Free Thoracodorsal Artery Perforator Flap Research Articles

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

BackgroundApplication 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.MethodsFrom 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.ResultsAll 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).ConclusionsThe 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.

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

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

Reconstruction of extensive scalp defects of oncologic origin using thoracodorsal artery perforator free flaps

Purpose: Ablation of malignant neoplasms of the scalp usually leaves extensive defects. Free musculocutaneous transfer using the latissimus dorsi muscle with a skin graft has been the gold standard for restoring such defects; however, this approach may be limited by potential functional morbidity and delayed healing of the grafted skin. This study presents a case series of microsurgical reconstruction with thoracodorsal artery perforator (TDAP) flaps for extensive scalp defects after radical oncologic resection.Methods: Consecutive patients with malignant scalp tumors who underwent wide local excision and defect coverage with TDAP free flaps between April 2019 and January 2023 were evaluated. Operation-related data and surgical outcomes, including donor- and recipient-site complications, postoperative shoulder function, and aesthetic results, were thoroughly assessed. As an oncologic outcome, local recurrence was also recorded.Results: Eleven patients who underwent reconstruction with an average flap size of 223.2 cm<sup>2</sup> (range, 160.0–406.0 cm<sup>2</sup>) were identified. The flaps were based on an average of 2.4 perforators. The donor-site wound was closed primarily in all cases. All flaps achieved complete wound healing within an average of 2 weeks and presented stable resurfacing of the scalp with satisfactory morphological outcomes. No functional shoulder disability was observed in the postoperative period. Five patients exhibited local recurrence but were appropriately treated in a timely manner.Conclusion: The free TDAP flap could be a potential, effective reconstructive tool for extensive scalp defects of oncologic origin and can overcome the recipient- and donor-site complications associated with the conventional procedure.

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.

Delayed Thoracodorsal Artery Perforator Free Flap for Calcaneal Degloving Injury Reconstruction

The thoracodorsal artery perforator (TDAP) flap has a long vascular pedicle that is ideal for lower extremity reconstruction, but it generally relies on the presence of a dominant septocutaneous perforator vessel. Surgical delay optimizes flap survival by creating relative ischemia to augment perforator vessels. In this report, we describe the use of a delayed free TDAP flap in the setting of an absent dominant perforator vessel for the reconstruction of a calcaneal degloving injury. A 22-year-old actively smoking patient with a body mass index of 33.5 presented with a nonhealing left heel wound with overlying necrotic changes after traumatic degloving injury. The entire weight-bearing portion of the calcaneal fat pad and the flanking regions were debrided. The TDAP flap was elevated, revealing three small thoracodorsal artery perforators. Given that a dominant perforator was absent, the flap was surgically delayed. Free-tissue transfer occurred 8 days later. This operation was conducted entirely in left lateral decubitus with simultaneous wound preparation and flap harvest. The flap was elevated on two perforators to elongate the pedicle's length and inset to cover exposed calcaneus and pad the heel. Six months postoperatively, the patient is doing well without flap compromise or ulceration. The TDAP flap is a versatile microsurgical tool, and surgical delay extends the utility of this flap when a dominant septocutaneous perforator is unavailable. Recipient site debridement may occur simultaneously with the TDAP delay procedure. Importantly, only one position is required for flap elevation, microsurgical anastomosis, and insetting, thus obviating intraoperative repositioning.

Clinicopathologic features of epidermoid cysts in the upper and lower extremities, including a case of malignant transformation in the palmoplantar region

Purpose: Epidermoid cysts are common benign skin neoplasms derived from the pilosebaceous apparatus that usually develop in hair-bearing regions such as the head and neck. Epidermal cysts rarely occur in the extremities, especially in the palmoplantar region. Therefore, they can be easily misdiagnosed as warts or calluses. Here, we present our experience treating epidermal cysts in the extremities, including a very rare case of malignant transformation into squamous cell carcinoma. Methods: This retrospective study enrolled all patients who underwent excision of epidermoid cysts in the upper and lower extremities from March 2006 to April 2021.Results: Among 249 patients, there were 10 (seven male and three female patients) who had epidermal cysts in the extremities (4.0%). All four plantar cysts were located in weight-bearing areas. One palmar epidermal cyst occurred 33 years after the trauma. There was one case of a highly recurrent epidermal cyst on the heel that was eventually diagnosed as squamous cell carcinoma arising from the cyst lining on excisional biopsy. After wide excision with a margin of 2 cm, the resulting defect was reconstructed using a free thoracodorsal artery perforator flap. Conclusion: Epidermoid cysts in the extremities, especially the palmoplantar region, are rare. Detailed history taking, including underlying diseases and trauma history, is helpful for diagnosis. Complete excision is necessary to avoid relapse and to confirm the final diagnosis, especially in cases suspected of malignant transformation arising from epidermoid cysts.

