid missing reliable perforators. Through the incision, the superficial and deep adipose layers were easily discriminated to search for reliable perforators. Even tiny perforators including pulsatile reliable perforators are well detected with the tractions and the most reliable one is selected under clean operative field with through bleeding control. Typically, several pulsatile perforators can be found around the anterior border of the LD muscle. Usually, reliable septocutaneous perforator(s) of the thoracodorsal artery or its branch is (are) encountered and the TDp flap is frequently selected. If this perforator is unsuitable or seem less reliable, the dissection proceeds posteriorly seeking the musculocutaneous perforators from the thoracodorsal artery that sprout from the LD muscle to obtain a LDp flap.7,9 When reliable perforators are not found, the dissection proceeds anteriorly as the last approach and the direct cutaneous perforator is faced to harvest a LTp.10 After identification of a reliable perforator, the dissection proceeds proximally to the main pedicle. Tiny branches are carefully ligated or cauterized by bipolar cautery. During the dissection vessel loops are recommended to use for safe traction, instead of grasping, which may cause perforator injury. Although reliable perforators show definite pulsation initially, their pulsations frequently disappear with spasm during the pedicle dissection. Therefore, the perforator pedicle should be frequently rinsed with vasodilator solution. Since venae comitantes of LTp is usually too small to match the recipient vein, the more reliable lateral thoracic vein is often included within the flap during the pedicle dissection. For a sensate flap, a lateral branch of the intercostal nerve is included, which is easily detected while searching for the reliable perforator. After dissection of the pedicle, the final flap design such as a freestyle or chimeric pattern can be considered based on reliable perforators and branches ready. An appropriate outline of the flap is finally made according to the size and the depth of the defect. The flap was then elevated from peripheral to proximal to the pedicle by controlling the thickness required. If thin flap is required, the flap can be thinned between the superficial and deep adipose layers using monopolar electrocautery, with the flap held under tension with two skin hooks and with care at the entrance of the perforator into the skin envelope. Anastomosis is completed using either 9–0 or 10–0 nylon sutures after the flap inset. Sometimes the branch of the pedicle is used for T-anastomosis to preserve the original flow in recipient artery.
Kim, Kim
Lateral Thoracic Perforator Flap
Kim, Kim
Fig. 1 (A) A 56-year-old male patient had squamous cell carcinoma of the right tonsil extending to the skin of the neck. (B) Two chimeric pattern flaps were elevated based on two reliable perforators that coursed to the lateral thoracic artery. A small pectoralis muscle flap was included as the third element in the chimeric pattern. (C) A chimeric pattern flap with a 10 7 cm flap for the outer surface, a 9 8 cm flap for the inner lining, and a small muscle flap were harvested based on the lateral thoracic perforator. The veins were anastomosed to facial vessels. (D) Postoperative view at 13-month follow-up.
too small, the lateral thoracic vein was included and a small portion of pectoralis major muscle was harvested together, to fill the dead space inside the cheek. The thin perforator flap was used for thin surfacing of the upper lip and inner lining of the buccal mucosa by folding it almost in half. Around 6 months after the surgery, the venous malformation had subsided without recurrence, and the patient was satisfied with the result (►Fig. 2 and ►Video1).
Discussion The axillary artery is divided into three parts by the pectoralis minor muscle.16,17 The second part gives rise to the thoracoacromial trunk and the lateral thoracic artery, while the third part produces the subscapular artery, and the posterior and anterior circumflex humeral arteries. The subscapular artery typically gives off two branches, the circumflex scapular and the thoracodorsal arteries (78.3%). Anteriorly, the thoracodorsal artery gives off septocutaneous perforators to the skin, before entering the LD muscle, either directly or via separate branches to the serratus anterior muscle. Then the thoracodorsal artery divides into transverse branches and branches descending deep into the LD muscle approximately 4 cm distal to the inferior scapular border and 2.5 cm medial to the lateral LD muscle border.16,18 These branches subseJournal of Reconstructive Microsurgery
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quently give rise to musculocutaneous perforators that penetrate the LD muscle. Hence, there are two options for perforator flaps from this region: a TDp flap, based on the septocutaneous perforators and a LDp flap, based on the musculocutaneous perforators, both from the thoracodorsal system.7,9,10,19 On the contrary, the lateral thoracic artery normally follows the lateral border of the pectoralis minor muscle to the thoracic wall and gives off a branch to the pectoralis major muscles, which supplies the lateral and lower part of the pectoralis major muscle and overlying skin. Then the lateral thoracic artery branches into a direct cutaneous vessel that supplies the skin over the lateral thoracic area. In females, the lateral thoracic artery is large and has lateral mammary branches to the mammary gland.20–23 The direct cutaneous perforators form the lateral thoracic artery provide the third perforator flap option, the so-called LTp in the lateral thoracic area between the two muscle borders of the pectoralis major and LD muscles.10 In our series, the LTp flap was not the flap of first choice.10 There are several situations however in which the LTp flap becomes the first option. While initially dissecting the septocutaneous perforator of the thoracodorsal artery, one may instead fortuitously meet a direct cutaneous perforator of the lateral thoracic artery. This may be the result of making the lateral thoracic incision too far forward. As numerous
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Kim, Kim
Fig. 2 (A) A 14-year-old male presented with a venous malformation on his upper lip and left cheek. (B) A 5 3 cm, thin lateral thoracic perforator flap was designed for upper lip reconstruction. (C) Six months after the surgery, the venous malformation had subsided without recurrence, and the patient was satisfied with the result. The flap covering the inner vermilion is well hidden in mouth closure. (D) Scar on donor site was located more anterior to the usual donor scar lines after the thoracodorsal or latissimus dorsi perforator flap.
