Latissimus dorsi musculocutaneous flap without muscle

Optimizing thoracodorsal artery perforator flap outcomes in oncoplastic breast surgery: multidimensional assistive techniques mitigate learning curve and enhance feasibility

This study aims to evaluate the feasibility and postoperative outcomes of the thoracodorsal artery perforator (TDAP) flap in oncoplastic breast surgery (OBS), incorporating multidimensional assistive techniques. We retrospectively analyzed 14 breast cancer patients treated with TDAP flap OBS from May 2020 to August 2023. Patients were divided into two groups: Group A (first 7 cases) and Group B (last 7 cases). Preoperative perforator localization was performed using color Doppler ultrasound and handheld Doppler, with intraoperative comparisons. Blood perfusion was assessed intraoperatively with indocyanine green (ICG) fluorescence imaging and postoperatively with infrared thermal (IRT) imaging. Patient satisfaction was measured using the BREAST-Q scale. Group A had longer operation times (4.05 ± 0.61 h vs. 3.27 ± 0.31 h, P = 0.011) and longer hospitalization (9.14 ± 2.27 days vs. 7.71 ± 1.60 days, P = 0.199). No flap necrosis occurred. Preoperative and intraoperative perforator positions were consistent. ICG imaging showed good flap blood supply; edge trimming improved perfusion in two cases. IRT imaging confirmed good blood perfusion in the first 3 days post-op. BREAST-Q scores for psychological health and sexual satisfaction were lower post-op (P < 0.001), but no significant differences were found in scores for chest physical health, shoulder and back physical health, or breast satisfaction. While TDAP flap surgery involves a learning curve, it is a highly feasible technique for OBS. Multidimensional assistive technologies significantly enhance preoperative perforator localization and intraoperative flap blood perfusion monitoring, thereby improving flap survival rates and patient satisfaction.

TDAP flap in reconstruction of a severe postburn contracture of the axillary region-a case report

Herein we report a case of a male patient who was burned with hot oil and as a consequence developed a severe axillary contracture with limited abduction and elevation of his left arm. Due to the restriction in the range of movements, our patient reported limitations in everyday activities with decreased quality of life. For this patient we proposed a reconstructive plan that required a combination of multiple techniques of scar release and reconstruction of the defect with thoracodorsal artery perforator (TDAP)-based flap. One year postoperatively, we achieved a significant improvement in range of motion. We showed that TDAP flap provides a thin and pliable tissue coverage with a safe vascular supply. Furthermore, we eliminated the need for prolonged splinting which enabled early postoperative rehabilitation. To conclude, TDAP flap proved to be an ideal flap for this scenario and when used in combination with other techniques, optimal end result can be achieved.

Angle-Adjusted Transverse Thoracodorsal Artery Perforator Flap in Lower Extremity Reconstruction: A Case Series of 63 Patients

BACKGROUND

The thoracodorsal artery perforator (TDAP) flap is a viable option for reconstructing various soft tissue defects. Despite its numerous benefits, including reduced donor site morbidity, the TDAP flap has not gained popularity because of its anatomical variations and technical challenges. Herein, we aimed to introduce the application of the angle-adjusted transverse TDAP flap in lower extremity reconstruction and provide novel perspectives, with emphasis of outcomes.

METHODS

We retrospectively analyzed data from patients who underwent lower extremity reconstruction using a novel, modified transverse-TDAP flap at a single center between 2015 and 2019. This modification introduced a more transverse pattern with an innovative angle adjustment of approximately 30°-60°, specifically designed to optimize coverage and adaptability to various defects and aimed to prevent irritation at the posterior aspect of the scar, which could otherwise lead to pain during rehabilitation-addressing a common challenge in traditional TDAP flap designs. We conducted a comprehensive assessment of the TDAP flap, including patient characteristics, surgical details, long-term outcomes, functional evaluation of donor site using the American Shoulder and Elbow Surgeons (ASES) Score, and postoperative complications.

RESULTS

Sixty-three consecutive patients who underwent TDAP free flap reconstruction were included. Mean follow-up duration was 54.3 months; most common etiology was trauma (25 cases; 39.7%), followed by diabetes (16 cases; 28.6%). Twenty-six cases (41.3%) involved lesions in the foot, and 11 (17.5%) involved lesions in the distal tibia. Complications included total flap loss in five patients and donor site complications in one patient. As assessed using the ASES, the average functional score of the donor site was 97.8 points.

CONCLUSIONS

The modified transverse-TDAP flap provides favorable outcomes with minimal donor site morbidity, making it a viable alternative in clinical practice. Its design ensures effective coverage with reduced complications, establishing it as a reliable choice for lower extremity reconstruction.

Angiographic Observation of the Perforators of Thoracodorsal Artery and Application of the Perforator Flaps in Repairing Adjacent Wounds

OBJECTIVE

The thoracodorsal artery perforator flap has not been widely used in clinical practice partly due to a lack of imaging evidence. The authors aim to investigate the types of thoracic dorsal artery perforators through angiography and provide our experiences in the utilization of thoracic dorsal artery perforator flaps to repair adjacent wounds.

METHODS

This study was divided into two parts. The first part was an angiography of the thoracodorsal artery in 12 patients based on DSA and CTA images from January 2015 to December 2023. The branches and perforators of the thoracodorsal artery were observed and classified. The second part study, between January 2019 and December 2023, illustrated the clinical application of thoracodorsal artery perforator flap in repairing neighboring wounds in 10 cases where a small area of muscular vascular pedicle was preserved with oblique branch of thoracodorsal artery trunk dissected to extend the pedicle. The donor area of the flap was closed primarily. The patients were followed up to evaluate the functional recovery of the shoulder joint after operation.

RESULTS

The perforators of thoracodorsal artery were classified into 2 types based on the number and diameter: type I, the dominant perforating type (1-2 dominant perforators plus varying numbers of tiny perforators); and type II, the capillary perforating type (a larger number of tiny perforators without dominant perforators). The diameter of the dominant perforator is >0.5 mm, while the diameter of the capillary perforators is <0.5 mm. In the first part of the study, there were 8 cases of dominant perforating type and 4 cases of capillary perforating type. In the second part of the study, 10 cases of thoracodorsal artery perforator flaps were applied to repair the chest wall (3 cases), the back (1 case), the axilla (2 cases), the shoulder (2 cases) and the upper arm (2 cases). All the flaps fully survived with no complications, such as hematoma and seroma in the donor area. The function of the shoulder joint was not affected in these patients.

CONCLUSIONS

The angiography showed that thoracodorsal artery perforators could be categorized into 2 types, namely the dominant perforators and capillary perforators. The thoracodorsal artery perforator flap with a small area of muscular vascular pedicle can be harvested with blood supply from both types of perforators. With reliable blood supply, flexible selection of tissue volume and minimal muscle injury, it becomes a good choice for repairing wounds on the thoracic-dorsal-shoulder area.

Breast-Conserving Surgery with Immediate Partial Breast Reconstruction by Using Pedicled Thoracodorsal Artery Perforator Flap: A 7-Year Follow-Up of 50 Women

Introduction

Thoracodorsal artery perforator (TDAP) flap has been used for more than 10 years in the immediate partial breast reconstruction (IPBR) of breast cancer, allowing many patients to maximize reserved autologous breast tissue who do not have indications for breast-conserving surgery (BCS). No large sample size survival data for this operation have been reported worldwide.

Methods

There are 212 primary breast cancer patients who were prepared to receive BCS with IPBR of pedicled TDAP flaps in our institution from June 2013 to December 2017. Finally, the operations were completed successfully in 50 cases. All patients were female with a median age of 40 years.

Results

The average diameter of TDAPs measured by Doppler ultrasound before the operation was 1.8 ± 0.6 mm (ranging from 0.6 to 3.3 mm). The average size of the flaps was 15 × 6 cm. The average time of operations was 282 ± 71 min (ranging from 120 to 425 min). The drainage tube was removed 4.8 ± 1.9 days after the operation (ranging from 3 to 12 days). All TDAP flaps survived, and the wound complication rate was 4% (2/50). The median follow-up time was 88 (67, 94) months (M [IQR]), with a 5-year ipsilateral breast tumor recurrence rate of 4% (95% CI: 0.1-9.5%), a 5-year breast cancer-free interval of 88.0% (95% CI: 79.0-97.0%), and a 5-year overall survival rate of 96.0% (95% CI: 90.5-99.9%).

