Sensate Thoracodorsal Artery Perforator Flap: A Focus on Its Preoperative Design and Harvesting Technique

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.

The versatile thoracodorsal artery perforator flap for extremity reconstruction: from simple to five types of advanced applications and clinical outcomes

BACKGROUND

Application of the thoracodorsal artery perforator (TDAP) flap is known to be a popular and reliable method for extremity reconstruction. This manuscript presents our clinical outcomes in reconstructing soft tissue defects using simple and advanced TDAP flaps.

METHODS

From 2013 to 2022, 53 patients with a mean age of 23 years (ranging from 2 to 72 years) underwent reconstructive surgery with different patterns of free TDAP flaps, including chimeric TDAP flaps, double skin paddle TDAP flaps, flow-through TDAP flaps, conjoined TDAP flaps, and microdissected debulking TDAP flaps.

RESULTS

All TDAP flaps survived. The size of the TDAP skin paddle ranged between 5 × 3 and 25 × 10 cm2. Primary closure of the donor site was achieved in all patients in the simple application group, and one patient in the advanced application group underwent partial skin grafting. Partial flap loss occurred in one case in the simple TDAP flap group and four cases in the advanced application group. There was one case of flap bulkiness and two cases of scar hyperplasia in the simple TDAP flap group. The mean follow-up duration was 11 months (4-46 months).

CONCLUSIONS

The free TDAP flap, with five types of advanced applications, makes it versatile for reconstructing different kinds of soft tissue defects of the extremities that can be used to achieve individualized defect reconstruction, minimize donor site morbidities, and an aesthetic appearance.

Comparison of outcomes between single- and multiple-perforator-based free perforator flaps: A systematic review and meta-analysis

BACKGROUND

Perforator-based free perforator flaps have become an important tool for the reconstruction of tissue defects. The effect of the number of perforators on the outcomes of perforator flaps has been widely debated. This study aimed to compare the outcomes of single- and multiple-perforator-based free perforator flaps in free-flap reconstruction.

METHODS

We searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database (CBM), Cochrane Library, and clinicaltrials.gov between January 2000 and June 2021 to identify studies that reported data on the outcomes of free perforator flaps. Two authors individually extracted data and performed quality assessment. Outcomes, including partial flap loss, total loss, fat necrosis, arterial insufficiency, venous insufficiency, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications, were evaluated.

RESULTS

Thirty-two studies with 2498 flaps were included in our analysis. No significant difference was found in the rates of partial loss and arterial insufficiency of flaps, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications. However, the multiple-perforator group showed significantly lower rates of total loss (relative risk [RR] = 1.08, 95% confidence interval [CI]: 0.78-1.79, p = .754), fat necrosis (RR = 1.79, 95% [CI]: 1.36-2.36, p = .000) and venous insufficiency (RR = 1.72, 95% CI: 1.07-2.79, p = .026) than the single-perforator group.

CONCLUSION

The rates of total loss, fat necrosis and venous insufficiency in the multiple-perforator group were lower than those in the single-perforator group. Hence, we recommend that multiple perforators be included in the free perforator flap when appropriate, to yield better clinical outcomes in reconstruction.

Coverage of exposed ankle and foot with the conjoined lower abdomen and groin flaps

BACKGROUND

Extensive soft-tissue defects around the ankle and foot pose a difficult challenge to surgeons. Considering that natural contour, the ideal solution should match a thin and pliable skin flap to allow shoe fitting and provide a functional move. As the conjoined flaps were increasingly utilized in covering various defects, we present our experience using the bipedicle conjoined flap on the lower abdomen and groin site.

METHODS

From May 2018 to September 2020, 36 patients (27 male and 9 female) with a mean age of 32 years (ranged, 21-54 years) underwent the one-stage coverage of ankle and foot defects with the bipedicle conjoined flap. A suitable "Y" bifurcation was dissected to enlarge vessel size or participated in intra-flap anastomosis. The mean dimension of the defect was 30 × 12 cm² (ranged, 20 × 8 cm² to 38 × 16 cm²). Primary donor-site closure was accomplished in all patients.

RESULTS

Thirty-six flaps survived completely without significant complications, and mild venous congestion was observed in one flap. The average flap size was 35 × 15 cm² (ranged, 22 × 10 cm² to 42 × 18 cm²). All flaps were available for a mean follow-up of 18 months (ranged, 12 to 24 months). Natural shape and walking function were successfully achieved with restored protective sensation.

CONCLUSIONS

Bipedicle conjoined flap harvested from the lower abdomen and groin is a great alternative, in selected patients seeking one-stage coverage for the exposed ankle and foot. Compared to single-pedicle flaps, the increased skin allows the wider coverage for the large defect with less morbidity and better outcomes.

Comparison of Thigh-Based versus Groin-Based versus Lateral-Thoracic-Based Flaps for Hand Resurfacing: A Review Article

BACKGROUND

Thigh-based, groin-based and lateral-thoracic-based flaps are available for microsurgical hand resurfacing – which is the best?

METHODS

BestBETS methodology was used to systematically evaluate the advantages and disadvantages. PubMed, EMBASE and Cochrane databases were searched up until Sep 2020, using the search strategy: hand re-surfacing, free-flap, groin-flap, thigh-flap, lateral thoracic-flap, advantages, and disadvantages.

