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Pedicled Perforator Flaps in Breast Reconstruction

  • Jan Yperman Ziekenhuis Ieper/ AZ West Veurne / AZ Damiaan Oostende

Abstract and Figures

During the last decade the concept of perforator flap surgery has greatly refined reconstructive microsurgery in general and reconstructive breast surgery in particular. Harvesting a flap without sacrificing the underlying muscle or the functional motor nerves characterizes this technique. Perforator flaps aim to reduce donor-site morbidity to an almost absolute minimum, respecting one of the main adagio's in medicine: primum non nocere. Pedicled perforator flaps have not yet been commonly used or widely described for breast reconstruction. Although the thoracodorsal and intercostal arteries provide many perforators to the region of the back, only the latissimus dorsi muscle or musculocutaneous flaps are in common usage in breast surgery, despite resulting in loss of the largest muscle in the body. Pedicled perforator flaps are a relatively new concept, not yet in wide usage for breast reconstruction. Our clinical experience using pedicled perforator flaps in breast surgery will be presented.
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Pedicled Perforator Flaps in Breast
Moustapha Hamdi, M.D., F.C.C.P.
and Bob De Frene, M.D., F.C.C.P.
During the last decade the concept of perforator flap surgery has greatly refined
reconstructive microsurgery in general and reconstructive breast surgery in particular.
Harvesting a flap without sacrificing the underlying muscle or the functional motor nerves
characterizes this technique. Perforator flaps aim to reduce donor-site morbidity to an
almost absolute minimum, respecting one of the main adagio’s in medicine: primum non
nocere. Pedicled perforator flaps have not yet been commonly used or widely described for
breast reconstruction. Although the thoracodorsal and intercostal arteries provide many
perforators to the region of the back, only the latissimus dorsi muscle or musculocutaneous
flaps are in common usage in breast surgery, despite resulting in loss of the largest muscle in
the body. Pedicled perforator flaps are a relatively new concept, not yet in wide usage for
breast reconstruction. Our clinical experience using pedicled perforator flaps in breast
surgery will be presented.
KEYWORDS: Pedicled flaps, perforator flaps, breast
Angrigiani et al
first described harvesting a
cutaneous island of the latissimus dorsi flap without
the muscle based on one cutaneous perforator. In our
department, the thoracodorsal artery perforator (TDAP)
flap is widely used as free flap for large defects on
However, the use of TDAP or other
pedicled perforator flaps for breast reconstruction is still
limited to few clinical reports. The latissimus dorsi (LD)
is largely used in breast surgery, which results in the
sacrifice of one of the most important muscles for
shoulder function. We described an algorithm of using
pedicled perforator flaps in breast surgery, which spares
the LD muscle.
The purpose of this article is to give an
update of the technique and the outcome.
The majority of patients with breast or thoracic defects
are suitable candidates for pedicled perforator flaps
instead of the formerly used LD musculocutanous flaps:
immediate or delayed partial breast reconstruction fol-
lowing tumorectomy/quadrantectomy
salvage procedure after significant partial failure of free
flap for breast reconstruction
reconstruction of large thoracic defects after oncological
postmastectomy breast reconstruction in combination
with an implant
breast augmentation with autologous tissue or correction
of congenital asymmetry.
Damage to the thoracodorsal pedicle (e.g., due to
previous axillary clearance) is an absolute contraindi-
cation to raising a TDAP flap, as it is for a traditional
LD flap. In this case, however, a perforator flap based
on intercostal vessels may still be harvested for lateral
defects on the breast. Previous surgery to the axilla
or lung (lateral thoracotomy) or radiotherapy to the
Department of Plastic Surgery, Gent University Hospital, Gent,
Address for correspondence and reprint requests: Moustapha
Hamdi, M.D., F.C.C.P., Gent University Hospital, Department of
Plastic Surgery, U.Z.G.— De Pintelaan 185, 9000 Gent, Belgium.
Perforator Flaps; Guest Editor, Aldona Spiegel, M.D.
Semin Plast Surg 2006;20:2;73–78. Copyright #2006 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-2006-941713. ISSN 1535-2188.
region may also result in damage to the perforator
Defects located at the inferomedial quadrant of
the breast are difficult to reach using a pedicled perforator
flap. However, some defects can be reconstructed by
pedicled perforator flaps based on the anterior thoracic
vessels such as intercostal or superior epigastric vessels.