Conclusion

IPBR using pedicled TDAP flaps is a good choice for repairing local breast defects in BCS. The advantages of this surgery are no influence on latissimus dorsi function, few complications in the donor area, and good long-term prognosis.

The Role of Deep Inferior Epigastric Perforator and Thoracodorsal Artery Perforator Flaps in Head and Neck Reconstruction

Head and neck reconstruction has evolved to a more accurate replacement of the missing tissues for aesthetic and functional benefits, besides a concern with the morbidity caused in the donor site. This has led us to the use of perforator flaps. Deep inferior epigastric perforator flap allows the harvest of a large well-vascularized skin paddle with adequate bulk for large and voluminous defects reconstruction. Its main uses described in the literature are: tongue reconstruction, orbitomaxillary reconstruction, and scalp reconstruction. Thoracodorsal artery perforator flap is derived from the subscapular system and allows the harvest of a large array of chimeric flaps.

Mapping of Thoracodorsal Artery Perforators: Accuracy of Thermography and Handheld Doppler

BACKGROUND

 The versatile musculocutaneous latissimus dorsi flap and the thoracodorsal artery (TDA) perforator flap have developed into indispensable approaches in reconstructive surgery. While the anatomy of the TDA is consistent, the skin perforators vary in location and course. Dynamic infrared thermography (DIRT) recently gained popularity for perforator identification; however, its use and accuracy in thoracodorsal artery perforator (TDAP) mapping is yet to be determined.

METHODS

 TDAPs were visualized in 50 cases by DIRT. Based on the thermographic hotspots, the corresponding perforators were then identified by color duplex ultrasound (CDU) and handheld Doppler in a blinded fashion by two separate examiners.

RESULTS

 The midpoint of all perforator fascia passages was localized 99.7 mm caudal and 13.5 mm medial of the posterior axillary fold. The positive predictive value of perforator identification by dynamic infrared thermography was 86.5% and the correlating perforator fascia passage was 9.9 ± 5.8 mm from the hotspot midpoint, with a maximum of 29 mm. The positive predictive value of perforator identification by handheld Doppler was 95% and the signal was 7.2 ± 5.1 mm from the perforator fascia passage.

CONCLUSION

 DIRT precisely localizes TDAPs. The fusion with CDU combines both modalities' advantages. The combination with handheld Doppler is a fast way of perforator imaging, decreasing the handheld Dopplers' high false positive rate.

Outcomes and Complications of Sole Reconstruction Using Lateral Thoracic Free Tissue Transfer

BACKGROUND

The complex structure of the sole of the foot makes the repair of extensive defects challenging. The present study, therefore, aimed to address a gap in current research by evaluating the potential of the lateral thoracic free flap, including perforator options and chimeric configurations, to be used as an advanced solution for comprehensive sole reconstruction.

PATIENTS AND METHODS

We retrospectively collected the following data from the charts of patients with sole defects, due to various causes, who underwent lateral thoracic free tissue transfers: patient demographics; etiologies; comorbidities; flap types and dimensions; pedicle length; operative time; follow-up period; complications; and management.

RESULTS

The present study included 54 patients who underwent lateral thoracic free tissue transfer, citing infection, trauma, tumor, and posttraumatic sequelae as the major etiologies. We used the following techniques for the reconstruction of sole defects: thoracodorsal artery perforator free flap (83.3%); latissimus dorsi musculocutaneous free flap (1.9%); and various chimeric pattern flaps (14.8%). Free tissue transfer in the lateral thoracic region offers versatility for reconstruction, as well as low donor site morbidity. Complications observed in the present study included wound dehiscence (9.3%), partial necrosis (9.3%), and pressure ulcers (22.2%), although most patients healed favorably without flap loss.

CONCLUSIONS

The lateral thoracic free flap is a viable option for the reconstruction of the sole of the foot and allows for the effective reconstruction of complex defects. It contains a sustainable skin paddle, and multiple components can be easily included as a chimeric type. Further studies should seek to identify ways to prevent pressure ulcers, which was the only known long-term complication in the present study.

[Current role of the latissimus dorsi flap in traumatology: Analysis of the activity of a plastic surgery department in a military hospital]

Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.

NIR-II Protein-Escaping Dyes Enable High-Contrast and Long-Term Prognosis Evaluation of Flap Transplantation

Real-time vascular positioning, postoperative flap monitoring, and vascular reconstruction assessment are of great importance in flap transplantation. Cyanine dyes offer the advantage of high resolution in the Near-infrared-II (NIR-II) imaging window. However, the nonspecific binding of many cyanine dyes to endogenous albumin leads to high organ accumulation and skin absorption, resulting in low-quality imaging and poor reproducibility of contrast during long-term (e.g., 7 days) postoperative monitoring. Here, a novel strategy is proposed that can be widely applied to prevent protein binding for NIR-I/II Cl-containing cyanine dyes. This strategy produces protein-escaping dyes, ensuring high fluorescence enhancement in the blood with rapid clearance and no residual fluorescence, allowing for short-term repeatable injections for vascular imaging. This strategy in the perioperative monitoring of pedicle perforator flap models in mice and rats is successfully applied. Furthermore, leveraging the universality of this strategy, multiple nonoverlapping protein-escaping probes that achieve dual-excitation (808 and 1064 nm) interference-free imaging of nerve-vessel and tumor-vessel simultaneously are designed and synthesized. These protein-escaping dyes enable long-term repeatable dual-color imaging of tumor localization, resection, and tumor-vessel reconstruction at the wound site.

Chest wall perforator flap partial breast reconstruction: a retrospective analysis of surgical, cosmetic and survival outcome

Introduction

Oncoplastic breast surgery includes volume replacement as well as volume displacement. Autologous tissue is the preferred approach for volume replacement and includes chest wall perforator flaps (CWPF). Although described more than a decade ago, CWPFs have not been adopted widely in clinical practice till recently. We report the largest single-centre institutional data on CWPFs.

Patients and methods

The study includes all patients who underwent breast conservation surgery (BCS) using CWPFs from January 2015 to December 2022. Data were retrieved from the institutional electronic record and Redcap database. The analysis was done using SPSS 23 and STATA 14.

Results

150 patients were included in the study. The mean age was 48.8 years (SD 10.4), and the body mass index was (26.6 kg/m2, SD 4.3). >50% of patients had breasts with small cup sizes (A&B) and mild ptosis (Non-ptotic and Grade 1 ptosis). 44.7% of patients underwent lateral intercostal artery perforator flap (LICAP), anterior intercostal artery perforator flap in 31.3%, lateral thoracic perforator flap (LTAP) in 12%, LICAP + LTAP in 11.3% and thoracodorsal artery perforator flap in 1%. Post-operatively, haematoma was seen in 1.3%, complete flap necrosis in 1.3%, seroma in 7%, wound dehiscence in 12%, and positive margin in 6.7%. 92 patients responded to the satisfaction assessment, of which >90% were happy with the surgical scars, comfortable going out in a public place, satisfied with the symmetry of the breast, and no one chose mastectomy in hindsight. The 5-year predicted disease free survival and overall survival were 86.4% and 94.7%, respectively.

Conclusion

BCS with CWPF is an excellent option for reconstruction in small to medium-sized breasts. It is associated with minimal morbidity and comparable patient-reported cosmetic and survival outcomes.

[Unilateral secondary breast reconstruction using a pedicled dorsal flap sparing the latissimus dorsi (TDAP and MSLD) in patients with a history of total mastectomy for breast cancer. Monocentric observational study]

INTRODUCTION

The use of pedicled dorsal flaps sparing the latissimus dorsi muscle (TDAP and MSLD flap) is a well-described reconstruction method in breast reconstruction after breast cancer. However, little data exists regarding patient satisfaction after this surgery. The main objective of this study was to evaluate patient satisfaction after unilateral total secondary breast reconstruction using a TDAP or MSLD flap. The secondary objectives corresponded to the evaluation of postoperative complications following this surgery, the evaluation of the duration of the reconstruction and the nature of additional interventions, the evaluation of the functional after-effects, and the evaluation of the chest size when the reconstruction is completed.

MATERIAL AND METHOD

This is a monocentric, retrospective cohort study, including 22 patients who underwent unilateral secondary total breast reconstruction using a TDAP or MSLD flap between January 1, 2018 and December 31, 2022. Patient satisfaction was assessed using three questionnaires validated in breast reconstruction: the Reconstruction module of the BREAST-Q, the MBROS-S and the MBROS-BI.