pulsatile perforators can be found along the anterior border of the LD muscle, it is helpful to make the incision anterior to the anterior border of the LD muscle to have the option of a TDp flap based on the septocutaneous perforator, which can be elevated more rapidly than the LDp flap, which requires transmuscular pedicle dissection. A far anterior incision is frequently made to harvest a big flap, and as a result one encounters direct cutaneous perforators. The anterior border of the LD muscle and the lateral border of pectoralis major muscles can usually be detected on the surface anatomy or by grasping the muscle bulk. Lateral traction and abduction of the arm can be helpful to identify them in the operative field. However, when the LD muscle border is indistinct, in obese patients or in children, the incision can by mistake be made too far anteriorly and a reliable lateral thoracic perforator will be detected first. Another problem one may confront is the anatomical variation of the lateral thoracic region. Several types of anatomical variation of the vessels of the lateral thoracic region have been described. The thoracodorsal artery is always present, but it may be a branch of the lateral thoracic artery (7.2%). The lateral thoracic artery may originate from the subscapular artery (4.2%), or the subscapular artery may arise from the lateral thoracic artery (5.4%).17 Usually, the main supply of the lateral thoracic region is from the thoracodorsal arterial system. However, in a minority of cases, the lateral thoracic artery dominates with an extended vascular territory and supplies the lateral thoracic region with several reliable perforators.7 Another anatomic variation involves the course of the perforator pedicle, which can vary regardless of the vascular dominance or branching pattern of the main arteries. Even if
the incision is made in the right place and a reliable perforator is found at the anticipated location, which is located preoperatively with the help of an audible Doppler and an anatomical landmark, some perforators have an aberrant course. Even though they appear to be septocutaneous perforators from the thoracodorsal arterial system, they turn abruptly anteriorly as they are traced proximally and eventually arrive at the lateral thoracic artery. In most of our patients, the LTp flap was used as the last option; when no reliable perforators could be found, the dissection was modified anteriorly to seek the lateral thoracic artery perforators. Alternatively, a direct cutaneous perforator was often detected together with other reliable perforators, and the flap design could be modified during the operation itself, depending on the status of the recipient. This procedure represents a type of free-style flap harvest technique, in which the final design of the flap is in only decided during the operation depending on what reliable perforators are detected. Therefore, the final flap can be double-pedicled or chimeric depending on the perforator selected. The LTp flap has the same characteristics and indications as the LDp or TDp flap from the thoracodorsal arterial system. It is also versatile in terms of tissue composition, and can by itself provide a chimeric flap or be combined with another perforator flap from the lateral thoracic region. Also, the LTp flap can be cut as thin as 5 to 7 mm in thickness by separating the superficial and deep adipose layers, since the skin of the anterior chest wall is thinner than that of the lateral thoracic region. Moreover, such a thin flap can be folded, which is useful for reconstructing the vocal cords and a hemilarynx. In addition, a sensate flap can always be obtained by incorporating the intercostal nerve. Journal of Reconstructive Microsurgery
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Lateral Thoracic Perforator Flap
Lateral Thoracic Perforator Flap
Kim, Kim
However, there are limitations to the LTp flap that precludes it from being the flap of choice. The course of the lateral thoracic artery is not as constant as that of the thoracodorsal artery.20,24,25 Taylor and Daniel reported that the lateral thoracic artery could not be identified in 3 of their 20 cadaver dissections,24 and another report noted that the artery was absent in 2 of 11 clinical cases.20 The lateral thoracic pedicle is also shorter and smaller than the thoracodorsal vessels. A reliable direct cutaneous perforator from the lateral thoracic artery can be 1 mm or less in diameter. Therefore, the lateral thoracic artery should be harvested more proximally to obtain sufficient pedicle length and diameter to match those of the recipient vessels. T-anastomosis or end-to-side anastomosis is occasionally required, which is technically demanding even to a skillful microsurgeon.26,27 Because of the short pedicle length, eccentric placement of the perforator pedicle by designing the flap more distally also helps to increase the pedicle length. As the perforator pedicle is positioned more anteriorly, the flap is usually designed further forward than flaps from the thoracodorsal arterial system; as a result, the donor site scar tends to spread beyond the anterior axillary fold, in contrast to the well-hidden scar in the lateral thoracic region if the flap is raised in the thoracodorsal system.28–30 Another drawback of the LTp is the very small venae comitantes, which are usually too small to match the recipient vein. Therefore, another vein, the lateral thoracic vein, is frequently harvested with the flap, but the reliable lateral thoracic vein may follow a separate course from the perforator pedicle. As the lateral thoracic artery is usually located in front of the lateral thoracic vein, dissection along the lateral thoracic pedicle may miss the vein. Thus, this vein should be kept in mind and included within the flap during pedicle dissection. Pedicle dissection is usually difficult because the lateral thoracic pedicle has a tortuous course and is embedded in a thick adipose layer. Moreover, the dissection proceeds anteriorly, underneath the flap, while the flap is lifted up, and this dissection procedure is more inconvenient for the surgeon than with the flaps from the thoracodorsal system. On the contrary, there is no bothersome intramuscular dissection or perforator injury during intramuscular dissection due to the characteristics of the direct cutaneous perforator. Hence, the LTp flap has both advantages and pitfalls.