Any partial breast defect accompanied by severe
and extended postirradiation damage presents a chal-
lenging surgery associated with a high complication risk;
therefore, a free-flap technique can be a better option
because it provides a larger amount of healthy tissue with
its blood supply.
Large breast defects in thin patients are often
difficult to reconstruct with pedicled perforator flaps due
to a lack of sufficient flap volume.
The blood supply to the LD muscle is well documented.
The thoracodorsal (TD) vessels are the main pedicle of
the LD muscle. After giving the serratus anterior (SA)
branch, the TD vessels divide into two branches, the
descending or vertical branch and the horizontal branch.
These branches give numerous perforators to the skin.
Anatomic studies on cadavers have shown that the
vertical intramuscular branch provides two to three
cutaneous perforators.
The largest perforator pierces
the muscle and usually enters the subcutaneous tissue
8 cm below the posterior axillary fold and 2 to 3 cm
posterior to the lateral border of the muscle. In our cases,
the perforators are usually found within 5 cm of the
anterior border of the LD muscle and between 7 and
10 cm caudally from the posterior axillary line. Our
clinical experience with the TDAP free flap showed
that a direct perforator of TD arising around the anterior
border of the LD muscle into the skin could be found
in some cases, which made the dissection much easier
and quicker, but the pedicle is shorter and the flap
may not be able to reach distant defects.
The intercostal vessels were described in Kerri-
gan and Daniel’s study
and various musculocutaneous
flaps were harvested based on the intercostal vessels. It
was Badran and El-Helaly
who first described harvest-
ing fasciocutanous intercostal flaps without including
the underlying muscles. Using the intercostal artery
perforator; flaps in breast surgery has recently been
reported by our studies.
The intercostal perforators
can be found anterior to the LD border, making the flap
dissection possible without disturbing or sacrificing the
TD vessels. These perforators pierce the serratus
muscle and turn medially, running above the LD
muscle, and are usually accompanied by a sensate
branch to the skin of the back. Following our anatomic
study, the largest perforators that may used for breast
surgery are encountered in four to five intercostal
spaces. Their distance form the anterior border of the
LD muscle ranges between 0.8 and 3 cm.
A vascular connection between the intercostal
perforators and the SA branch is found in 37% of cases.
This connection allows harvesting the intercostal perfo-
rator flaps but with the SA as a main pedicle.
The pedicled perforator flaps commonly used for breast
or thoracic reconstruction are the TDAP flap, the
intercostal artery perforator (ICAP) flap, and the serra-
tus anterior artery perforator (SAAP) flap.
Sometimes, a segment of LD muscle may need to
be included in the flap due to anatomical variations.
Muscle-sparing thoracodorsal (MS-LD) flaps are clas-
sified as follows
MS-LD I, in which a small piece of LD muscle (4
2 cm) is incorporated within the flap
MS-LD II, where a larger segment of up to 5 cm width
is designed along the anterior border of the LD
MS-LD III, where a larger area of LD muscle is
The ICAP flaps are classified as follows
Dorsal intercostal artery perforator flap: when the flap is
based on perforators arising from the vertebral seg-
ment of the intercostal vessels
Lateral intercostal artery perforator (LICAP): when the
flap is based on perforators originating from the costal
Anterior intercostal artery perforator (AICAP) flap:
when the flap is based on perforators that originate
from the muscular or rectal segment
Obviously, only the LICAP and AICAP flaps
have clinical application in breast surgery.
Preoperative Assessment and Flap Design
The patient is always marked before surgery. Breast size,
tumor size, tumor location, and the estimated defect size
are all taken into account. The thickness of the skin and
fat of the back is determined with a pinch test. Doppler
examination is performed with the patient lying in a
lateral position, similar to that during surgery, with the
arm abducted to 90 degrees.
A 5- to 8-mHz handheld Doppler probe allows
accurate localization of the perforator. The flap is de-
signed to include the located perforators and lies in the
direction of the lines of relaxed skin tension (or bra line).
To include any direct perforators, the flap should always
extend over the anterior border of the LD. The width of
the flap is determined by the size of the defect and the
possibility for primary closure of the donor site. More
recently, the spiral multidetector computed tomography
scan has been introduced to evaluate the skin vasculari-
This new technology is revolutionary in under-
standing the vascular anatomy and moreover, planning
perforator flaps.