RESULTS

The MBROS-S satisfaction score is 71.4%. The MBROS-BI body image score is 62%. With the BREAST-Q, the Satisfaction with Breast score is estimated at 53.1; the Satisfaction with Back score is estimated at 75.5; the physical well-being score regarding the chest is evaluated at 71.7; the physical well-being score concerning the shoulder and back is evaluated at 67.4; the psychosocial well-being score is assessed at 67.4; the sexual well-being score is estimated at 48.7; and for women who have benefited from reconstruction associated with a prosthesis, the satisfaction score regarding the implant is 71.6.

CONCLUSION

Unilateral total secondary breast reconstruction with a dorsal pedicled flap sparing the latissimus dorsi muscle is an elegant, reliable, and respectful way to reconstruct a breast, and appears to give high levels of satisfaction.

Systematic review of the free thoracodorsal artery perforator flap for head and neck reconstruction

BACKGROUND

The thoracodorsal artery perforator (TDAP) flap has gained interest as a option for reconstruction of head and neck defects while minimizing donor site morbidity as compared to traditional workhorse flaps. The primary aim of this systematic review is to assess the postoperative outcomes and efficacy of this flap.

METHODS

Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system.

RESULTS

Twenty articles containing 168 patients undergoing at least one TDAP flap reconstruction met the inclusion criteria. There were no incidences of total flap failure and only 10 incidences of partial flap failure (5.95 %). Flap complications and donor site morbidity was low. The average MINORS score of the studies suggested a moderately high amount of bias.

CONCLUSIONS

Based on limited quality evidence, this review suggests that TDAP flap is a safe and feasible option for head and neck reconstruction with comparable success rates as other commonly used flaps, with low complication rate and donor site morbidity. Further large-scale studies are warranted.

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

BACKGROUND

When abdomen-based free flap reconstruction is contraindicated, the muscle-sparing thoracodorsal artery perforator (TDAP) flap may be considered for total autologous breast reconstruction. The TDAP flap is often limited by volume and is prone to distal flap necrosis. We aim to demonstrate our experience combining the delay phenomenon with TDAP flaps for total autologous breast reconstruction.

METHODS

Patients presenting for autologous breast reconstruction between April 2021 and August 2023 were recruited for surgically delayed TDAP flap reconstruction when abdominally based free flap reconstruction was contraindicated because of previous abdominal surgery or poor perforator anatomy. We dissected the TDAP flap except for a distal skin bridge and then reconstructed the breast 1 to 7 days later. Data included flap dimensions (in centimeters × centimeters), delay time (in days), predelay and postdelay perforator caliber (in millimeters) and flow (in centimeters per second), operative time (in minutes), hospital length of stay (in days), complications/revisions, and follow-up time (in days).

RESULTS

Fourteen patients and 16 flaps were included in this study. Mean age and body mass index of patients were 55.9 ± 9.6 years and 30.1 ± 4.3 kg/m2, respectively. Average flap skin island length and width were 32.1 ± 3.3 cm (n = 8 flaps) and 8.8 ± 0.7 cm (n = 5 flaps), respectively. Beveled flap width reached 16.0 ± 2.2 cm (n = 3 flaps). Average time between surgical delay and reconstruction was 2.9 days, ranging from 1 to 7 days (n = 18 flaps). Mean predelay and postdelay TDAP vessel caliber and flow measured by Doppler ultrasound increased from 1.4 ± 0.3 to 1.8 ± 0.3 mm (P = 0.03) and 13.3 ± 5.2 to 43.4 ± 18.8 cm/s (P = 0.03), respectively (n = 4 flaps). Complications included 1 donor site seroma and 1 mastectomy skin flap necrosis. Follow-up ranged from 4 to 476 days (n = 17 operations).

CONCLUSIONS

We demonstrate surgically delayed TDAP flaps as a viable option for total autologous breast reconstruction. Our series of flaps demonstrated increased perforator caliber and flow and enlarged volume capabilities and had no incidences of flap necrosis.

Clinical Study on the Thoracodorsal Artery Perforator Flap in Breast-Conserving Reconstruction of T2 Breast Cancer

BACKGROUND

Breast-conserving surgery combined with oncoplastic breast surgery has become the standard surgical treatment for early breast cancer.

OBJECTIVE

The purpose of this study was to investigate the safety and efficacy of the thoracodorsal artery perforator flap (TDAPF) in breast-conserving reconstruction of T2 breast cancer.

METHODS

Thirty patients with T2 breast cancer admitted to our hospital from January 2019 to December 2020 were enrolled to receive pedicled TDAPF for repairing breast defects after breast-conserving surgery. Intraoperative conditions, postoperative complications, and shape satisfaction after breast reconstruction were recorded.

RESULTS

The operation was successfully completed in all 30 patients, with an operation time of 177.77 ± 24.39 min, bleeding of 44.17 ± 7.67 mL, and length of hospital stay of 5.23 ± .97 d. There was no deformity or seroma at the donor site. Breast shape recovered well after operation. After operation, one patient had fat liquefaction in the recipient site, which healed well after wound treatment. The incidence of postoperative complications was 3.33%. Postoperative follow-up lasted 16-28 months, with a median of 22 months. The Breast-Q score for breast satisfaction was 61.83 ± 12.87 at 6 months after operation, compared to 62.07 ± 11.78 before operation (P > .05).

CONCLUSIONS

TDAPF, featuring a high survival rate, moderate flap area, fewer postoperative complications, and high satisfaction with breast shape after operation. For east asian women with moderate breast size, TDAPF is a safe, effective choice for repairing defects in breast-conserving surgery for T2 breast cancer.

Free Thoracodorsal Artery Perforator Flap for Head and Neck Reconstruction: An Indian Experience

Background  We describe our experience with use of free thoracodorsal artery perforator (TDAP) flap for head and neck (H&N) cancer reconstruction, with respect to the patient and disease profile, suitable defect characteristics, the reconstructive technique, and complications. Methods  Consecutive patients ( N  = 26) undergoing free TDAP flap for H&N onco-reconstruction, in a single center, were included from January 2015 to December 2018 and the data were analyzed. Results  Perforator(s) were reliably predicted preoperatively, using handheld Doppler. Lateral position was comfortable for the harvest. Twenty flaps were harvested on a single perforator, more commonly musculocutaneous ( n  = 16). The thoracodorsal nerve and latissimus dorsi muscle could be preserved, completely in almost all cases. The skin paddle was horizontally ( n  = 5) or vertically ( n  = 21) oriented, both giving a satisfactory scar. The flap was used as a single island or two islands by de-epithelializing intervening skin. Pedicle length was sufficient in all cases. Four cases were explored for suspected venous insufficiency. Two had thrombosis, of which one was salvaged, while the other necrosed. One flap had minimal partial necrosis, which was managed with secondary suturing. The 5-year follow-up showed good oral competence, mouth opening, and cosmetic satisfaction among patients. Conclusion  TDAP flap provides all the advantages of a perforator-based free flap and of back as a donor site with close color match to the face, relatively hairless, and thickness in between the thigh and the forearm. It can be a useful tool to provide an ideal functional and aesthetic outcome, with a hidden donor site and minimal donor site morbidity in selected cases.

Thoraco-dorsal artery perforator flap for totally autologous primary breast reconstruction. Assessment of feasibility with standard reporting scales

This study reports on feasibility and applicability of totally autologous primary breast reconstructions based on TDAP flaps using a standard set of internationally approved reporting scales. We reviewed 15 cases in patients with a good donor area in the back not suitable for implant or free flaps reconstructions. Complications according to Clavien Dindo were: 1 Grade 1 (seroma in the back). The ABS-BAPRAS quality assurance indicators 10, 11, and 12 were entirely fulfilled. No pedicled flap loss occurred; no unplanned return to theatre and no unplanned readmission within 3 months. Breast-related quality of life values are reported at 3 months and one year in four domains of the BREAST Q v. 2.0 (breast reconstruction post-op questionnaire). At 1 year the mean Q-score for satisfaction with breast was 70.5, for psychosocial well-being was 72.3; for sexual well-being was 58.8; for physical well-being (chest wall) was 70.60. The TDAP based totally autologous breast reconstruction reported to be a feasible and safe alternative to implant based or free flaps reconstructions according to consolidate international outcome reporting measures.

Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap

INTRODUCTION

Around the knee reconstruction is challenging for reconstructive surgeons. Several methods have been proposed, including perforator and muscle flaps; however, all have advantages and disadvantages. As the success rate of free-flap surgery increases, reconstruction around the knee using this method is becoming increasingly popular. Nevertheless, there are no large-scale case reports in the previous literature using either a thoracodorsal artery perforator flap (latissimus dorsi (LD) perforator flap) or a muscle-sparing latissimus dorsi (msLD) flap for reconstruction around the knee. In this retrospective report, we describe our clinical experiences and present an algorithm regarding recipient vessel choice in free-flap reconstructive surgery of around the knee defects.

PATIENT AND METHODS

Fifty-six cases in which a flap from the lateral thoracic area was used to reconstruct an around the knee defect between January 2016 and March 2022 were reviewed. The patients were aged 18-87 years (mean, 52.13 years), and of the 56 patients, 36 were male and 20 were female. Injuries were caused by trauma, contracture, rheumatoid vasculitis, tumor, infection, burns, sunken deformity, and pressure sores. The 56 cases included 22 with a defect including the knee, 14 with a defect below the knee (7 of the primary below-knee amputation [BKA] and 7 of the secondary BKA), 9 involving the distal medial thigh, 8 involving the distal lateral thigh, 2 involving the popliteal area, and 1 involving the middle thigh. Most cases were reconstructed using a single LD perforator flap or msLD flap. Chimeric or supplementary flaps were used when extensive coverage or dead space obliteration was required. The average size of the defect area was 253.6 cm2 (range: 5 × 6-21 × 39 cm2 ).

RESULTS

In the cases, the recipient artery used included the following: descending genicular artery (23), superficial femoral artery (14), descending branch of the lateral circumflex femoral artery (14), anterior tibial artery (2), popliteal artery (2), and posterior tibial artery (1). The recipient vein included the greater saphenous vein (24), descending branch of the lateral circumflex femoral vein (14), superficial femoral vein (7), descending genicular vein (6), anterior tibial vein (2), popliteal vein (2), and posterior tibial vein (1). The average flap size was 281.8 cm2 (range: 4 × 8-35 × 19 cm2 ). All flaps survived; however, seven complications occurred, including 2 partial flap losses, 1 arterial insufficiency, 1 hematoma, 1 minor dehiscence, 1 donor-site graft loss, and 1 short BKA. Normal knee range of motion (121-140°) was observed in 34 patients and 16 showed varying degrees of limited range of motion. Motion was not observed in four patients who underwent knee fusion and could not be evaluated in two patients who underwent above-knee amputation. The mean follow-up duration was 24.6 months (range: 4-72 months).

CONCLUSION

The LD perforator flap is ideal for the reconstruction of around the knee defects because it enables a long pedicle, large flap, and chimeric design. The msLD flap is ideal because it enables strong stump support, dead-space obliteration, and infection control. Moreover, since the two flaps are distant from the knee, this method is advantageous in terms of postoperative rehabilitation and there is minimal donor-site morbidity due to the thin nature of the LD muscle. In addition, the flap can be elevated in three positions and the operation can be completed without positional changes in various recipient vessel locations. Based on our experience, we conclude that the LD flap has the potential to be used as widely as or in preference to the anterolateral thigh flap in the reconstruction of around the knee defects.

The reverse LICAP flap: A laterally based submammary perforator flap for breast reconstruction

INTRODUCTION

The traditional donor sites for autologous breast reconstruction include the abdomen, thigh, buttock, and posterior thorax. Herein, we describe the use of the reverse lateral intercostal perforator (LICAP) flap originating from the submammary region as an option for breast reconstruction.

METHODS

Fifteen patients (30 breasts) were included in this retrospective review. The procedure was performed for immediate reconstruction following a nipple sparing mastectomy utilizing an inframammary incision or an inverted T pattern with preservation of the fifth anterior intercostal perforator (n = 8), volume replacement after implant explantation (n = 5), and partial lower pole resurfacing with exteriorization of a portion of the LICAP skin paddle (n = 2).

RESULTS

Flap survival was achieved in all patients. Three flaps (10%) had 1-2 cm of intraoperative distal tip ischemia, which was managed by excision prior to inset and closure. At the 12-month postoperative follow-up, stable results with good nipple position, breast shape, and projection were achieved in all patients.

CONCLUSIONS

The reverse LICAP flap is a safe, effective, and reliable option for breast reconstruction following mastectomy.

Reconstruction of the thoracic radiation-induced ulcer with the pedicled internal mammary artery fasciocutaneous flap: Review of the literature and a case report

Objective

The pedicled Internal Mammary Artery Perforator (IMAP) flap is not yet a well-known technique. However, it seems practical for use in thoracic radiation-induced ulcer, especially in recurrence after the failure of convenient reconstructive techniques. This technique is applied to patients with breast hypertrophy. In this article, we present our experience with the indications, surgery details, and advantages of this technique.

Materials and methods

A 63-year-old woman had a right mastectomy 11 years ago. The patient's ulcers recurred after radiotherapy and were treated with a regional and local flap. The opposite breast was ptotic, and the patient was not eligible for microsurgery. The patient underwent reconstruction using the contralateral pedicle IMAP flap.

Results

The IMAP flap was designed with a size of 14 × 22 cm, including the inferior half of the breast and the areolar. The flap could completely cover the chest wall defect, and the contralateral breast was reduced to match. The final results were evaluated after two years of follow-up.

Conclusion

The contralateral breast pedicle IMAP flap is a reliable, versatile, and easy-to-perform technique. This flap is a useful technique for chest wall coverage after radiation-induced ulcers, particularly in elderly patients. The major limitation of this technique is the higher risk of second primary breast cancer as the transfer flap of the contralateral breast.

Hilaire H, Allen RJ. Surgical Delay of Thoracodorsal Artery Perforator Flaps for Bilateral Autologous Breast Reconstruction

Autologous reconstruction accounts for nearly one-quarter of all breast reconstruction cases in the United States, with the abdomen functioning as the most popular donor site. This case describes a 62-year-old woman who presented to our clinic with a remote history of estrogen receptor+/progesterone+ breast cancer and bilateral implant-based reconstruction. After grade IV capsular contracture of her left breast, she presented for autologous reconstruction. Due to her body habitus and prior belt lipectomy, deep inferior epigastric perforator flap reconstruction was contra-indicated. The thoracodorsal artery perforator (TDAP) flap is well described in the literature, and was chosen as an alternative salvage procedure to avoid latissimus harvest and the need for implants. The TDAP flap is often limited in volume and prone to distal tip necrosis, limiting its use in breast reconstruction. We have previously demonstrated the utility of the surgical delay phenomenon in improving the reliability of superficial inferior epigastric artery free flap breast reconstruction. In this case, we demonstrate the surgically delayed TDAP flap as a viable alternative to the latissimus flap with implants for bilateral total autologous breast reconstruction.

The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Application of Three Different Types of Pedicled Latissimus Dorsi Flaps in Repairing Nearby Deep Soft Tissue Defects: Cosmetic Result and Shoulder Functionality Evaluation in One Center

Objective

The latissimus dorsi (LD) flap has generally been considered a workhorse flap in clinics. However, the impairment of shoulder function and the dramatic appearance in the donor site are the major problems associated with traditional latissimus dorsi myocutaneous flap (LDMF). Here, we analyzed the reliability of three types of LD flaps in repairing deep soft tissue defects in the upper limbs, shoulder, back, and chest wall.

Methods

From December 2016 to December 2020, 21 patients from our center underwent reconstruction of deep soft tissue defects using different types of LD flaps. The distribution of the thoracodorsal artery and the location of its branches were confirmed by imaging examination. Based on the defects, traditional LDMF, thoracodorsal artery perforator flap with capillary perforators (TAPcp), or low-skin-paddle pedicled LDMF was selected and specifically designed for each patient. The appearance satisfaction and shoulder functional of daily life recovery were evaluated.

Results

A total of 12 traditional LDMF, 4 TAPcp, and 5 low-skin-paddle pedicled LDMFs were used. All flaps survived well. The donor site was sutured directly with satisfactory appearance (n = 7) or repaired using skin grafts (n = 14). Compared to traditional LDMF, TAPcp and low-skin-paddle pedicled LDMF have faster shoulder function of daily life recovery.

Conclusion

Based on the characteristics of defects, personalized design of different types of LD flaps is a reliable option to repair different defects.