RESULTS

Overall, 31 papers were identified which were used to synthesize the discussion and conclusions.

CONCLUSION

Thigh-based anterolateral thigh (ALT) flaps offer the greatest versatility.

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.

Reconstruction of recalcitrant pressure ulcers with latissimus dorsi muscle-splitting free flaps

BACKGROUND

Reconstruction of recalcitrant pressure ulcers is very challenging because all available local tissues have been exhausted. Although occasionally suggested as reconstructive options in some reports, free flaps are still not favored for pressure ulcers because of the less available recipient vessels in buttock area and the need for position change. Here, we describe our experience with latissimus dorsi muscle-splitting free flaps harvested in prone position for recalcitrant pressure ulcers.

METHODS

Between January 2012 and January 2020, 10 patients of recalcitrant pressure ulcers underwent reconstruction using latissimus dorsi muscle-splitting free flaps. To harvest flaps in the prone position, the curvilinear incision was made along the line connecting the lateral border of the scapula and the midaxillary line of the armpit and the latissimus dorsi muscle was split just below the skin incision. Only the required amount of muscle was harvested including the 5 × 3 cm sized muscle cuff around bifurcation points of the transverse and descending branches.

RESULTS

Flap size ranged from 16 × 9 to 24 × 14 cm and the gluteal vessels were mainly used as recipients. The mean operation time was 170 mins. All the flaps survived but two patients suffered wound disruption and partial flap loss, respectively. During the mean follow-up periods of 2.45 years, there were no recurrences at the reconstruction site, and no patient complained of donor site morbidity.

CONCLUSIONS

Based on the results obtained from this consecutive series of patients, latissimus dorsi muscle-splitting free flaps are valuable option for recalcitrant pressure ulcer reconstruction.

[Long-term functional evaluation of complex traumatic heel defects reconstructed by flap in children]

INTRODUCTION

Complex heel injuries in children are rare and their management requires coverage combining resistance and thinness, to allow walking and footwear. The objective of this study was to create a decision-making algorithm for heel defect in children.

MATERIALS

Children received for heel defect, reconstructed with flap in our plastic surgery unit of Bordeaux with a follow-up greater than 10 years were investigated. Three children operated between 1999 and 2003 were included. A free contralateral reinnervated medial plantar flap, a free latissimus dorsi flap and a lateral supramalleolar flap were performed. Patients were reviewed in consultation to assess quality of reconstruction and functional outcomes. Three scores were used, the Foot Function Index (FFI), the AOFAS Ankle and Hindfoot Scale and the Maryland Foot Score.

RESULTS

No growth disorder has been found. Scores greater than 80 for the Maryland Foot Score and AOFAS Ankle and Hindfoot Scale and less than 10 for the FFI were very satisfactory in cases 1 and 3. We found pain and greater functional impairment in the second case.

CONCLUSIONS

"Like-with-like" reconstruction remains the gold standard, whether in loco-regional or free flap. The fasciocutaneous flaps allow custom reliable coverage with little donor site morbidity. Loco-regional flaps remain easily accessible but donor site sequelae are not negligible.

Surgical refinements and sensory recovery of using transverse sensate thoracodorsal artery perforator flaps to resurface ring-avulsed fingers

To improve the use of thoracodorsal artery perforator flaps in resurfacing ring-avulsed fingers, the relations between the thoracodorsal artery perforators and intercostal nerves were investigated. The surgical refinements, clinical results, and sensory recovery of flaps were presented. Eleven patients with ring-avulsed fingers were reviewed. Separated and conjoint relations were found. Eleven flaps were harvested with 3 refinements. First is the transverse flap design. Second is operating color Doppler sonography to identify the relations. Third is using the conjoint relation to facilitate adequate flap thinning. Four patients had separated relation, and 7 patients had conjoint relation. Only 1 patient showed flap tip necrosis. Two patients with separated relation needed flap debulking. Ten patients acquired protective to normal tactile sensation, and 9 patients gained fair to normal discriminative sensation. The free transverse sensate thoracodorsal artery perforator flaps can be an option in the reconstruction of ring-avulsed fingers.

Novel flaps for head and neck reconstruction

The head and neck region is important both functionally and aesthetically and its reconstruction poses a formidable challenge for plastic surgeons. A perforator flap is a flap of skin or subcutaneous tissue supplied by a vessel that perforates the deep fascia to gain access to flap. With improvement in our knowledge of the anatomy of blood supply to the skin, the perforator flaps have opened a whole new horizon for the plastic surgeon to choose flaps with better function and cosmesis. The locally available perforators enable flaps to be designed with excellent match in tissue characteristics. Perforator flaps limit donor site morbidity and as they are islanded complete insetting is possible in a single stage. The principal perforator flaps such as facial artery perforator flap, platysma flap and its variant the submental flap and supra-clavicular artery flap used in the head and neck reconstruction are discussed. The more commonly used flaps are the free radial artery forearm flap and the anterolateral thigh flap while the novel ones are the thoracodorsal artery perforator flap, medial sural artery perforator flap and the toe-web flap for commissure reconstruction. The indications, reach and drawbacks of these flaps have been discussed in this review.