The patient is positioned in lateral decubitus with the
arm abducted to 90 degrees. Skin and subcutaneous
tissue are incised down to the level of the muscle fascia;
the initial dissection can be beveled outward if more flap
volume is desired. Flap elevation proceeds from distal to
proximal and from medial to lateral at the level just
above the LD muscle fascia until the preoperatively
identified perforators are located. Dissection of the
perforator is done in the standard way as in every
standard type of perforator flap. Wide exposure by
muscle splitting is mandatory to free the perforator and
to clip the side branches. The dissection is done toward
the main pedicle to obtain adequate pedicle length for
flap transfer.
The Thoracodorsal Artery Perforator Flap
Dissection of a perforator originating from the descend-
ing branch of the thoracodorsal pedicle is easier because
fewer branches of the thoracodorsal nerve are encoun-
tered and also the intramuscular vessel course is usually
shorter. A perforator should be visibly pulsatile. If the
surgeon is satisfied with the caliber and the quality of
the perforator complex and committed to harvesting the
perforator flap, the perforator vessel is fully dissected.
However, if the perforators are small but visibly pulsatile,
a muscle-sparing technique (MS-LD I) is used to
harvest the flap. In this case, the perforators will be
dissected within the split LD muscle but not within the
muscular part incorporated into the flap. Thus multiple
small perforators are included in a 2- to 4-cm cuff of LD
muscle and sustain the type I muscle-sparing flap.
If only numerous small nonpulsatile perforators
are available, then the flap should be converted to a type
MS-LD II flap, containing a bigger piece (up to 5 cm) of
muscle, to incorporate the maximum number of perfo-
rators within the flap.
Once dissection of the vessels is complete, the
skin paddle is carefully passed through the split LD
muscle, then subcutaneously through the axillary region
into the breast defect.
The donor site is closed primarily. The patient is
then turned into a supine position and the flap is inset
into the defect and shaped. The flap is either partially or
totally de-epithelialized depending on the nature of the
defect. The pliable perforator flap easily lends itself to
being folded as required to fill the defect.
The Intercostal Artery Perforator Flap
When ICAP flaps are indicated, an intercostal perforator
may be identified and dissected to its origin from the
intercostal bundle through the split SA muscle. An
intercostal nerve may be included in the ICAP flap,
which is therefore raised as a sensate flap. Dissecting the
pedicle within the periosteum under the rib lengthens
the pedicle but is technically more difficult. The ICAP
flap is transferred to the breast defect similarly to the
TDAP flap.
The Serratus Anterior Artery Perforator
If an appropriately sized perforator is identified in front
of the anterior border of the LD, it can be dissected and
followed back to the major nutrient artery. If the
perforator is based on the artery to SA, the flap is raised
by dissecting the pedicle within the fascia of the SA
muscle. Side branches to the muscle are ligated and care
taken to avoid damaging nerve branches.
A selection algorithm for pedicled perforator flaps
in partial breast reconstruction is presented in Fig. 1.
Figure 1 Our surgical algorithm in choosing of pedicled flaps for breast: TDAP, thoracodorsal artery perforator; LICAP, lateral
intercostal artery perforator; AICAP, anterior inter-costal artery perforator; SAAP, serratus anterior artery perforator; MS-LD, muscle-
sparing latissimus dorsi.
Over the past 6 years, 101 pedicled perforator flaps have
been used in our department for breast or thoracic
reconstruction. The main indication was for immediate
partial breast reconstruction (Figs. 2–6). Good breast
contour and high patient satisfaction can be obtained
using pedicled perforator flaps. Furthermore, there is
only minimal decrease in flap volume postoperatively as
opposed to the LD musculocutaneous flap, which can
lose up to 30% of volume secondary to muscle atrophy.
The average flap size was 20 8 cm (range of
length 16 to 25 cm and width 6 to 10 cm). The mean
operative time was 2.5 hours (range 1.5 to 3 hours).
In 95% of cases, the flaps based on a single perforator. In
8% of cases the perforator flaps were converted to
muscle-sparing LD flaps.
Figure 2 (A–C) Preoperative views of a patient who had left
breast cancer at the superolateral quadrant. The patient underwent
a quadrantectomy with sentinel lymph node dissection with im-
mediate partial breast reconstruction by a completely de-epithe-
lialized TDAP.
