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-
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
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.
CLASSIFICATION OF PEDICLED
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
74 SEMINARS IN PLASTIC SURGERY/VOLUME 20, NUMBER 2 2006
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
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
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
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.
PEDICLED PERFOR ATOR FLA PS IN BRE AS T RECONS TRUC TIO N/HAMDI, FRENE 75
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-
Figure 3 Design of ﬂaps. The perforators were marked by a
unidirectional Doppler. Figure 4 The TDAP ﬂap based on one perforator.
76 SEMINARS IN PLASTIC SURGERY/VOLUME 20, NUMBER 2 2006
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.
PEDICLED PERFOR ATOR FLA PS IN BRE AS T RECONS TRUC TIO N/HAMDI, FRENE 77
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
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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