Funding This work was supported by the research fund of Hanyang University (HY-2013-G).
Note This article is a renewal of the article “Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region” published in J Plast Reconstr Aesthet Surg (2011;64:(1)596–602); the article has been revised with additional follow-ups. The content of this article was also presented in the panel on “Flaps, flaps, flaps: Fifteen new flaps” at the World Society for Reconstructive Microsurgery meeting, July 12 to 14, 2013 in Chicago.
Financial Disclosure The authors have no financial interests in the products, devices, or drugs mentioned in this article.
References 1 Kim CY, Naidu S, Kim YH. Supermicrosurgery in peroneal and
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Conclusion
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Although the LTp flap is another option in the lateral thoracic region, and is suitable for a variety of reconstructions, issues such as the variable anatomy of the pedicle and the anterior location of donor site scar have to be addressed. Therefore, while this flap can be useful, perforator flaps from the thoracodorsal system should be considered the primary safe and reliable option. However, because of the versatility of the two established perforator flaps based on the thoracodorsal system and with the added option of the LTp flap, the lateral thoracic region could become a universal donor site that offers several opportunities for perforator flap harvesting.
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soleus perforator-based free flap coverage of foot defects caused by occlusive vascular diseases. Plast Reconstr Surg 2010;126(2): 499–507 Yang WG, Chiang YC, Wei FC, Feng GM, Chen KT. Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing. Plast Reconstr Surg 2006;117(3):1004–1008 Kim JT, Kim SK. Hand resurfacing with the superthin latissimus dorsi perforator-based free flap. Plast Reconstr Surg 2003;111(1): 366–370 Agostini T, Russo GL, Zhang YX, Spinelli G, Lazzeri D. Adipofascial anterolateral thigh flap safety: applications and complications. Arch Plast Surg 2013;40(2):91–96 Lazzeri D, Huemer GM, Nicoli F, et al. Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: a systematic review. Arch Plast Surg 2013;40(1): 44–50 Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator flaps: what is a true perforator flap? Plast Reconstr Surg 2001; 107(3):874–876 Kim JT. Latissimus dorsi perforator flap. Clin Plast Surg 2003; 30(3):403–431 Kim JT. New nomenclature concept of perforator flap. Br J Plast Surg 2005;58(4):431–440 Kim JT. Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps. Plast Reconstr Surg 2005;115(3):755–763 Kim JT, Ng SW, Naidu S, Kim JD, Kim YH. Lateral thoracic perforator flap: additional perforator flap option from the lateral thoracic region. J Plast Reconstr Aesthet Surg 2011;64(12): 1596–1602 Kim JT, Ng SW, Kim YH. Application of various compositions of thoracodorsal perforator flap for craniofacial contour deformities. J Plast Reconstr Aesthet Surg 2011;64(7):902–910 Kim CY, Kim YH. Supermicrosurgical reconstruction of large defects on ischemic extremities using supercharging techniques on latissimus dorsi perforator flaps. Plast Reconstr Surg 2012; 130(1):135–144
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13 Kim SW, Hwang KT, Kim JD, Kim YH. Reconstruction of post-
22 Teo WL, Ong YS, Tan BK. Radical surgical excision and use of lateral
infected scalp defects using latissimus dorsi perforator and myocutaneous free flaps. J Craniofac Surg 2012;23(6): 1615–1619 Kim SW, Han SC, Hwang KT, Ahn BK, Kim JT, Kim YH. Reconstruction of infected abdominal wall defects using latissimus dorsi free flap. ANZ J Surg 2013;83(12):948–953 Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg 2013;40(5):575–583 Schaverien M, Wong C, Bailey S, Saint-Cyr M. Thoracodorsal artery perforator flap and Latissimus dorsi myocutaneous flap—anatomical study of the constant skin paddle perforator locations. J Plast Reconstr Aesthet Surg 2010;63(12):2123–2127 Olinger A, Benninger B. Branching patterns of the lateral thoracic, subscapular, and posterior circumflex humeral arteries and their relationship to the posterior cord of the brachial plexus. Clin Anat 2010;23(4):407–412 Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap: anatomic basis and clinical application. Ann Plast Surg 2003;51(1):23–29 Kim JG, Lee SH. Comparison of the multidetector-row computed tomographic angiography axial and coronal planes’ usefulness for detecting thoracodorsal artery perforators. Arch Plast Surg 2012; 39(4):354–359 Harii K, Torii S, Sekiguchi J. The free lateral thoracic flap. Plast Reconstr Surg 1978;62(2):212–222 Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30(3):331–342, v
thoracic flap for intractable axillary hidradenitis suppurativa. Arch Plast Surg 2012;39(6):663–666 Yang JD, Ryu DW, Lee JW, et al. Usefulness of a lateral thoracodorsal flap after breast conserving surgery in laterally located breast cancer. Arch Plast Surg 2013;40(4):367–373 Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56(3):243–253 Bhattacharya S, Bhagia SP, Bhatnagar SK, Aabdi SM, Chandra R. The anatomical basis of the lateral thoracic flap. Eur J Plast Surg 1990; 13:238–240 Komatsu S, Yamada K, Yamashita S, et al. Evaluation of the microvascular research center training program for assessing microsurgical skills in trainee surgeons. Arch Plast Surg 2013; 40(3):214–219 Leung CC, Ghanem AM, Tos P, Ionac M, Froschauer S, Myers SR. Towards a global understanding and standardisation of education and training in microsurgery. Arch Plast Surg 2013;40(4):304–311 Goon P, Man CB, Dickson M. Seroma reduction: using barbed sutures (v-loc) to close latissimus dorsi donor sites. Arch Plast Surg 2013;40(6):787–788 Shin IS, Lee DW, Lew DH. Efficacy of quilting sutures and fibrin sealant together for prevention of seroma in extended latissimus dorsi flap donor sites. Arch Plast Surg 2012;39(5):509–513 Cha HG, Kang SG, Shin HS, Kang MS, Nam SM. Does fibrin sealant reduce seroma after immediate breast reconstruction utilizing a latissimus dorsi myocutaneous flap? Arch Plast Surg 2012;39(5): 504–508
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Lateral Thoracic Perforator Flap
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Another Option of Perforator Flap in the Lateral Thoracic Area: Lateral Thoracic Perforator Flap Jeong Tae Kim, MD, PhD1
Sang Wha Kim, MD2
1 Department of Plastic and Reconstructive Surgery, College of
Medicine, Hanyang University, Seoul, Korea 2 Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
Address for correspondence Sang Wha Kim, MD, Department of Plastic and Reconstructive Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, Catholic University of Korea, 271 Chenbo-ro, Uijeongbu-si, Gyeonggi-do, 480-717, Korea (e-mail: [email protected]).