Figure 3 Design of flaps. The perforators were marked by a
unidirectional Doppler. Figure 4 The TDAP flap based on one perforator.
Pedicled perforator flaps became our first choice in
almost every partial breast reconstruction, resulting in
an improved functional and aesthetic outcome for the
Breast autologous augmentation is the second
large indication of pedicled perforator flaps.
who have a fat-skin access at the lateral axillary region, in
particular those who had bariatric surgery with massive
weight loss, are good candidates for these techniques.
Muscle preservation is a sound rationale and is
likely to contribute to reduced donor-site morbidity.
Donor-site morbidity after raising a pedicle perforator
flap is reduced to an absolute minimum as the LD
muscle is left intact with functional motor innervation.
Figure 5 (A–C) Postoperative views at 6-month follow-up show
good contour and breast symmetry.
Figure 6 (A) Preoperative and (B) postoperative views of the donor site.
Perforator flap surgery is initially more difficult
than traditional myocutaneous LD flap harvest. This
kind of challenging but ultimately fulfilling surgery
necessitates some training with the attendant learning
curve. Significantly there was no seroma formation at the
pedicled perforator flap donor site.
Patients were also
less likely to complain of pain and appeared more
comfortable after pedicled flaps, although this was not
assessed objectively.
Another important consideration in selecting
pedicled perforator flaps is the potential to harvest the
LD muscle flap at a later date. This is evident in the case
of the ICAP flap where the thoracodorsal pedicle is not
disturbed. In the case of the pedicled TDAP or SAAP
flap, it is dependent on the length of pedicle being used.
Clinical experience with pedicled perforator flaps in-
creased dramatically and more studies from different
centers are encouraged.
Pedicled perforator flaps are an additional tool in the
armamentarium of the reconstructive breast surgeon,
and we suggest that they should be considered whenever
an adequate perforator is encountered. Safe and reliable
harvest of these flaps requires a thorough knowledge of
the anatomy of the various perforator flaps and expertise
in perforator flap surgery.
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... In 2005, Hamdi et al [6,7] reported the use of CWPF in the form of thoracodorsal artery perforator (TDAP) and intercostal artery perforator (ICAP) flaps. They showed the safety and feasibility of CWPF in breast reconstruction. ...
... However, patient satisfaction with the scar needs to be assessed. Recently, authors have reported that besides functional benefits, CWPFs have the added advantage of minimal donor site morbidity with excellent cosmetic outcomes and better patient satisfaction [6][7][8]. ...
... This study showed that CWPFs offer an excellent option for partial breast reconstruction in women with small and medium-sized breasts, with good patient-reported aesthetic outcomes and minimal morbidity. Various CWPFs used in partial breast reconstruction are reported in the literature, including TDAP, LTAP, LICAP and AICAP [6][7][8][9]. Apart from TDAP, all of these flaps were used in our series. We found that CWPFs could be used for tumours located in any quadrant of the breast although they were most frequently used laterally, and rarely in the upper inner quadrant. ...
Full-text available
Partial breast reconstruction using chest wall perforator flaps (CWPF) is a recent option used by breast surgeons, mainly for lateral quadrant defects with a relatively large volume of excision. We report a single-centre experience of CWPF with surgery details, complications, re-excision, aesthetic and oncological outcomes. This was a prospective observational cohort study of patients who had undergone breast conservation surgery (BCS) plus CWPF reconstruction. All variables were recorded prospectively in the institutional database. A survey was done to analyse patient satisfaction at about 6 months after completion of radiotherapy. Forty patients had CWPF based reconstruction in 3 years. 57.5 % of patients had lateral intercostal artery perforator (LICAP) flap, 5% had lateral thoracic artery perforator (LTAP) flap, 27.5% had combined LICAP plus LTAP and 10% patients had anterior intercostal artery perforator (AICAP) flap. Tumour excision cavity defect was of the lateral quadrant in 82.5%, central quadrant in 10% and medial quadrant in 7.5% of patients. The margin was positive for five patients, out of which four required cavity shave and one had a mastectomy. One patient had complete flap loss, and two patients developed surgical site infection. 96% of patients were satisfied with the scar, and 88% were happy with the treated breast in comparison to the opposite breast. 92% were comfortable going out in public and felt that in retrospect their decision not to have a mastectomy was correct. With a median follow up of 18 (10, 22) months, one patient died, and four had recurrences. CWPF may be used for partial breast reconstruction in the small non-ptotic breast with excellent outcome and high patient satisfaction scores.