LICAP Versus TDAP for the Reconstruction of Partial Breast Defects

Perforator flaps are the latest development in reconstructive surgery. Pedicled chest wall perforator flaps can be utilized in many cases of partial breast reconstruction. This research compares the outcome and technique of thoracodorsal artery perforator flap (TDAP) and the lateral intercostal artery perforator flap (LICAP) in the reconstruction of partial breast defects. Patient records were reviewed for the time period between 2011 and 2019 at the Breast Unit of the National Cancer Institute of Cairo University. Eighty three patients were accessible for the study. (46 cases of TDAP flap and 37 cases of LICAP flap). Relevant clinical data were extracted from patients' records. A special visit was organized for all 83 patients, where a digital photograph was taken in an antroposterior view. The photographs were later processed via BCCT.core software to obtain an objective cosmetic outcome assessment. Complication rates and cosmetic outcome were comparable for both techniques. TDAP flap proved to require more tedious dissection and preoperative Doppler mapping to localize perforator vessels. On the other hand, LICAP was technically easier with more consistent perforators. Pedicled chest wall perforator flaps constitute an excellent reconstructive option in partial breast defects. TDAP flap and LICAP are two reliable perforator flaps which can reconstruct outer breast defects with acceptable outcome.

Recent advances in surgical techniques for breast reconstruction

Although the number of patients with breast cancer continues to rise worldwide, survival rates for these patients have significantly improved. As a result, breast cancer survivors are living longer, and quality of life after treatment is of increasing importance. Breast reconstruction is an important component that affects quality of life after breast cancer surgery. With the development of silicone gel implants in the 1960s, autologous tissue transfer in the 1970s, and tissue expanders in the 1980s, breast reconstruction has advanced over the decades. Furthermore, the advent of perforator flaps and introduction of fat grafting have rendered breast reconstruction a less invasive and more versatile procedure. This review provides an overview of recent advances in breast reconstruction techniques.

Attributes of a Good Microsurgeon-A Brief Counsel to the Up-and-Coming Prospects

Microsurgery, which deservedly sits on top of the reconstruction ladder, has been a boon to plastic surgery. It is because of this marvelous tool that plastic surgeons the world over have been able to tackle many reconstructive dilemmas, which were once considered to be an improbability. Microsurgery-aided revolutions have rendered a new meaning to all forms of reconstruction-whether it is postoncological, posttraumatic, or postlymphedema reconstruction. As the most advanced reconstructive medium at our disposal that has broadened the horizons of plastic surgery exponentially, it is but obvious that many budding plastic surgeons are drawn toward this subspecialty. In lieu of the aforementioned facts, it is necessary to sensitize all such aspiring surgeons about the various intricacies concerning the field of microsurgery. This article with its focus on the six desirable microsurgical attributes of "Clarity, Curiosity, Perseverance, Passion, An Open Mindset and Action," is meant to be a modest attempt on part of the authors to share their microsurgical insights, procured through their respective journeys, with budding aspirants, hoping to sensitize as well as motivate them for the challenging path that lies ahead.

[Morbidity and quality of life following breast reconstruction by autologous latissimus dorsi, muscle sparing and perforator flaps]

INTRODUCTION

Morbidity following autologous latissimus dorsi flap (ALD), muscle sparing latissimus dorsi flap (MSLD) and thoracodorsal artery perforator flap (TAP) is controversial. The purpose of this study was to measure morbity using Quick Dash at 1 month and 1 year following breast reconstruction with one of these three flaps. The second objective was the evaluation of quality of life using Breast-Q.

PATIENTS AND METHOD

Thirty four consecutive patients who had undergone breast reconstruction were included in this monocentric and prospective study: 10 patients in the ALD group, 12 patients in the MSLD group and 12 patients in the TAP group.

RESULTS

At 1 month and 1 year following surgery, the variation of Quick Dash was 13,63 and 2,38 in the ALD group, 3,41 and -1,13 in the MSLD group and 5,69 and 0 in the TAP group. Satisfaction whith breasts, psychosocial, sexual and chest well-being were higher in the ALD group. Satisfaction with back was higher in the MSLD and TAP groups. Back and shoulder well-being was comparable regardless of the flap. Seroma occurrence was very rare in case of TAP, rare and not abundant in case of MSLD and frequent in case of ALD.

CONCLUSION

This study appears to confirm that immediate morbidity is less important with MSLD or TAP than ALD. Hoewever at one year following surgery, morbity seems to be comparable with the 3 flaps. Patients satisfaction seems to be higher with ALD except for the aspect of the back.

Useful Flaps for Plastic Surgeons to Know

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe different useful flaps. 2. Identify pitfalls of specific flaps. 3. Incorporate tips that facilitate flap use.

SUMMARY

We have a wide selection of flaps to choose from for any given reconstruction. This article describes the use of different flaps that the author has found useful in his practice. Some of these flaps are mainstream, whereas others are not. The article does not suggest that these are the only flaps that one should use, nor does it go into great detail on the dissection of each flap except where the author has identified pitfalls or where he can offer tips and tricks that facilitate use of these flaps. Flaps are described from head to toe.

[Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers]

Objective

To explore the effectiveness of microdissected thin thoracodorsal arterial perforator flap (TDAP) in repairing diabetic foot ulcers (DFUs).

Methods

The clinical data of 11 patients with DFUs admitted between March 2020 and February 2021 were retrospectively analyzed, including 5 males and 6 females, aged from 22 to 67 years, with an average of 49.3 years. There were 10 cases of type 2 diabetes and 1 case of type 1 diabetes; the duration of diabetes ranged from 3 months to 25 years (median, 8 months). The duration of DFUs ranged from 6 days to 120 months (median, 1 month). There were 6 cases of grade 3 and 5 cases of grade 4 according to Wagner classification. The tissue necrosis and purulent secretions were found in all ulcer wounds, as well as different degrees of tendon and bone exposure; skin defects ranged from 5 cm×3 cm to 17 cm×6 cm. The DFUs were repaired by microdissected thin TDAP, including 6 cases of flaps (including 1 case of lobulated flap), ranging from 10.0 cm×4.5 cm to 26.0 cm×7.0 cm; 5 cases of chimeric perforator flaps, the range of the flap was 10.0 cm×4.5 cm to 16.0 cm×5.5 cm, and the range of the muscle flap was 6 cm×2 cm to 10 cm×3 cm. The donor site was sutured directly.

Results

The operation time ranged from 3.42 to 11.17 hours, with an average of 5.92 hours. All 11 flaps survived and no vascular crisis occurred; 1 patient had a sinus at the edge of the flap, and the surgical area healed well after dressing change. All 11 patients were followed up 6-12 months, with an average of 9 months. The flap texture was good, the recipient site was in good shape, and there was no swelling; the foot contour was good, the shoes were comfortable to wear, and the movement was good. The incision at the donor site healed by first intention, leaving only linear and concealed scar, without obvious depression deformity, and the shoulder joint function was good.

Conclusion

On the premise of ensuring sufficient blood supply to the lower extremities and strengthening perioperative management, the microdissected thin TDAP to repair DFUs wounds can achieve better effectiveness and appearance; however, the prolonged operation time increases the probability of anesthesia and surgical risks in patients with DFUs.

Variations of Extended Latissimus Dorsi Musculocutaneous Flap for Reconstruction of Large Wounds in the Extremity

Objective

The aim of the present study was to report a novel nomenclature system for extended latissimus dorsi musculocutaneous (LD) flaps. To evaluate the clinical application and surgical efficacy of the different extended LD flaps for large wounds in the extremities.

Methods

From January 2004 to December 2018, 72 consecutive patients who received extended LD flaps were retrospectively analyzed. Patients' ages ranged from 2 to 68 years with 37 males and 35 females. All wounds were extensive in either the upper or lower limbs, while the skin defect area ranged from 18 cm × 10 cm to 37 cm × 21 cm. Forty‐one wounds were located in the calf, 18 in the foot and ankle, six in the shoulder and upper arm, four in the thigh, and three at the knee joint. Twenty‐eight patients had fractures, and six of these patients with segmental bone defects (ranging in size from 3 to 7 cm) required secondary orthopaedic procedures. Single‐ and double‐wing extended LD flaps were designed and harvested according to the shape of the wounds.