Abstract
Keywords
► free tissue flaps ► perforator flap ► thoracic arteries
Background The lateral thoracic donor site provides two types of perforator flap; the latissimus dorsi perforator flap based on the musculocutaneous perforator, and the thoracodorsal perforator flap based on the septocutaneous perforators from the thoracodorsal artery. In this article, we introduce a direct cutaneous perforator derived from the lateral thoracic artery, which provides another option for harvesting a perforator flap from the lateral thoracic region. Patients and Methods Overall 17 patients underwent reconstructions using the lateral thoracic perforator flap for defects resulting from tumor-ablative surgery in the head and neck region, chronic osteomyelitis, and trauma or chronic wounds of the lower extremities. Results All flaps survived without major complications and six of the flaps were harvested in a chimeric pattern. Conclusion When the latissimus dorsi and thoracodorsal perforator flaps are not suitable, the lateral thoracic perforator flap provides another option from the lateral thoracic region that is useful for a variety of reconstructions. However, anatomic variation and the shorter and smaller pedicle compared with the thoracodorsal vessels are drawbacks of the lateral thoracic perforator flap that make it difficult to approach. The combination of the versatility of the previous two perforator flaps based on the thoracodorsal system and this additional type of lateral thoracic perforator flap makes the lateral thoracic region a universal donor site.
Perforator flaps are popular in every field of reconstructive surgery, with their advantages of low donor-site morbidity, thinness, and pliability, which makes them suitable for reconstruction of the head and neck as well as the extremities.1–5 A perforator is defined as a terminal cutaneous vessel that penetrates a muscle to reach the skin, and true perforator flaps are based on such skin vessels.6 Only musculocutaneous perforators are considered true perforators, and flaps based on other types of perforator are not regarded as perforator flaps. However, owing to advances in microsurgical techniques and anatomic studies of perforator angiosomes, it is
widely accepted that the inclusion of septocutaneous and direct cutaneous perforators is useful for providing a variety of flap options in conventional donor regions. Previously the lateral thoracic donor site provided two options for perforator flaps; the latissimus dorsi perforator (LDp) flap based on the musculocutaneous perforator, and the thoracodorsal perforator (TDp) flap based on the septocutaneous perforators from the thoracodorsal artery.7–10 These perforator flaps have been used in many reconstructive fields and can even be harvested in a supine position, which make a two-team approach feasible during head and neck operations and lower extremity reconstructions.11–15
received October 21, 2013 accepted after revision December 15, 2013 published online July 10, 2014
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DOI http://dx.doi.org/ 10.1055/s-0034-1370358. ISSN 0743-684X.
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J Reconstr Microsurg 2014;30:443–450.
Lateral Thoracic Perforator Flap
Kim, Kim
Table 1 Patients’ list Case number
Gender
Age (y)
Diagnosis
Flap size (cm2)
Flap pattern
1
M
31
Recurrent squamous cell carcinoma, neck
20 12
Thin flap for resurfacing
2
M
60
Recurrent buccal cancer
65
For controlled resurfacing
3
M
53
Hypophalangeal cancer
86
Sensate flap
4
M
37
Chronic wound with osteomyelitis of the right leg
7 3, 4 2
Chimeric flap (þ skin flap for multiple resurfacing)
5
M
73
Esophalgeal cancer
96
Double pedicled flap
6
M
39
Crushing injury, left foot
13 10, 12 7
Chimeric flap (þ skin flap for multiple resurfacing)
7
F
51
Chronic ulcer, left leg
12 7
Thin flap for resurfacing
8 (Case 1)
M
56
Tonsillar squamous cell carcinoma, right
10 7, 9 8
Chimeric flap (þ skin flap for inner lining þ muscle flap for dead space)
9
M
57
Hypopharyngeal cancer
14 9, 3 2
Chimeric flap (þ skin monitoring flap)
10
M
59
Laryngeal cancer
86
Thin folded flap for hemilaryngeal reconstruction
11
F
54
Arteriovenous malformation, right heel
12 5
Sensate flap
12
F
56
Parotid cancer, left
16 10
For thin resurfacing
13
F
73
Chronic osteomyelitis, skin and soft tissue defect, left
12 8
Chimeric flap (þ adiposal flap for implantable monitoring)
14
M
42
Parotid cancer, right
17 10
Double pedicled flap (þ thoacodorsal)
15 (Case 2)
M
14
Venous malformation, upper lip and cheek
53
Thin flap for lip reconstruction & prevention of recurrence
16
M
65
Skin and soft tissue defect, right hand dorsum
14 8
Chimeric flap (þ adiposal flap for implantable monitoring)
17
M
13
Posttraumatic contracture, wrist & forearm, right
15 7
Thin flap for resurfacing & contracture release
Abbreviations: F, female; M, male; y, years.