Clinical application effects of two longitudes three transverses method in perforator location of thoracodorsal artery perforator flap and deep wound repair

Objective: To explore the clinical application value of two longitudes three transverses method in the location of the perforator of thoracodorsal artery perforator and deep wound repair. Methods: The retrospectively observational study was conducted. From December 2018 to June 2020, 17 patients with deep wounds who were admitted to the Affiliated Hospital of Zunyi Medical University met the inclusion criteria and were included in this study, including 7 males and 10 females, aged 12 to 72 years. The wound areas of patients after debridement were 7 cm×3 cm to 11 cm×7 cm. Two longitudinal lines were located through the midpoint of the armpit, the posterior superior iliac spine, and the protruding point of the sacroiliac joint, and three transverse lines were located 5, 10, and 15 cm below the midpoint of the armpit between the two longitudinal lines, i.e. two longitudes three transverses method, resulting in two trapezoidal areas. And then the thoracodorsal artery perforators in two trapezoidal areas were explored by the portable Doppler blood flow detector. On this account, a single or lobulated free thoracodorsal artery perforator flap or flap that carrying partial latissimus dorsi muscle, with an area of 7 cm×4 cm to 12 cm×8 cm was designed and harvested to repair the wound. The donor sites were all closed by suturing directly. The number and location of thoracodorsal artery perforators, and the distance from the position where the first perforator (the perforator closest to the axillary apex) exits the muscle to the lateral border of the latissimus dorsi in preoperative localization and intraoperative exploration, the diameter of thoracodorsal artery perforator measured during operation, and the flap types were recorded. The survivals of flaps and appearances of donor sites were followed up. Results: The number and location of thoracodorsal artery perforators located before operation in each patient were consistent with the results of intraoperative exploration. A total of 42 perforators were found in two trapezoidal areas, with 2 or 3 perforators each patient. The perforators were all located in two trapezoid areas, and a stable perforator (the first perforator) was located and detected in the first trapezoidal area. There were averagely 1.47 perforators in the second trapezoidal area. The position where the first perforator exits the muscle was 2.1-3.1 cm away from the lateral border of the latissimus dorsi. The diameters of thoracodorsal artery perforators were 0.4-0.6 mm. In this group, 12 cases were repaired with single thoracodorsal artery perforator flap, 3 cases with lobulated thoracodorsal artery perforator flap, and 2 cases with thoracodorsal artery perforator flap carrying partial latissimus dorsi muscle. The patients were followed up for 6 to 16 months. All the 17 flaps survived with good elasticity, blood circulation, and soft texture. Only linear scar was left in the donor area. Conclusions: The two longitudes three transverses method is helpful to locate the perforator of thoracodorsal artery perforator flap. The method is simple and reliable. The thoracodorsal artery perforator flap designed and harvested based on this method has good clinical effects in repairing deep wound, with minimal donor site damage.

Clinical effect of free thoracodorsal artery perforator flap in reconstructing large scar on the facial subunit

Objective: To explore the clinical effect of free transplantation of thoracodorsal artery perforator flap in reconstructing large scar on the facial subunit. Methods: From April 2014 to March 2018, 7 patients with large facial scar were admitted to Ningbo NO.6 Hospital, including 3 males and 4 females, aged from 31 to 49 years, 4 with frontal involvement and 3 with chin and neck. Color Doppler ultrasound was used for the positioning of the thoracodorsal artery perforating vessel, and scar resection was performed according to the principle of facial subunit repair. The wound area was 8 cm×6 cm-21 cm×8 cm, and the wound was repaired with the free thoracodorsal artery perforator flap in the area of 9 cm×7 cm-22 cm×9 cm. The donor site was closed directly by suturing. The consistency of the location of the perforating vessel explored during the operation with its preoperative positioning and the flap survival were recorded. The color, texture, and appearance of the flap and the healing condition, scar formation, and function of the donor area were observed during follow-up. Results: The locations of the perforating vessels of 7 patients explored during the operation were consistent with those positioned by color Doppler ultrasound before the operation. All the flaps of the 7 cases survived successfully after operation. Postoperative follow-up of 12-18 months showed that the flap color was similar to the surrounding skin of the recipient area, with soft texture and no obvious contracture. Slight bloated appearance was observed in the flaps of 4 cases. All the 7 patients had postoperative healing of the flap donor site without obvious scar hyperplasia or influence on shoulder joint function. Conclusions: The anatomy of the perforating vessel of the thoracodorsal artery perforator flap is relatively constant and the flap can be cut in large area with soft texture, good appearance, and concealed donor area, which is a good choice for reconstructing large scar on the facial subunit.