Results

The flaps received consisted of 64 single‐wing and eight double‐wing extended LD flaps, and the mean flap harvest time was 56.2 min. The donor sites were closed primarily for all patients. Additional subcutaneous veins were anastomosed to the recipient's vessels in 14 patients. The venous crisis was noticed on the first postoperative day in four cases. Two flaps were salvaged after emergency re‐exploration, and another two patients' flaps were necrosed. In these two patients, lower limb amputation and extended LD flap on the other side were used, respectively, for the final treatment. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Six patients had segmental bone defects that required secondary orthopaedic procedures, two patients were repaired with vascularized iliac crest bone grafts, and another four patients were reconstructed by the Ilizarov technique. All the patients' bone defects achieved union and most patients achieved good functional recovery at the recipient site. The mean follow‐up was 15.7 months (range, 10–56 months). No significant donor site morbidities limiting patients' daily activities occurred during the follow‐up. Eight patients developed a donor site hypertrophic scar, three patients on the back, and five on the anterolateral thigh.

Conclusion

Single‐ and double‐wing extended LD flaps are simple and reliable methods for large skin and soft tissue defects in the extremity, with good functional and aesthetic results.

The First Dorsal Metacarpal Artery Perforator Free Flap: The Comet Flap

BACKGROUND

Distal extremity defects pose a particular challenge to the reconstructive surgeon, however, advances in perforator flaps have expanded the armamentarium of potential reconstructive options. Herein, we present our experience in reconstructing distal extremity defects using a thin, cutaneous free flap based on the perforator of the first dorsal metacarpal artery - "the Comet flap."

METHODS

A retrospective review was performed on all patients who presented with a distal extremity defect and underwent reconstruction using a Comet flap between 2015 and 2019. Patient demographics, flap anatomy and harvest, and postoperative course were reviewed and analyzed.

RESULTS

A total of sixteen patients were included. The mean patient age was 36.5 years old. Trauma was the most common etiology. The average defect size was 5.4x3.2cm. The average pedicle length of the Comet flap ranged from 3.5 to 30cm, depending on involvement of the radial vessels. All donor sites underwent uncomplicated closure with local rhomboid flaps. One flap was complicated by an acute venous thrombosis that was successfully treated operatively. Flap survival rate was 95%. All patients were able to maintain their preoperative range of motion and were satisfied with their final outcome. Follow-up time ranged from 6 to 50 months.

CONCLUSION

Local flaps remain an important reconstructive approach for distal extremity defects; however, in complex soft tissue injuries, free tissue transfers become necessary. The Comet flap is a safe, versatile, and reliable flap for reconstructing upper and lower extremity defects that can be performed in a single procedure under regional anesthesia.

"Locoregional perforator flaps in breast reconstruction: An anatomic review & quadrant algorithm"

BACKGROUND

Plastic surgeons' firm grasp of perforator anatomy allows them to be increasingly mindful of esthetic outcomes, patient satisfaction, and donor-site function when approaching breast reconstruction. Mindfulness of these outcomes has contributed to the widespread use of locoregional perforator flaps in post-mastectomy and post-BCS reconstruction.

METHODS

A literature search of the PubMed database was performed to identify relevant studies reporting the use of locoregional perforator flaps in post-mastectomy breast reconstruction. Selected manuscripts were analyzed and grouped by pedicled flap category. Articles were additionally assessed for the advantages and disadvantages of each flap and reported complications.

RESULTS

Following three rounds of review, 30 of 101 (29.7%) articles were retained as specifically pertinent to the use of locoregional flaps in breast reconstruction surgery. They were categorized by locoregional perforator flap used (TDAP, LICAP, AICAP, LTAP, or IMAP). In total, the included studies reported on the use of perforator flaps in 829 patients, with complications occurring in 73 of 418 patients (17.5%). Commonly reported complications across all included studies were hematomas (n = 10), infection (n = 7), fat necrosis/steatofibrosis (n = 31), extruded expanders (n = 1), dehiscence (n = 2), seroma (n = 2), required cosmetic correction of the donor area (n = 5), flap congestion (n = 11), flap failure (n = 2), poor esthetic outcome (n = 4), grade II capsular contracture (n = 3, all of whom received postoperative radiation), and keloid scars(n = 1).

CONCLUSIONS

Though the available literature remains anecdotal, locoregional flap-based reconstruction may provide some benefit in post-BCS reconstruction by sparing donor-site musculature and nerve supply and by minimizing adverse events.

Optimizing Aesthetics in Reconstructive Breast Surgery Using Muscle-Sparing Latissimus Dorsi Flap in Radiated and Nonradiated Patients

BACKGROUND

The latissimus dorsi musculocutaneous flap (LDMF) has been a workhorse for breast reconstruction. Its high rate of donor-site morbidity has led to the advent of the muscle-sparing latissimus dorsi flap (MSLDF). However, there are very limited reports using the MSLDF in irradiated patients. Prior studies of MSLDF have either precluded previously radiated patients from receiving MSLDF or have included them as part of their larger MSLSDF cohort without specifically analyzing their outcome as a separate group or comparing them to the traditional LDMF group.

OBJECTIVE

We describe the technique and outcome of MSLDF in both radiated and nonradiated patients and compare the outcome to our LDMF patients.

METHODS

A retrospective chart review of patients undergoing breast reconstruction between 2003 and 2020 using either a pedicled MSLDF or LDMF with a transverse skin paddle was conducted. All patients underwent a 2-stage reconstruction with the flap and tissue expander placement done during the first stage, and replacement with implant and, if needed, fat grafting to enhance soft tissue during the second stage. Complications, subjective functional morbidity, and aesthetic outcomes were reviewed.

RESULTS

A total of 35 MSLDFs and 40 LDMFs were performed: 24 MSLDFs (69%) and 25 LDMFs (63%) were inset into a previously irradiated field. There were 2 cases of infection requiring explantation in both MSLDF (8.3%) and LDMF (8.0%) radiated cohorts. There were no cases of donor-site seroma in the MSLDF cohorts versus 12 (30%) in the LDMF cohorts. Minor distal tip superficial epidermolysis was seen in 5 MSLDFs (14.3%), 3 of which were in the radiated cohort, and in 1 LDMF (2.5%) radiated cohort with no cases of flap loss. Functional and aesthetic outcomes were satisfactory. Four patients who had a unilateral MSLDF had a completion upper back lift.

CONCLUSIONS

This is the largest series to date demonstrating the use of the MSLDF in both nonradiated and radiated patients and comparing it to a standard LDMF for breast reconstruction by the same surgeon. The pedicled MSLDF is a versatile option for breast reconstruction in radiated patients, and radiation should not be considered a contraindication for its use.

A cost-effectiveness analysis of delayed breast reconstruction with pedicled flaps from the back

BACKGROUND

Variability in breast reconstruction methods provides an opportunity to investigate whether a method is superior to another with regard to cost, quality, or both. We performed a cost-effectiveness analysis (CEA) study based on tertiary endpoint data from a randomized clinical trial to compare the cost-effectiveness of delayed breast reconstruction by either a latissimus dorsi flap (LD) or a thoracodorsal artery perforator flap (TAP).

MATERIAL & METHODS

A total of 50 women were included for unilateral delayed breast reconstruction and were randomized to reconstruction by either the LD flap (n = 18) or the TAP flap (n = 22). The CEA was based on differences in shoulder function after the reconstruction. Direct and indirect costs relating to the two procedures were assessed by the Danish Diagnosis-Related Groups tariffs.

RESULTS

Our analysis showed a significant positive effect of introducing the TAP flap on the total shoulder score with an additional cost of $2779. The incremental cost-effectiveness ratio was $4481 and based on a willingness to pay (WTP) $500, we found an estimated net benefit of $519, which was statistically significant (p = 0.0375). The cost-effectiveness acceptability curve indicated that there is a 96.3% probability for the TAP flap being cost-effective to the LD flap at a WTP threshold of $500.

CONCLUSION

From a societal perspective, our cost-effective analysis demonstrated that the TAP flap is the more cost-effective method of breast reconstruction compared to the LD flap with respect to patient-reported shoulder-related disability.

Modification of oncoplastic breast surgery with immediate volume replacement using a thoracodorsal adipofascial flap

Background

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We report a useful technique including the use of a thoracodorsal adipofascial cutaneous flap for reconstructing defects in the outer quadrant area after partial mastectomy, which achieved excellent results.