In this article, we introduce a direct cutaneous perforator derived from the lateral thoracic artery, which provides another option for harvesting a perforator flap from the lateral thoracic region. With the versatility of the previous two perforator flaps based on the thoracodorsal system and the added option of the lateral thoracic perforator (LTp) flap, the lateral thoracic region could gain recognition as a universal donor site supplying three types of skin perforator flaps as well as muscle and bone flaps, together with various types of chimeric flap.
double-pedicled pattern for circumferential reconstruction of the esophagus and for resurfacing large areas. Patient data including gender, age, diagnosis, flap size, and flap patterns were reviewed retrospectively, and are summarized in ►Table 1.
Operation Technique (►Video 1)
Video 1
Patients and Methods We performed 17 reconstructive procedures with LTp flaps. In six cases, we used them for thin resurfacing or in a thin folding pattern. In six other cases, they were used along with other tissue components in a chimeric pattern. The LTp flaps were harvested with an intercostal nerve in a sensate pattern in two cases, and with supplementary perforators in a Journal of Reconstructive Microsurgery
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Harvesting a lateral thoracic perforator flap in the supine position in case 2. Online content including video sequences viewable at: www.thieme-connect.com/products/ejournals/html/ 10.1055/s-0034-1370358.
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Results Of the 17 patients who received lateral thoracic perforator flaps, 13 were male and 4 female and their mean age was 49 years (range, 13–73 years). The defects requiring reconstruction were caused by tumor-ablative surgery, chronic osteomyelitis, and trauma or chronic wounds of the lower extremities, etc. Flap dimensions ranged from 4 2 cm2 to 20 12 cm2 (►Table 1). No major complications such as flap failure or vascular compromise were found, and all the cases were uneventful during follow-up. There were no minor complications related to the flaps, such as hematomas, seromas, and infections apart from one patient who suffered mild wound dehiscence at the flap 2 weeks after the procedure, but this healed in response to conservative treatment. Another patient had hypertrophic scarring of the donor site wound. The mean follow-up period was approximately 11 months.
Case Reports Case 1 A 56-year-old male patient with squamous cell carcinoma of the right tonsil extending to the skin underwent wide resection of the tumor with radical neck dissection. The resulting defect required reconstruction with two components, one for the inner lining and the other for outer resurfacing. Thin flaps from the lateral thoracic region were planned. Two chimeric pattern flaps were designed preoperatively based on two perforators. After skin incision, reliable perforators were found at the anticipated positions. However, during dissection proximal to the main pedicle, the perforator was found to course to the lateral thoracic artery, which was the dominant artery of the lateral thoracic region in this patient. The flap was changed to the LTp flap, with a skin paddle of the same design. In addition, a muscular branch was encountered during dissection, and a small muscle flap of the pectoralis major was included as the third chimeric pattern component. The chimeric pattern flap was harvested with a 10 7 cm skin flap for the outer resurfacing, a 9 8 cm flap for the inner lining, and a small muscle flap for the dead space between pedicle and suction drain. The lateral thoracic artery and vein were anastomosed to facial vessels. Postoperative recovery was uneventful and the patient started radiation therapy and chemotherapy 3 weeks after surgery. There was no recurrence during a 13-month follow-up (►Fig. 1).
Case 2 A 14-year-old boy presented with a venous malformation on his upper lip and left cheek. Wide excision of the lesion was performed including the maxilla, alveolar bone, upper lip, and inner and outer soft tissue of the cheek area. A 5 3 cm thin perforator flap from the lateral thoracic area was designed for lip reconstruction. Although the skin incision was made in the right place and a reliable perforator was found at the expected location, the perforator was discovered during dissection to course aberrantly anteriorly to the lateral thoracic vessels. Since the venae comitantes of the lateral thoracic vessel was Journal of Reconstructive Microsurgery
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All these flaps were harvested with the patient in the supine position, with abduction of the arms. As surface landmarks, we marked the border of the pectoralis major and the anterior border of the latissimus dorsi (LD) muscle, which are the source boundaries of septocutaneous and direct cutaneous perforators in the lateral thoracic territory. A parallel incision was made over the midportion between the two borders of the muscles. After incision, both margins of the skin were pulled toward the surgeon with traction sutures to provide traction and countertraction and to avoid missing reliable perforators. Through the incision, the superficial and deep adipose layers were easily discriminated to search for reliable perforators. Even tiny perforators including pulsatile reliable perforators are well detected with the tractions and the most reliable one is selected under clean operative field with through bleeding control. Typically, several pulsatile perforators can be found around the anterior border of the LD muscle. Usually, reliable septocutaneous perforator(s) of the thoracodorsal artery or its branch is (are) encountered and the TDp flap is frequently selected. If this perforator is unsuitable or seem less reliable, the dissection proceeds posteriorly seeking the musculocutaneous perforators from the thoracodorsal artery that sprout from the LD muscle to obtain a LDp flap.7,9 When reliable perforators are not found, the dissection proceeds anteriorly as the last approach and the direct cutaneous perforator is faced to harvest a LTp.10 After identification of a reliable perforator, the dissection proceeds proximally to the main pedicle. Tiny branches are carefully ligated or cauterized by bipolar cautery. During the dissection vessel loops are recommended to use for safe traction, instead of grasping, which may cause perforator injury. Although reliable perforators show definite pulsation initially, their pulsations frequently disappear with spasm during the pedicle dissection. Therefore, the perforator pedicle should be frequently rinsed with vasodilator solution. Since venae comitantes of LTp is usually too small to match the recipient vein, the more reliable lateral thoracic vein is often included within the flap during the pedicle dissection. For a sensate flap, a lateral branch of the intercostal nerve is included, which is easily detected while searching for the reliable perforator. After dissection of the pedicle, the final flap design such as a freestyle or chimeric pattern can be considered based on reliable perforators and branches ready. An appropriate outline of the flap is finally made according to the size and the depth of the defect. The flap was then elevated from peripheral to proximal to the pedicle by controlling the thickness required. If thin flap is required, the flap can be thinned between the superficial and deep adipose layers using monopolar electrocautery, with the flap held under tension with two skin hooks and with care at the entrance of the perforator into the skin envelope. Anastomosis is completed using either 9–0 or 10–0 nylon sutures after the flap inset. Sometimes the branch of the pedicle is used for T-anastomosis to preserve the original flow in recipient artery.