Clinical Applications of the Thoracodorsal Artery Perforator Flap in Extremity Soft Tissue Reconstruction

Introduction: For a long time, the free or pedicled thoracodorsalartery perforator (TDAP) flaps were used for reconstructionof large cutaneous defects. These may be regionalsoft tissue defects of trunk, axilla and breast where the pedicledflap used, or distant tissue defects of face, elbow, forearmand lower extremity where the free TDAP flap is used.Aim of the Study: This study aimed to evaluate the clinicalapplications of the thoracodorsal artery perforator flap (TDAP)either free or pedicled in the reconstruction of soft tissuedefects of extremities.Patients and Methods: This study was conducted on 20patients admitted to the Plastic Surgery Departments of bothTanta & Al Azhar Universities during the period from September2015 to December 2017. These patients were presentedby extremity soft tissue defects that required a flap reconstruction.Results: The results showed that the TDAP flap is aversatile and robust flap in soft tissue reconstruction of theextremities. This flap has great advantages as a long vascularpedicle; large skin paddle can be harvested, minimal donorsite morbidity and thin skin paddle to resurface shallowdefects. The TDAP flap showed also some drawbacks likemeticulous and time-consuming dissection of the perforators,donor site scar widening.

Reconstruction of the soft tissue defects of limbs using the free thoracodorsal artery perforator flaps

Objective To investigate the clinical effects of reparing the complicated soft tissue defects of limbs with free thoracodorsal artery perforator(TDAP) flaps. Methods From April, 2009 to March, 2014, 19 limbs (including 8 upper limbs and 11 lower limbs) soft tissue defects with bone and tendon exposure were repaired with free TDAP flaps in the secondary stage. There were 12 thoracodorsal artery perforator flaps, 5 polyfoliate perforator flaps, 1 chimeric muscle flap, and 1 chimeric muscle polyfoliate flap. The sizes of the flaps ranged from 5.0 cm×6.0 cm-20.0 cm×11.0 cm. Seventeen wounds of the dornor site were closed directly, and the other 2 were closed with skin grafts. Results Sixteen flaps survived successfully. Two flaps had venous congestion and survived at last after taking the stitches out. One flap had partial necrosis and repaired by skin graft finally. The clinical results were satisfactory after 12-18 months following-up, and the scars of the dornor sites of all but 3 patients were not obvious. All the shoulder function were normal. Conclusion The TDAP flap has dependable blood supply, good texture, less dornor site morbility. The polyfoliate TDAP flap can be used for repairing irregular defect. The chimeric latissimus TDAP flap can be used for the function reconstruction. The free TDAP flap is suited for repairing soft tissue defects of the limbs. Key words: Thoracodorsal artery perforator flap; Polyfoliate flap; Limbs; Soft tissue defect; Transplantation

Comprehensive Analysis of Donor-Site Morbidity following Free Thoracodorsal Artery Perforator Flap Harvest.

The authors evaluated donor-site morbidity following free thoracodorsal artery perforator flap harvest comprehensively and investigated patient-and operation-related factors that might contribute to adverse outcomes. A retrospective analysis was conducted for all cases of free thoracodorsal artery perforator flap reconstruction performed between January of 2002 and December of 2014. Donor-site morbidity was evaluated in three aspects: postoperative complications, scar-related problems, and functional impairment. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was administered postoperatively to assess donor-site function. A total of 293 patients were analyzed. The median follow-up period was 19.0 months. Donor-site complications developed in 33 patients (11.3 percent). Wound dehiscence (7.4 percent) and seroma (3.0 percent) were the most common complications. Harvesting thoracodorsal artery perforator flaps on multiple perforators or segmental latissimus dorsi muscle-chimeric flaps increased the rate of seroma formation but did not affect other donor-site morbidities significantly. Patient American Society of Anesthesiologists classification was a significant predictor of wound dehiscence and overall donor-site complications. Thirty-one patients (10.6 percent) had scar-related problems, including 18 hypertrophic and 13 widened scars. A transverse skin paddle design had a significant protective effect on developing scar-related problems, compared with the nontransverse design. The mean Quick-Disabilities of the Arm, Shoulder and Hand questionnaire score was 2.68 (range, 0 to 18.2), and 90 percent of patients scored less than 10. Flap dimensions were positively correlated with the questionnaire score. The present study suggests that the free thoracodorsal artery perforator flap is associated with low donor-site morbidity and minimal dysfunction. Careful consideration of patient condition and thoughtful planning could further minimize donor-site morbidity. Therapeutic, IV.

Velopharyngeal function after free thoracodorsal artery perforator flap in lateral and superior oropharyngeal cancer.