... 9 Schwabegger et al. developed the MSLD technique in 2003 using the anterior muscle fringe with a vertical skin portion. 13 Hamdi et al. described transverse skin paddles with thoracodorsal artery perforator flaps for breast reconstruction with or without implants in 2006 and 2008, [14][15][16][17][18] and Saint-Cyr et al. used transverse skin paddles with thoracodorsal descending branches and a muscular fringe in 2009, [19][20] achieving low morbidity and satisfactory functional and esthetic results. ...
Full-text available
Background : To evaluate seroma complications, two techniques were carried out in breast reconstruction: conventional latissimus dorsi flap (CLD) and muscle-sparing latissimus dorsi flap (MSLD) after cancer-related mastectomy. Methods : A total of 108 postmastectomy procedures were performed with autologous tissue reconstruction with latissimus dorsi flaps (LDs) between January 2016 and May 2020. The patients were divided into two groups. The first group was reconstruction with the CLD, and the second group was reconstruction with the MSLD. Forty (40) patients in the first group and 68 patients in the second group were analyzed. Seroma formation was evaluated as the primary outcome. Results : The total number of seromas found in the donor area was 27, of which 45% (n = 18) were found with the CLD and 13.24% (n = 9) with the MSLD, with a difference of 31.76% in favor of the MSLD, with an 95% CI of 14-49 (p < 0.001). Conclusions : We found a significantly lower incidence of seroma as a complication in patients who underwent MSLD breast reconstruction compared with those who underwent CLD breast reconstruction.
... Perforator flap reconstruction is a relatively new procedure. Although Hamdi et al described its use in partial breast reconstruction in 2006, 9,10 its popularity has picked up pace only recently. The two groups in this study were comparable. ...
Full-text available
Background: Chest wall perforator flaps (CPF) and therapeutic mammoplasty (TM) are often done in patients with anticipated poor cosmetic outcome with level 1 breast conservation surgery. The aim of this study was to assess the complications and oncological outcomes between CPF and TM. Methods: Prospectively collected data of breast conservation surgery between September 2016 and January 2021 by a single surgeon were reviewed. Specific outcomes included complications needing intervention, re-excision and mastectomy rate, locoregional recurrence, and distant metastasis. Patients were followed up at 3 months and then every 12 months. Statistical analysis included chi-squared test and independent t test, and a P value of less than 0.05 was considered significant. Results: There was no statistically significant difference between CPF and TM with regard to patient characteristics except for BMI and bra cup size, which was significantly higher in the TM group. One patient who had TM returned to the operating room for a hematoma evacuation, and one patient who had CPF had fat grafting, for unsatisfactory cosmetic outcome. Five of the 30 patients having CPF had further re-excision surgery for inadequate margins, but none needed mastectomy, and four of the 43 patients having TM had further surgery (one had re-excision of margins and three had mastectomy) and this was not statistically significant (P = 0.346). There was no locoregional recurrence in CPF and TM groups after a median follow-up of 22 months and 25 months, respectively. Conclusion: There is no significant difference in early complications and oncological outcomes between CPF and TM.
... While good cosmetic outcomes are often achieved, donor site morbidity and long patient downtime remain an issue (6). The intercostal perforator flaps have fewer of these problems but it often does not have sufficient volume for full reconstruction after mastectomy (7,8). Volume replacement techniques after breast-conserving surgery using perforator flaps commonly include the anterior intercostal artery perforator (AICAP) and lateral intercostal artery perforator (LICAP) flaps (9,10). ...
... The inferior epigastric artery (arteria epigastrica inferior) is a branch of the external iliac artery. It is used in breast reconstruction employing a DIEP flap with a vascular microfusion with the internal thoracic artery at the level of the 3 rd rib [5,6]. ...
... To minimize the scarification of functional muscles, perforator flaps, such as the intercostal artery perforator flap or the thoracodorsal artery perforator (TDAP) flap, can also be applied. However, TDAP is a method that can be used selectively for a laterally located cancer in all areas, except the lower inner quadrant (LIQ) [24][25][26]. Compared with the classical preoperative design, all these surgical methods employ the concept of incision minimization, which incorporates the idea of scarless surgery. ...