Kim, Kim
Lateral Thoracic Perforator Flap
Kim, Kim
Fig. 1 (A) A 56-year-old male patient had squamous cell carcinoma of the right tonsil extending to the skin of the neck. (B) Two chimeric pattern flaps were elevated based on two reliable perforators that coursed to the lateral thoracic artery. A small pectoralis muscle flap was included as the third element in the chimeric pattern. (C) A chimeric pattern flap with a 10 7 cm flap for the outer surface, a 9 8 cm flap for the inner lining, and a small muscle flap were harvested based on the lateral thoracic perforator. The veins were anastomosed to facial vessels. (D) Postoperative view at 13-month follow-up.
too small, the lateral thoracic vein was included and a small portion of pectoralis major muscle was harvested together, to fill the dead space inside the cheek. The thin perforator flap was used for thin surfacing of the upper lip and inner lining of the buccal mucosa by folding it almost in half. Around 6 months after the surgery, the venous malformation had subsided without recurrence, and the patient was satisfied with the result (►Fig. 2 and ►Video1).
Discussion The axillary artery is divided into three parts by the pectoralis minor muscle.16,17 The second part gives rise to the thoracoacromial trunk and the lateral thoracic artery, while the third part produces the subscapular artery, and the posterior and anterior circumflex humeral arteries. The subscapular artery typically gives off two branches, the circumflex scapular and the thoracodorsal arteries (78.3%). Anteriorly, the thoracodorsal artery gives off septocutaneous perforators to the skin, before entering the LD muscle, either directly or via separate branches to the serratus anterior muscle. Then the thoracodorsal artery divides into transverse branches and branches descending deep into the LD muscle approximately 4 cm distal to the inferior scapular border and 2.5 cm medial to the lateral LD muscle border.16,18 These branches subseJournal of Reconstructive Microsurgery
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quently give rise to musculocutaneous perforators that penetrate the LD muscle. Hence, there are two options for perforator flaps from this region: a TDp flap, based on the septocutaneous perforators and a LDp flap, based on the musculocutaneous perforators, both from the thoracodorsal system.7,9,10,19 On the contrary, the lateral thoracic artery normally follows the lateral border of the pectoralis minor muscle to the thoracic wall and gives off a branch to the pectoralis major muscles, which supplies the lateral and lower part of the pectoralis major muscle and overlying skin. Then the lateral thoracic artery branches into a direct cutaneous vessel that supplies the skin over the lateral thoracic area. In females, the lateral thoracic artery is large and has lateral mammary branches to the mammary gland.20–23 The direct cutaneous perforators form the lateral thoracic artery provide the third perforator flap option, the so-called LTp in the lateral thoracic area between the two muscle borders of the pectoralis major and LD muscles.10 In our series, the LTp flap was not the flap of first choice.10 There are several situations however in which the LTp flap becomes the first option. While initially dissecting the septocutaneous perforator of the thoracodorsal artery, one may instead fortuitously meet a direct cutaneous perforator of the lateral thoracic artery. This may be the result of making the lateral thoracic incision too far forward. As numerous
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446
Kim, Kim
Fig. 2 (A) A 14-year-old male presented with a venous malformation on his upper lip and left cheek. (B) A 5 3 cm, thin lateral thoracic perforator flap was designed for upper lip reconstruction. (C) Six months after the surgery, the venous malformation had subsided without recurrence, and the patient was satisfied with the result. The flap covering the inner vermilion is well hidden in mouth closure. (D) Scar on donor site was located more anterior to the usual donor scar lines after the thoracodorsal or latissimus dorsi perforator flap.