Methods

During the past 15 years, some modifications have been added to the original method at a rate of one modification every 2–5 years. We classified these modifications into the original method and four modified methods. Modification I: addition of a crescent-shaped dermis on the distant edge of the thoracodorsal adipofascial flap (TDAFF), Modification II: addition of a crescent-shaped dermis on the proximal edge of the TDAFF, Modification III: addition of inframammary formation plus Modification II, and Modification IV: change of a crescent-shaped dermis to a Benz-shaped (shaped like the Mercedes Benz logo) one plus Modification III. We compared the plastic period, postoperative complications, oncological results, and cosmetic results among the original and four modified groups.

Results

The patient number was 26, 9, 15, 23, and 10 in the original and Modification I, II, III, and IV groups, respectively. The median observation period was 115, 92, 67, 51, and 32 months, respectively. Postoperative complications were seen in 5 (19%), 0, 2 (13%), 1 (5%), and 0 patients, respectively. Local recurrence was seen in 3 (12%), 0, 0, 0, and 0 patients, respectively. Distant recurrence was seen in 1 (4%), 1 (11%), 3 (20%), 0, and 0 patients, respectively. Cosmetic results evaluated as good–excellent were seen in 19 (73%), 5 (56%), 11 (73%), 19 (83%), and 10 (100%) patients, respectively.

Conclusions

Oncoplastic surgery using an immediate volume replacement technique with a thoracodorsal adipofascial flap was improved by adding some modifications.

Outcome Comparison of Different Reconstructive Approaches for Axillary Defects Secondary to Radical Excision of Hidradenitis Suppurativa

BACKGROUND

Radical excision of debilitating hidradenitis suppurativa lesions is the only curative approach in the advanced stages of the disease. Different concepts for axillary reconstruction do exist, but data on their clinical outcome are scarce.

METHODS

This is a retrospective cohort study of two reconstructive methods (posterior arm flap vs. vacuum-assisted closure [VAC] + split-thickness skin graft [STSG]) for axillary defects in patients with severe axillary hidradenitis suppurativa treated at the University Hospital Zurich between 2005 and 2020.

RESULTS

A total of 35 patients (mean age 36 ± 10 years, mean BMI 29 ± 5 kg/m2, Hurley stage II-III) with 67 operated axillae were stratified according to their type of reconstruction. Median operation time in the flap group was 144 min (IQR 114-207) (cumulative 181 min [IQR 124-300]) and 50 min (IQR 40-81) in the VAC + STSG group (cumulative 151 min [IQR 94-194], p < 0.01; p = 0.20 [cumulative time]). The cumulative length of stay was 6 ± 3 days in the flap group and 14 ± 7 days in the VAC + STSG group (p < 0.01). Time to complete wound healing was 27 days (IQR 20-49) in the flap group and 62 days (IQR 41-75) in the VAC + STSG group (p < 0.01). Vancouver Scar Scale score was 6 (IQR 4-9) in the flap group and 11 (IQR 9-12) in the VAC + STSG group (p < 0.01). Protective sensory recovery was most satisfactory in the flap group (p < 0.01). Forty-four percent of patients of the VAC + STSG group demonstrated functional impairment of arm abduction. Time to return to work was less in group A with 42 days (IQR 27-57) needed as compared to group B with 48 days (IQR 34-55) needed (p = 0.32). The average cost saving was 25% higher for the flap group than for the VAC + STSG group.

CONCLUSION

Despite an increased operation time, axillary reconstruction by the posterior arm flap yields a reduced length of stay, less time to complete wound healing along with restoration of a protective sensibility, and less axillary scarring avoiding functional deficits - eventually allowing earlier return to work.

Evaluation of seromas in postmastectomy breast reconstruction: A retrospective observational study

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.

Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using the Ultrasound

BACKGROUND

 Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps.

PATIENTS AND METHODS

 From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap.

RESULTS

 Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed.

CONCLUSION

 Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.

Outcome comparison between thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap in axillary reconstruction after hidradenitis suppurativa excision

BACKGROUND

Thoracodorsal artery perforator (TDAP) flap and muscle-sparing latissimus dorsi (MSLD) flap have been frequently used for axillary coverage after hidradenitis suppurativa (HS) excision. However, none showed superiority to others. This study compared both flaps to define the ideal option, highlighting flap outcomes and functional and aesthetic results.

METHODS

A retrospective study was conducted to compare both flaps that were used for axillary reconstruction in nine patients with bilateral HS Hurley stage III between 2017 and 2020. Eight TDAP and 10 MSLD flaps underwent functional evaluation using shoulder abduction angle (SA); the Disabilities of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS) for pain; and the Dermatology Life Quality Index (DLQI) questionnaires. Aesthetic assessment included the Scar Cosmesis Assessment and Rating (SCAR) scale and arm-chest interval.

RESULTS

The mean operating time was 194.4 ± 51.58 and 128.5 ± 31.45 min for TDAP and MSLD (p = .009), respectively. Flap complications were significantly higher in the TDAP group (p = .034). There was no significant difference between both groups regarding SA; DASH, DLQI, VAS, and SCAR scale (p > .05). The mean arm-chest interval was significantly longer in the MSLD than in the TDAP group by 6.9 mm (p = .001).

CONCLUSIONS

TDAP and MSLD are comparable versatile flaps to eradicate axillary HS with higher TDAP flap complications. Although the TDAP flap is less bulky than the MSLD flap, the MSLD flap shortens the harvesting time without a significant difference in functional outcomes and scar results.

Strategy of harvesting extended thoracodorsal artery perforator flaps for resurfacing the large soft-tissue defects of extremities

BACKGROUND

The authors presented their strategy to harvest extended thoracodorsal artery (TDA) perforator flaps for resurfacing the large soft-tissue defects of extremities.

MATERIALS AND METHODS

Thirty-three free extended TDA perforator flaps were harvested in 33 patients. The mean flap size was 145.2 cm². The maximal flap length and the width were 30 cm and 10 cm, respectively. The color Doppler sonography (CDS) was used for preoperative assessment of perforators. Indocyanine green angiography (ICGA) was used for intraoperative assessment of flap viability in three patients.

RESULTS

The vascular thrombosis, donor-site scar widening, and delayed recipient-site wound healing were not significantly related to the patient and flap characteristics. Flap tip or partial necrosis was significantly related to age and peripheral vascular disease. True positive rate, false negative rate, and positive predictive value of CDS for perforator identification were not different significantly between attending surgeon and residents. In the distance discrepancy of CDS, significant difference was found based on the classifications of perforator size, perforator type, and sonographic operator. The ICGA identified a hypoperfused distal area in a 30 cm long flap.

CONCLUSION

The CDS locates the TDA perforators more precisely when scanned by experienced hands, in larger size or septocutaneous perforators. Using reliable and more perforators, applying muscle-sparing technique, considering suprafascial course of perforator and proper flap orientation are helpful in harvesting extended TDA perforator flaps. ICGA is an option for assessing flap viability, especially in elders and patients with peripheral vascular diseases.

Thoracodorsal Artery Perforator Flap for Chronic Radiation-Induced Ulcer of the Axilla in Vietnam

Breast cancer is the leading cause of death in females worldwide. Radiotherapy plays an important role for locoregional control in the comprehensive management of breast cancer. Chronic radiation-induced ulcer of the axilla can occur, and it is complicated to treat for these lesions. The application of a thoracodorsal artery perforator flap offers many advantages to be one of the most efficient treatments for radiation-induced ulcers of the axillary region. We introduce a series of 5 patients with radiation-induced ulcers of the axilla treated by using a thoracodorsal artery perforator flap. The mean operative time was 190 minutes. During at least a two-year follow-up, no complication has been found, and the patient has achieved good cosmetic result without movement limitation of the upper limb.

Free thoracodorsal artery polyfoliate perforator flaps for repairing multiple soft tissue defects in the hand

Background

Hand injury is commonly associated with multiple soft tissue defects. Polyfoliate flaps grafting is the optimal approach for multiple wounds.The feasibility of clinical using of free thoracodorsal artery polyfoliate perforator flaps for repairing multiple soft tissue defects in the hand needs to be confirmed in clinical practice.

Methods

Fifteen patients with hand soft tissue defects that were repaired using free thoracodorsal artery polyfoliate perforator flaps from January 2015 to February 2018 was retrospectively analysed. The survival rate, the operative time, the appearance and sensory recovery of the flaps, and hand function were evaluated.

