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Discussion of ‘Transverse thoracodorsal artery perforator flaps: experience with 31 free flaps’
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 380e381
COMMENTARY
Discussion of ‘Transverse thoracodorsal artery perforator flaps: experience with 31 free flaps’ Ernest S. Chiu a, Francisco G. Bravo a, John W. Siebert b a
Tulane Health Sciences Center, Division of Plastic and Reconstructive Surgery, 1430 Tulane Avenue, SL-22, New Orleans, LA 70112, USA b University of Wisconsin Hospital, Division of Plastic and Reconstructive Surgery, 600 Highland Avenue, Madison, WI 53792, USA Received 23 April 2007; accepted 15 October 2007
The authors are commended for their excellent work using the ‘transverse’ thoracodorsal artery perforator (TDAP) flap for free flap reconstruction.1 The main thrust of this paper is that the authors have created a ‘new flap design’ to decrease tension in the donor site location and improve overall aesthetic results. Their case examples demonstrate an acceptable donor site scar. The TDAP flap was first described as a ‘latissimus dorsal musculocutaneous flap without muscle’ in 1995.2 It was then re-discovered, re-named (TDAP), and reported in 2004.3 The authors of this latest paper are commended on trying to conceal the donor site scar when harvesting a back flap. However, like many good ideas, the improved donor site location concept was reported by the senior author of the current Commentary (J. W. S.) when the inframammary extended circumflex scapular flap (IMECS flap) based off the anterior branch of the circumflex scapular artery was introduced in 1997.4 It has now been successfully used for vascularised fat grafting in over 200 facial contour deformity patients. Their article also confirms that an inframammary fold (the manuscript authors call it a ‘transverse flap’ but an ‘oblique flap’ may be more accurate) incision leaves a well-concealed scar with minimal donor site morbidity. If the scar position has been optimised, the reader should wonder if one flap is ‘better’ than the other? To answer this question, we compare how the transverse TDAP and IMECS flaps are similar and different. They E-mail address: [email protected] (E.S. Chiu).
are similar in that both flap pedicles originate from the subscapular artery system, both result in minimal donor site morbidity and, as discussed above, can be used in a transverse skin island design. Both flaps can be harvested in a lateral oblique position which allows for a two-team approach (recipient vessel preparation, flap harvest) in microvascular reconstruction. Significant flap anatomy divergence occurs below the skin island paddle before the parent vessels return to the subscapular artery. The transverse TDAP flap, a perforator flap, can be viewed as a deep inferior epigastric artery perforator (DIEP) flap, while the IMECS flap can be viewed as the superficial inferior epigastric artery (SIEA) flap. Like the DIEP flap, the majority of the transverse TDAP flaps require intramuscular dissection in search of its parent vessel (i.e. thoracodorsal artery). Occasionally, the perforators perfusing the overlying skin paddle (horizontal or transverse) are not always located 2 cm from the anterior border of the latissimus in Doppler auscultated locations (personal experience), thus a wider dissection may be necessary in the search for a perforator. This can be disheartening since the TDAP flap could be elevated yet the perforator is absent in the designed skin island. The IMECS flap is an axial fasciocutaneous flap nourished by the transverse branch of the circumflex scapular artery, and originates from the triangular space bordered by the teres minor, teres major, and long head, triceps muscle. Like the SIEA flap, the IMECS flap does not require muscle dissection. The flap is designed along the axis formed from the ipsilateral
1748-6815/$ - see front matter ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.10.051
Transverse thoracodorsal artery perforator flaps inframammary fold to the origin of the circumflex scapular artery. In our clinical experience using the IMECS flap, we have not encountered cases where the skin paddle was inadequately perfused by the transverse branch of the circumflex scapular artery. It also does not require perforator selection decision making. The flaps are different in that the IMECS flap pedicle (6e8 cm in length) is usually shorter than the transverse TDAP flap pedicle (10e14 cm). The longer pedicle allows the TDAP flap to be used as a local flap for anterior breast/chest soft tissue defects. Because the IMECS pedicle origin is more posterior, pedicle rotation to anterior breast defects is difficult and ill advised. Both flaps can be harvested as an osteocutaneous or composite free tissue flap. The vessel diameters for both flaps are excellent for microsurgical anastomosis to recipient vessels. Finally, proper surgical wound closure is as important as scar location planning. An excessively large flap harvested even in relaxed skin tension lines can result in unfavorably widened scars. Placement of permanent ‘subfascial’
381 sutures as advocated by Ted Lockwood can aid in decreasing suture line tension (i.e. improve final scar). Both the transverse TDAP and IMECS flaps have advantages and disadvantages. Transverse skin island flap design has been confirmed to be effectively hidden with minimal donor site morbidity. Which flap is better? You be the judge.
References 1. Lee S-H, Mun G-H. Transverse thoracodorsal artery perforator flaps: experience with 31 free flaps. J Plast Reconstr Aesthet Surg 2008;61:372e9. 2. Angrigiani C, Grilli D, Siebert JW. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96:1608. 3. Guerra AB, Metzinger SE, Lund KM, et al. The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg 2004;114:32. 4. Siebert JW, Longaker MT, Angrigiani C. The inframammary extended circumflex scapular artery flap: an aesthetic improvement of the parascapular flap. Plast Reconstr Surg 1997;99:71.