Full-text available
Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has been accepted for decades, breast and plastic surgeons have been striving to develop more advanced surgical skills that ensure non-inferior oncologic outcomes with better cosmetic outcomes. Endoscopic or robotic devices, which are currently available only for chest or abdominal surgeries, could be used for breast surgery to ensure better cosmetic outcomes. The authors refer to this surgical concept as "aesthetic scar-less breast surgery and reconstruction," a term that encompasses the consequential concepts rather than naming it with simple technical words such as endoscopy-assisted or robot-assisted surgery. The "scar-less" term simply means leaving less of a scar, and better results can be expected by designing incisions on invisible areas. Herein, we summarize our experiences with various techniques of "aesthetic scar-less" surgery and review the existing literature on this topic.
... This resulted in a lengthy dissection only to later realize a larger and more favorably coursed perforator was available, and identification of this would have been facilitated by performing CT angiogram and appropriate reporting of the exact location on the thoracic wall. We recognize surgeons can successfully perform the TDAP flap based entirely on preoperative markings made with a Doppler probe [21,22]. However, although this modality is cheaper and more easily accessible, it generates more false-positive and false-negative signals and provides less detailed anatomic and functional vessel information. ...
Full-text available
Introduction: Since its introduction by Angrigiani the Thoracodorsal Artery Perforator (TDAP) flap has become a popular choice in partial breast reconstruction for volume replacement. Although mainly used to provide volume, it has also been reported as an adjunct to implant-based breast reconstruction. Methods: Patients undergoing salvage breast reconstruction surgery with the TDAP flap in the last 20 years were identified from the senior author’s logbook and their clinical data collected from EpicTM, the hospital electronic medical records system. Results: Two such patients, aged 44 and 52 years, were identified. The first had “impending failure” of a subpectoral implant reconstruction following severe cutaneous radiation reaction and poor quality soft tissues overlying the implant, coupled with recurrent seromas. The second had partial SIEA abdominal free flap fat necrosis, leading to volume loss, severe cutaneous scarring and significant deformity. The flap dimensions were 10 cm × 25 cm and 8 cm × 25 cm, respectively. They were each based on a single vascular perforator– one arising from the horizontal and the other from the vertical branch of the thoracodorsal vessels. Both flap transfers were successful and resulted in viable reconstructions despite the challenging indications. Discussion and Conclusion: The TDAP flap was successfully used to perform salvage breast reconstruction in both prosthetic and autologous cases which presented with ongoing challenges. We believe our technique of the TDAP flap for tertiary breast reconstruction provides adequate soft tissue replacement with minimal donor morbidity, and advocate that it be considered for difficult salvage cases when other options are not available.
Limberg flap is currently not commonly used in breast oncoplasty. We present our experience with Limberg flap reconstruction in breast cancer patients who underwent breast conservation surgery. This study was conducted at a tertiary cancer centre in Kerala, India. We reviewed the records of patients with breast cancer who underwent Limberg flap reconstruction with breast conservation surgery from 1st January 2020 to 31st October 2021. Data collected included age, quadrant of tumour, side of tumour, T and N stage, status at surgery (primary or post neoadjuvant therapy), type of surgery, flap complications following surgery and breast deformity following surgery. Seventeen patients underwent Limberg flap reconstruction during the study period. The median age of the patients was 51 years. The commonest stage was cT1N0M0. Twelve patients underwent primary surgery and 5 post neoadjuvant chemotherapy. No patient had postoperative flap complications or breast deformity. Limberg flap is simple, versatile and robust and should be a part of the armamentarium of breast surgeons.