pulsatile perforators can be found along the anterior border of the LD muscle, it is helpful to make the incision anterior to the anterior border of the LD muscle to have the option of a TDp flap based on the septocutaneous perforator, which can be elevated more rapidly than the LDp flap, which requires transmuscular pedicle dissection. A far anterior incision is frequently made to harvest a big flap, and as a result one encounters direct cutaneous perforators. The anterior border of the LD muscle and the lateral border of pectoralis major muscles can usually be detected on the surface anatomy or by grasping the muscle bulk. Lateral traction and abduction of the arm can be helpful to identify them in the operative field. However, when the LD muscle border is indistinct, in obese patients or in children, the incision can by mistake be made too far anteriorly and a reliable lateral thoracic perforator will be detected first. Another problem one may confront is the anatomical variation of the lateral thoracic region. Several types of anatomical variation of the vessels of the lateral thoracic region have been described. The thoracodorsal artery is always present, but it may be a branch of the lateral thoracic artery (7.2%). The lateral thoracic artery may originate from the subscapular artery (4.2%), or the subscapular artery may arise from the lateral thoracic artery (5.4%).17 Usually, the main supply of the lateral thoracic region is from the thoracodorsal arterial system. However, in a minority of cases, the lateral thoracic artery dominates with an extended vascular territory and supplies the lateral thoracic region with several reliable perforators.7 Another anatomic variation involves the course of the perforator pedicle, which can vary regardless of the vascular dominance or branching pattern of the main arteries. Even if
the incision is made in the right place and a reliable perforator is found at the anticipated location, which is located preoperatively with the help of an audible Doppler and an anatomical landmark, some perforators have an aberrant course. Even though they appear to be septocutaneous perforators from the thoracodorsal arterial system, they turn abruptly anteriorly as they are traced proximally and eventually arrive at the lateral thoracic artery. In most of our patients, the LTp flap was used as the last option; when no reliable perforators could be found, the dissection was modified anteriorly to seek the lateral thoracic artery perforators. Alternatively, a direct cutaneous perforator was often detected together with other reliable perforators, and the flap design could be modified during the operation itself, depending on the status of the recipient. This procedure represents a type of free-style flap harvest technique, in which the final design of the flap is in only decided during the operation depending on what reliable perforators are detected. Therefore, the final flap can be double-pedicled or chimeric depending on the perforator selected. The LTp flap has the same characteristics and indications as the LDp or TDp flap from the thoracodorsal arterial system. It is also versatile in terms of tissue composition, and can by itself provide a chimeric flap or be combined with another perforator flap from the lateral thoracic region. Also, the LTp flap can be cut as thin as 5 to 7 mm in thickness by separating the superficial and deep adipose layers, since the skin of the anterior chest wall is thinner than that of the lateral thoracic region. Moreover, such a thin flap can be folded, which is useful for reconstructing the vocal cords and a hemilarynx. In addition, a sensate flap can always be obtained by incorporating the intercostal nerve. Journal of Reconstructive Microsurgery
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Lateral Thoracic Perforator Flap
Lateral Thoracic Perforator Flap
Kim, Kim
However, there are limitations to the LTp flap that precludes it from being the flap of choice. The course of the lateral thoracic artery is not as constant as that of the thoracodorsal artery.20,24,25 Taylor and Daniel reported that the lateral thoracic artery could not be identified in 3 of their 20 cadaver dissections,24 and another report noted that the artery was absent in 2 of 11 clinical cases.20 The lateral thoracic pedicle is also shorter and smaller than the thoracodorsal vessels. A reliable direct cutaneous perforator from the lateral thoracic artery can be 1 mm or less in diameter. Therefore, the lateral thoracic artery should be harvested more proximally to obtain sufficient pedicle length and diameter to match those of the recipient vessels. T-anastomosis or end-to-side anastomosis is occasionally required, which is technically demanding even to a skillful microsurgeon.26,27 Because of the short pedicle length, eccentric placement of the perforator pedicle by designing the flap more distally also helps to increase the pedicle length. As the perforator pedicle is positioned more anteriorly, the flap is usually designed further forward than flaps from the thoracodorsal arterial system; as a result, the donor site scar tends to spread beyond the anterior axillary fold, in contrast to the well-hidden scar in the lateral thoracic region if the flap is raised in the thoracodorsal system.28–30 Another drawback of the LTp is the very small venae comitantes, which are usually too small to match the recipient vein. Therefore, another vein, the lateral thoracic vein, is frequently harvested with the flap, but the reliable lateral thoracic vein may follow a separate course from the perforator pedicle. As the lateral thoracic artery is usually located in front of the lateral thoracic vein, dissection along the lateral thoracic pedicle may miss the vein. Thus, this vein should be kept in mind and included within the flap during pedicle dissection. Pedicle dissection is usually difficult because the lateral thoracic pedicle has a tortuous course and is embedded in a thick adipose layer. Moreover, the dissection proceeds anteriorly, underneath the flap, while the flap is lifted up, and this dissection procedure is more inconvenient for the surgeon than with the flaps from the thoracodorsal system. On the contrary, there is no bothersome intramuscular dissection or perforator injury during intramuscular dissection due to the characteristics of the direct cutaneous perforator. Hence, the LTp flap has both advantages and pitfalls.
Funding This work was supported by the research fund of Hanyang University (HY-2013-G).
Note This article is a renewal of the article “Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region” published in J Plast Reconstr Aesthet Surg (2011;64:(1)596–602); the article has been revised with additional follow-ups. The content of this article was also presented in the panel on “Flaps, flaps, flaps: Fifteen new flaps” at the World Society for Reconstructive Microsurgery meeting, July 12 to 14, 2013 in Chicago.
Financial Disclosure The authors have no financial interests in the products, devices, or drugs mentioned in this article.