COMMENTARY
Discussion of ‘Transverse thoracodorsal artery perforator flaps: experience with 31 free flaps’ Ernest S. Chiu a, Francisco G. Bravo a, John W. Siebert b a
Tulane Health Sciences Center, Division of Plastic and Reconstructive Surgery, 1430 Tulane Avenue, SL-22, New Orleans, LA 70112, USA b University of Wisconsin Hospital, Division of Plastic and Reconstructive Surgery, 600 Highland Avenue, Madison, WI 53792, USA Received 23 April 2007; accepted 15 October 2007
The authors are commended for their excellent work using the ‘transverse’ thoracodorsal artery perforator (TDAP) flap for free flap reconstruction.1 The main thrust of this paper is that the authors have created a ‘new flap design’ to decrease tension in the donor site location and improve overall aesthetic results. Their case examples demonstrate an acceptable donor site scar. The TDAP flap was first described as a ‘latissimus dorsal musculocutaneous flap without muscle’ in 1995.2 It was then re-discovered, re-named (TDAP), and reported in 2004.3 The authors of this latest paper are commended on trying to conceal the donor site scar when harvesting a back flap. However, like many good ideas, the improved donor site location concept was reported by the senior author of the current Commentary (J. W. S.) when the inframammary extended circumflex scapular flap (IMECS flap) based off the anterior branch of the circumflex scapular artery was introduced in 1997.4 It has now been successfully used for vascularised fat grafting in over 200 facial contour deformity patients. Their article also confirms that an inframammary fold (the manuscript authors call it a ‘transverse flap’ but an ‘oblique flap’ may be more accurate) incision leaves a well-concealed scar with minimal donor site morbidity. If the scar position has been optimised, the reader should wonder if one flap is ‘better’ than the other? To answer this question, we compare how the transverse TDAP and IMECS flaps are similar and different. They E-mail address: [email protected] (E.S. Chiu).
are similar in that both flap pedicles originate from the subscapular artery system, both result in minimal donor site morbidity and, as discussed above, can be used in a transverse skin island design. Both flaps can be harvested in a lateral oblique position which allows for a two-team approach (recipient vessel preparation, flap harvest) in microvascular reconstruction. Significant flap anatomy divergence occurs below the skin island paddle before the parent vessels return to the subscapular artery. The transverse TDAP flap, a perforator flap, can be viewed as a deep inferior epigastric artery perforator (DIEP) flap, while the IMECS flap can be viewed as the superficial inferior epigastric artery (SIEA) flap. Like the DIEP flap, the majority of the transverse TDAP flaps require intramuscular dissection in search of its parent vessel (i.e. thoracodorsal artery). Occasionally, the perforators perfusing the overlying skin paddle (horizontal or transverse) are not always located 2 cm from the anterior border of the latissimus in Doppler auscultated locations (personal experience), thus a wider dissection may be necessary in the search for a perforator. This can be disheartening since the TDAP flap could be elevated yet the perforator is absent in the designed skin island. The IMECS flap is an axial fasciocutaneous flap nourished by the transverse branch of the circumflex scapular artery, and originates from the triangular space bordered by the teres minor, teres major, and long head, triceps muscle. Like the SIEA flap, the IMECS flap does not require muscle dissection. The flap is designed along the axis formed from the ipsilateral
1748-6815/$ - see front matter ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.10.051
Transverse thoracodorsal artery perforator flaps inframammary fold to the origin of the circumflex scapular artery. In our clinical experience using the IMECS flap, we have not encountered cases where the skin paddle was inadequately perfused by the transverse branch of the circumflex scapular artery. It also does not require perforator selection decision making. The flaps are different in that the IMECS flap pedicle (6e8 cm in length) is usually shorter than the transverse TDAP flap pedicle (10e14 cm). The longer pedicle allows the TDAP flap to be used as a local flap for anterior breast/chest soft tissue defects. Because the IMECS pedicle origin is more posterior, pedicle rotation to anterior breast defects is difficult and ill advised. Both flaps can be harvested as an osteocutaneous or composite free tissue flap. The vessel diameters for both flaps are excellent for microsurgical anastomosis to recipient vessels. Finally, proper surgical wound closure is as important as scar location planning. An excessively large flap harvested even in relaxed skin tension lines can result in unfavorably widened scars. Placement of permanent ‘subfascial’
381 sutures as advocated by Ted Lockwood can aid in decreasing suture line tension (i.e. improve final scar). Both the transverse TDAP and IMECS flaps have advantages and disadvantages. Transverse skin island flap design has been confirmed to be effectively hidden with minimal donor site morbidity. Which flap is better? You be the judge.
References 1. Lee S-H, Mun G-H. Transverse thoracodorsal artery perforator flaps: experience with 31 free flaps. J Plast Reconstr Aesthet Surg 2008;61:372e9. 2. Angrigiani C, Grilli D, Siebert JW. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96:1608. 3. Guerra AB, Metzinger SE, Lund KM, et al. The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg 2004;114:32. 4. Siebert JW, Longaker MT, Angrigiani C. The inframammary extended circumflex scapular artery flap: an aesthetic improvement of the parascapular flap. Plast Reconstr Surg 1997;99:71.