Larger breast tumors that are unsuitable for breast conservation surgeries are common in the developing world and are usually treated with mastectomy. This report showcases our experience with the muscle-sparing latissimus dorsi (MSLD) flap for breast reconstruction after wide local excision or partial mastectomy. This is a retrospective review of patients undergoing breast reconstruction with MSLD flap after wide local excision between February 2016 and June 2018. The study of the aesthetic and functional outcomes was the primary objective and postoperative morbidity (pain, seroma, flap necrosis) as secondary objective. The aesthetic outcome was assessed individually by the patient and doctor as satisfactory, fair, good, and excellent. Donor site appearance was graded as satisfactory or unsatisfactory. Disability of the shoulder was assessed subjectively (limitation to perform activities involving overhead abduction at shoulder joint) and objectively by measuring the range of motion at shoulder joint. Ten patients (5 carcinoma, 5 phyllodes) were included. The mean tumor size at time of operation was 4.2 cm for breast cancer patients (assessable in 4 patients) and 6.5 cm (4–9.5 cm) for phyllodes. Skin island of flap had a mean size of 7.5 × 8 cm. Donor site was closed primarily. No donor site seroma was seen. Necrosis of flap margins occurred in one. The aesthetic outcome was good in two and excellent in eight; donor site was rated as satisfactory in all. No patient experienced disability of the shoulder on subjective assessment and objective assessment. MSLD flap offers a satisfactory aesthetic outcome with minimal functional arm compromise or donor site morbidity.
The use of chest wall perforator flaps (CWPFs) following breast conservation surgery for breast cancer has become a useful tool in the armamentarium of the oncoplastic breast surgeon, however robust evidence for the technique is lacking. The aim of this study was to conduct a systematic review appraising the current evidence for the use of CWPFs, evaluating clinical, oncological and cosmetic outcomes. A PRISMA‐compliant systematic review, with PROSPERO published protocol a priori and search of all relevant database and trial registries between 1990 to July 2020. Eleven studies amounting to 432 cases were reviewed and considered to be at high risk of bias due to small sample size, selective outcome reporting and selection bias. Heterogeneity due to lack of consensus of outcome measures prevented meaningful analysis. Fifty-two (12.3%) clinical complications were recorded: seroma (n = 9; 2.1%), fat necrosis (n = 9; 2.4%), haematoma (n = 8; 1.9%), infection (n = 9; 2.1%), and flap necrosis (n = 9; 2.1%). Thirty-four (10.8%) patients had an involved positive margin, 29 patients underwent re-excision (9.3%) and four underwent completion mastectomy (1.3%). One local recurrence and six distant recurrences were observed during a mean follow up of 21 months (1–49). A pooled patient cosmetic satisfaction descriptor of good or excellent was described in 93% of cases. CWPFs are a safe method of partial breast reconstruction following BCS. They are associated with a low complication rate, acceptable short-term oncological outcomes and satisfactory cosmetic outcome. There is a relative paucity in quality of data in this field and larger prospective studies are needed to investigate outcomes further.
Background: The use of lateral thoracic, skin and fat for breast reconstruction is advantageous because it does not require the use of muscle transfer, and the donor-site incision is well. hidden under the arm. In patients with redundant skin at the thoracic flank, use of this tissue has the added benefit of removal of an unsightly roll. The lateral thoracic skin and fat flap can be harvested using microsurgical technique based on three different pedicles: the thoracodorsal artery perforators; a direct cutaneous branch of the thoracodorsal; axillary; or lateral thoracic arteries; and the lateral thoracic intercostal perforating vessel. Methods: The authors describe the techniques for harvest of lateral thoracic tissue based on each of the pedicle options. A case is then presented-to illustrate each option, and an algorithm is suggested for deciding which pedicle to use. Results:. The authors have used lateral thoracic tissue for partial breast reconstruction for a variety of defects., In this report, the authors review the results of three illustrative cases. Conclusions: Partial breast reconstruction may be required for patients after breast-conserving therapy or breast reconstruction by other methods. Lateral thoracic tissue can be safely transferred to correct defects in treated or reconstructed breasts, or to obtain symmetry. Knowledge of the vascular anatomy to this region is helpful in understanding the pedicle options when harvesting this tissue. The authors present an algorithm for determining which pedicle is most appropriate for the transfer of lateral thoracic tissue for partial breast reconstruction.
The intercostal island flap is a new omnipotential flap that is extremely valuable for torso reconstruction, provided one understands the intricacies of intercostal anatomy. Human cadaver dissections were done to determine the precise course and branching pattern of the lower (T7-T11) intercostal neurovascular bundles. On the basis of these dissections, the intercostal structures can be divided into four anatomical segments: vertebral, costal groove, intermuscular, and rectus. The anatomical segments can be safely combined in many ways to create versatile skin flaps. Three different clinical applications with requisite modifications in surgical technique are described in detail to exemplify important anatomical observations. The potential value of the intercostal island flap in reconstructive surgery is discussed.