Results

The flaps of all 15 patients survived. Vascular crisis occurred in one patient, and the flap was saved after exploratory operation. The 15 patients were followed up for 12–26 months. Sensation in the flaps was partially recovered in all 15 patients. The wound in the donor area was closed directly with sutures. Mean score of scars at the donor site were assessed using the modified Vancouver scar scale (VSS) was 2.7. A puffed appearance in the recipient area was noted in four patients. To obtain a more satisfactory appearance, revision of the flap was performed once in these four patients. The Total Active Movement (TAM) evaluation system was used to assess the results, which were considered excellent in seven patients, good in six patients, fair in two patients, and poor in none of the patients. Ten of the 15 patients returned to their primary jobs.

Conclusion

Free thoracodorsal artery polyfoliate perforator flaps are appropriate for repairing multiple soft tissue defects in the hand, offer a satisfactory appearance, require a short operative time, and have little impact on the function and aesthetics of the donor site.

A Retrospective Comparative Analysis of Latissimus Dorsi (LD) Flap Versus Thoracodorsal Artery Perforator (TDAP) Flap in Total Breast Reconstruction with Implants: A Pilot Study

INTRODUCTION

 In breast surgery, an autologous flap combined with implant may reduce the risk or repair the soft-tissue defects in several cases. Traditionally, the preferred flap is the myocutaneous latissimus dorsi (LD) flap. In the perforator flap era, the evolution of LD flap is the thoracodorsal artery perforator (TDAP) flap. The aim of this study is the comparison between LD flap and TDAP flap with implants in terms of early complications and shoulder function.

METHODS

 We performed a retrospective cohort study in accordance with the STROBE guidelines. Between January 1 2015 and January 1 2020, 27 women underwent a unilateral total breast reconstruction with LD or TDAP flap combined with an implant at our institution. 15 women were operated with LD flap and 12 with TDAP flap. The most frequent indications for intervention were results of mastectomy and radiation-induced contracture. We evaluated several data in terms of clinical and demographical characteristics, operative and perioperative factors, and follow-up variables. We assessed shoulder function through the Disability of the Arm, Shoulder and Hand Questionnaire (DASH).

RESULTS

 The rate of complications was significantly lower in the TDAP group compared with the LD group (16.7% vs 60.0%, p = 0.047. Table 3). Although the small sample size limited further detailed statistical analyses, we particularly noticed no cases of donor site seroma in the TDAP group, as compared with four in the LD group. Patients in the TDAP group had an ∼11-point lower mean DASH score compared with the LD group (9.8 vs 20.5). This difference was statistically significant (p = 0.049).

CONCLUSIONS

 TDAP flap seems to be a reliable technique for soft-tissue coverage in total breast reconstruction with implants. In comparison with the traditional LD flap, it could be a more favorable option in terms of less complications and better quality of life.

The concept of "whole perforator system" in the lateral thoracic region for latissimus dorsi muscle-preserving large flaps: An anatomical study and case series

BACKGROUND

Previous studies have reported on the abundant cutaneous perforating blood vessels around the latissimus dorsi (LD) lateral border, such as a thoracodorsal artery perforator (TDAP) of septocutaneous type (TDAP-sc) and muscle-perforating type (TDAP-mp), or the lateral thoracic artery perforator (LTAP). These perforators have been clinically utilized for flap elevation; however, there have been few studies that accurately examined all the cutaneous perforators (TDAP-sc, TDAP-mp, LTAP) around the LD lateral border. Here, we propose a new "whole perforator system" (WPS) concept in the lateral thoracic region and a methodology that enables elevating large flaps with reliable perfusion in a muscle-preserving manner.

METHODS

We first performed an anatomical study that verified the number and perforating points of all perforators around the LD lateral border using the results of dynamic contrast-enhanced magnetic resonance imaging of patients with breast cancer. Following the anatomical evaluation, we performed large muscle-preserving flap transfer that contained all of the perforators around the LD lateral border in an actual clinical setting.

RESULTS

A total of 175 latissimus dorsi from 98 patients were included. The mean number of perforators (TDAP-sc + TDAP-mp + LTAP) per side was 4.51±1.44 (2-9); TDAP-sc was present in 57.1% (100/175) of cases, and TDAP-mp in 76.6% (134/175); the TDAP total prevalence rate (TDAP-sc + TDAP-mp) was 96.0% (168/175). The LTAP existence rate was 94.3% (165/175). Distance from the axillary artery to the TDAP-sc was 148.7±56.3 mm, which was significantly proximal to the TDAP-mp (183.8±54.2 mm) and LTAP (172.2±81.3 mm).

CONCLUSION

The lateral thoracic region has an abundant cutaneous perforator system derived from the descending branch of the thoracodorsal and lateral thoracic arteries. Clinical application of the lateral thoracic WPS flap is promising, with a large survival area even with muscle-preserving procedures and requiring a relatively simple procedure.

Mapping 216 Perforator Flaps Using Highly Portable Tablet-Based Color Doppler Ultrasound (PT-CDU)

BACKGROUND

 The first reports of using color Doppler ultrasound for evaluation of the microvasculature were in the 1990s. Despite the early reports of its efficacy, color Doppler ultrasound did not achieve popularity nor general usage in part due to the cumbersome size, cost and poor resolution. This is the first study to demonstrate the potential utility of a new, highly portable, tablet-based color Doppler ultrasound (PT-CDU) system for imaging perforator flaps.

METHODS

 The deep inferior epigastric artery (DIEP), lateral arm (LA), anterolateral thigh (ALT), thoracodorsal artery (TDAP), and the medial sural artery (MSAP) perforator flaps were imaged within classic topographic landmarks to visualize and measure variables related to perforator flap anatomy. The Philips Lumify L12-4 linear array probe attached to the Samsung Galaxy Tab A tablet was the system used for all examinations.

RESULTS

 A total of 216 flaps were scanned in 50 healthy adult volunteers: 44 DIEP, 44 LA, 40 ALT, 48 TDAP, and 40 MSAP. Precise anatomic information regarding perforator size, number, and location was obtained. Overall, the percent of flaps having at least 1 perforator within the specified topographical landmarks was 89% for the DIEP, 84.1% for the LA, 72.5% for the ALT, 50% for the TDAP, and 30% for the MSAP (p = 2.272e-09). The percent of patients having an asymmetry (right versus left) in the number of perforators was 72.7% (ALT), 65% (DIEP), 59.1% (LA), 41.7% (TDAP), and 30% (MSAP) (p = 0.0351).

CONCLUSIONS

 Portable, tablet-based color Doppler ultrasound offers high-resolution images of perforators and represents a facile technology that may be of interest to microsurgeons in the planning of perforator flaps. Variations in vascular anatomy were well-demonstrated. This surgeon-driven imaging technology may represent an excellent alternative to other imaging modalities.

Large wounds reconstruction of the lower extremity with combined latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap transfer

BACKGROUND

Management of large wounds of the lower extremities remains a challenge for plastic and reconstructive surgeons. Herein, a surgical technique and clinical algorithm using the combined transfer of a latissimus dorsi (LD) musculocutaneous flap and flow-through anterolateral thigh (ALT) perforator flap for the treatment of extensive soft-tissue defects is described.

METHODS

From January 2012 to September 2018, 12 patients (six men and six women) aged 6-37 years, sustained injuries in road traffic accidents with large soft-tissue defects in the lower extremities. Seven cases were Gustillo Anderson type IIIB open fractures and two cases were Gustillo Anderson type IIIC open fractures. Two wounds were located in the knee joint, four in the calf, and six in the ankle and foot. The skin defect size ranged from 25 × 20 cm² to 36 × 25 cm² . All patients in this series underwent reconstruction using combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap, wherein the LD was attached through its pedicle to the distal continuation of the ALT flap.

RESULTS

The size of the flow-through ALT perforator flaps ranged from 13.5 × 6.5 cm² to 31 × 8.5 cm² . The size of the LD musculocutaneous skin paddle ranged from 25 × 6 cm² to 34 × 7 cm² , and that of the muscle paddle ranged from 13 × 3.5 cm² to 30 × 11 cm² . One patient experienced postoperative thrombosis of the venous pedicle, and the flap was salvaged after emergency re-exploration and thrombectomy. No other complications were observed postoperatively. The mean follow-up period was 26.8 months. All patients were able to ambulate independently at the end of the follow-up period.

CONCLUSIONS

The combined transfer of the LD musculocutaneous flap and flow-through ALT perforator flap ensured adequate surface coverage, making it a feasible procedure for large soft-tissue defects.