References 1 Kim CY, Naidu S, Kim YH. Supermicrosurgery in peroneal and
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Conclusion
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Although the LTp flap is another option in the lateral thoracic region, and is suitable for a variety of reconstructions, issues such as the variable anatomy of the pedicle and the anterior location of donor site scar have to be addressed. Therefore, while this flap can be useful, perforator flaps from the thoracodorsal system should be considered the primary safe and reliable option. However, because of the versatility of the two established perforator flaps based on the thoracodorsal system and with the added option of the LTp flap, the lateral thoracic region could become a universal donor site that offers several opportunities for perforator flap harvesting.
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soleus perforator-based free flap coverage of foot defects caused by occlusive vascular diseases. Plast Reconstr Surg 2010;126(2): 499–507 Yang WG, Chiang YC, Wei FC, Feng GM, Chen KT. Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing. Plast Reconstr Surg 2006;117(3):1004–1008 Kim JT, Kim SK. Hand resurfacing with the superthin latissimus dorsi perforator-based free flap. Plast Reconstr Surg 2003;111(1): 366–370 Agostini T, Russo GL, Zhang YX, Spinelli G, Lazzeri D. Adipofascial anterolateral thigh flap safety: applications and complications. Arch Plast Surg 2013;40(2):91–96 Lazzeri D, Huemer GM, Nicoli F, et al. Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: a systematic review. Arch Plast Surg 2013;40(1): 44–50 Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator flaps: what is a true perforator flap? Plast Reconstr Surg 2001; 107(3):874–876 Kim JT. Latissimus dorsi perforator flap. Clin Plast Surg 2003; 30(3):403–431 Kim JT. New nomenclature concept of perforator flap. Br J Plast Surg 2005;58(4):431–440 Kim JT. Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps. Plast Reconstr Surg 2005;115(3):755–763 Kim JT, Ng SW, Naidu S, Kim JD, Kim YH. Lateral thoracic perforator flap: additional perforator flap option from the lateral thoracic region. J Plast Reconstr Aesthet Surg 2011;64(12): 1596–1602 Kim JT, Ng SW, Kim YH. Application of various compositions of thoracodorsal perforator flap for craniofacial contour deformities. J Plast Reconstr Aesthet Surg 2011;64(7):902–910 Kim CY, Kim YH. Supermicrosurgical reconstruction of large defects on ischemic extremities using supercharging techniques on latissimus dorsi perforator flaps. Plast Reconstr Surg 2012; 130(1):135–144
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13 Kim SW, Hwang KT, Kim JD, Kim YH. Reconstruction of post-
22 Teo WL, Ong YS, Tan BK. Radical surgical excision and use of lateral
infected scalp defects using latissimus dorsi perforator and myocutaneous free flaps. J Craniofac Surg 2012;23(6): 1615–1619 Kim SW, Han SC, Hwang KT, Ahn BK, Kim JT, Kim YH. Reconstruction of infected abdominal wall defects using latissimus dorsi free flap. ANZ J Surg 2013;83(12):948–953 Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg 2013;40(5):575–583 Schaverien M, Wong C, Bailey S, Saint-Cyr M. Thoracodorsal artery perforator flap and Latissimus dorsi myocutaneous flap—anatomical study of the constant skin paddle perforator locations. J Plast Reconstr Aesthet Surg 2010;63(12):2123–2127 Olinger A, Benninger B. Branching patterns of the lateral thoracic, subscapular, and posterior circumflex humeral arteries and their relationship to the posterior cord of the brachial plexus. Clin Anat 2010;23(4):407–412 Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap: anatomic basis and clinical application. Ann Plast Surg 2003;51(1):23–29 Kim JG, Lee SH. Comparison of the multidetector-row computed tomographic angiography axial and coronal planes’ usefulness for detecting thoracodorsal artery perforators. Arch Plast Surg 2012; 39(4):354–359 Harii K, Torii S, Sekiguchi J. The free lateral thoracic flap. Plast Reconstr Surg 1978;62(2):212–222 Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30(3):331–342, v
thoracic flap for intractable axillary hidradenitis suppurativa. Arch Plast Surg 2012;39(6):663–666 Yang JD, Ryu DW, Lee JW, et al. Usefulness of a lateral thoracodorsal flap after breast conserving surgery in laterally located breast cancer. Arch Plast Surg 2013;40(4):367–373 Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56(3):243–253 Bhattacharya S, Bhagia SP, Bhatnagar SK, Aabdi SM, Chandra R. The anatomical basis of the lateral thoracic flap. Eur J Plast Surg 1990; 13:238–240 Komatsu S, Yamada K, Yamashita S, et al. Evaluation of the microvascular research center training program for assessing microsurgical skills in trainee surgeons. Arch Plast Surg 2013; 40(3):214–219 Leung CC, Ghanem AM, Tos P, Ionac M, Froschauer S, Myers SR. Towards a global understanding and standardisation of education and training in microsurgery. Arch Plast Surg 2013;40(4):304–311 Goon P, Man CB, Dickson M. Seroma reduction: using barbed sutures (v-loc) to close latissimus dorsi donor sites. Arch Plast Surg 2013;40(6):787–788 Shin IS, Lee DW, Lew DH. Efficacy of quilting sutures and fibrin sealant together for prevention of seroma in extended latissimus dorsi flap donor sites. Arch Plast Surg 2012;39(5):509–513 Cha HG, Kang SG, Shin HS, Kang MS, Nam SM. Does fibrin sealant reduce seroma after immediate breast reconstruction utilizing a latissimus dorsi myocutaneous flap? Arch Plast Surg 2012;39(5): 504–508
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Lateral Thoracic Perforator Flap
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