The lateral intercostal flap is a new neurovascular flap that may be used as a free or island flap. It is based on the lateral cutaneous branch of a single posterior intercostal neurovascular bundle. The donor area of the flap is the anterolateral skin of the abdomen. The flap is large, thin, and has a long pedicle that contains the lateral cutaneous nerve. The donor pedicles of the flap are multiple, and its venous drainage is adequate. The detection and design of this flap were based on information gained from the dissection of 95 intercostal spaces in 40 fresh cadavers. The flap was then applied 12 times in 11 patients. Ten flaps were successful, one flap was partially lost, and one was completely lost. The flap was used as a noninnervated flap to resurface six defects in the neck and one facial defect, and it was used as an innervated flap to cover two hand defects and two heel defects.
The possibility of raising the cutaneous island of the latissimus dorsi musculocutaneous flap without muscle based on only one cutaneous perforator is presented in this paper. An anatomic study performed in 40 fresh cadaver specimens injected with colored latex demonstrated that the vertical intramuscular branch of the thoracodorsal artery gives off two to three cutaneous branches (perforators) that are consistently present. The largest one, measuring approximately 0.4 to 0.6 mm in diameter, provides the blood supply to a 25 x 15 cm cutaneous island. The incorporation of the proximal trunk of the thoracodorsal artery lengthens the pedicle, facilitating the anastomosis or the arc of rotation (in the case of island flaps) but does not increase the amount of tissue transferable. Five clinical cases were done with this technique without tissue necrosis or flap loss.
Based on the dissection of 20 fresh cadavers, the authors have detailed further the vascular anatomy of the thoracodorsal artery and its cutaneous perforator vessels. The thoracodorsal artery showed a constant bifurcation into a horizontal branch and a lateral branch, located on the deep surface of the latissimus dorsi muscle 4 cm (range, 3-6 cm) distal to the inferior scapular border and 2.5 cm (range, 1-4 cm) medial to the lateral free margin of the muscle. In 20 specimens there was a total of 64 musculocutaneous perforators larger than 0.5 mm. Thirty-six perforators (56%) originated from the lateral branch and 28 perforators (44%) originated from the horizontal branch. All perforators originated within a distance of 8 cm from the neurovascular hilus and ran in proximity with the horizontal or lateral branches. In 11 dissections (55%) there was also a direct cutaneous branch originating from the extramuscular course of the thoracodorsal artery before the neurovascular hilus. This cutaneous branch did not pierce the latissimus muscle but rounded the lateral muscle edge and supplied the overlying subcutaneous tissue and skin. It is hoped that the constant anatomy will encourage surgeons in the future to use the thoracodorsal artery perforator flap more often.
Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.
The thoracodorsal artery perforator flap is a relatively new flap that has yet to find its niche in reconstructive surgery. At the authors' institution it has been used for limb salvage, head and neck reconstruction, and trunk reconstruction in cases related to trauma, burns, and malignancy. The authors have found the flap to be advantageous for cranial base reconstruction and for resurfacing the face and oral cavity. The flap has been used successfully for reconstruction of traumatic upper and lower extremity defects, and it can be used as a pedicled flap or as a free tissue transfer. The perforating branches of the thoracodorsal artery offer a robust blood supply to a skin-soft-tissue paddle of 10 to 12 cm x 25 cm, overlying the latissimus dorsi muscle. The average pedicle length is 20 cm (range, 16 to 23 cm), which allows for a safe anastomosis outside the zone of injury in traumatized extremities; the flap can be made sensate by neurorrhaphy with sensory branches of the intercostal nerves. Vascularized bone can be transferred with this flap by taking advantage of the inherent vascular anatomy of the subscapular artery. A total of 30 pedicled and free flap transfers were performed at the authors' institution with an overall complication rate of 23 percent and an overall flap survival rate of 97 percent. Major complications, such as vascular thrombosis, return to the operating room, fistula formation, recurrence of tumor, and flap loss, occurred in 17 percent of the patients. Despite these drawbacks, the authors have found the thoracodorsal artery perforator flap to be a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction cases.
Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.
A technique is described for autologous breast augmentation based on perforator flaps of the lateral chest wall. Raising these flaps as perforator flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.