The purpose of this study was to report our experience with the free thoracodorsal artery perforator flap for reconstruction of the oropharynx and soft palate in head and neck cancer using a retrospective review of the medical charts of all patients undergoing oropharyngeal reconstruction by free thoracodorsal artery perforator flap during the same procedure as cancer resection between January 2011 and April 2013. Evaluation of speech, feeding and the presence of nasal emissions was performed 6 months after treatment in accordance with the Declaration of Helsinki. Nine patients were evaluated. Clear understanding of the patient was reported by the family and the examiner for seven patients, while understanding difficulties were reported for two patients (1 case of flap dehiscence and 1 technical error of flap fixation). The results indicated that, due to its complex anatomy and function, reconstruction of the soft palate remains a delicate procedure. The free thoracodorsal artery perforator flap allows functional soft palate reconstruction, while limiting donor site morbidity.

The clinic application of thoracodorsal artery perforator flap: a report of 16 cases

To investigate the effects of free and pedicled thoracodorsal artery perforator (TDAP) flaps for repairing skin and soft tissue defects in limbs, neck, axillary and shoulder. From October 2009 to Auguest 2011, 16 TDAP flaps were used to repair skin and tissue defects. Among them, five ipsilateral pedicled flaps were used to repair wounds in neck, axillary and shoulder. 11 free TDAP flaps were used to repair the wounds with bone or tendon exposure. In 12 cases, the flaps were pedicled with thoracodorsal artery and vein-lateral branches-perforators, in 4 cases, pedicled with thoracodorsal artery and vein-serratus anterior muscular branches-perforators. The deep fascia, the latissimus dorsi and thoracodorsal nerve were not included in all flaps. The flaps size ranged from 10 cm x 5 cm to 26 cm x 10 cm. All 16 flaps survived completely with primary healing both at donor site and recipent area. After a follow-up of 3 to 24 months, all flaps gained good texture and appearance. Only linear scar was left at donor area. The shoulder could move freely. TDAP flap has good texture, long vascular pedicle,and reliable blood supply, leaving less morbidity at donor site. The latissimus dorsi and thoracodorsal nerve are also preserved. The pedicled TDAP flap is an ideal flap for repairing the ipsilateral skin and soft tissue defects of the neck, shoulder, axillary. The free TDAP flap is suited for repairing skin and soft tissue defects of the extremities.

Plantar reconstruction with free thoracodorsal artery perforator flaps

The plantar region presents unique challenges for reconstructive surgeons. Reconstruction using a thoracodorsal artery perforator (TDAP) flap yields favourable results in various fields of microsurgical reconstruction, but reports on the reconstruction of plantar defects are sparse. Here, the authors present their experience in the reconstruction of various defects in the plantar region using free TDAP flaps. From January 2005 to July 2011, 40 free TDAP flaps were transferred for reconstructive purposes to restore skin and soft-tissue defects in the plantar region. Hospital and outpatient records were reviewed independently for all patients. A patient questionnaire including five questions was administered to subjectively evaluate reconstructive results. A total of 24 male and 16 female patients were enrolled in this study. The mean age was 47.8 years and ranged from 7 to 77 years. The most common cause of defect was oncology related (n=21), followed by trauma-related (n=11), diabetes-related (n=6) and other causes. The average flap size was 63.7 cm2 and ranged from 25 to 212 cm2. All flaps survived except for one, resulting in a below-knee amputation. The mean follow-up period was 20.4 months. Four patients underwent secondary revisional procedures, including simple defatting in two patients and excision of redundant skin due to flap instability in two patients. The satisfaction surveys were completed by 34 (85%) patients. Patients reported high levels of satisfaction in terms of pain, limitation of daily activities, donor site satisfaction and overall satisfaction. Most patients were satisfied and reported that they would recommend the procedure to others. An appropriately thinned free TDAP flap with thick skin provided favourable outcomes with high patient satisfaction and is a valuable option for the restoration of skin and soft-tissue defects in the plantar region.

The free thoracodorsal artery perforator flap in head and neck reconstruction

European Annals of Otorhinolaryngology, Head and Neck Diseases - Vol. 129 - N° 3 - p. 167-171

Free or Pedicled Thoracodorsal Artery Perforator Flap for Repair of Soft Tissue Defect on the Upper Limb

Free or Pedicled Thoracodorsal Artery Perforator Flap for Repair of Soft Tissue Defect on the Upper Limb

Comparison of Clinical Outcomes between Single- and Multiple-Perforator–Based Free Thoracodorsal Artery Perforator Flaps

Although thoracodorsal artery perforator flaps have not gained popularity in the reconstructive era, the results of recent studies regarding the vascularity of thoracodorsal artery perforator flaps are promising. In the present study, the authors aimed to determine the clinical outcomes of free multiple-perforator versus single-perforator thoracodorsal artery perforator flaps. Eighty-seven patients with various defects underwent reconstruction with free thoracodorsal artery perforator flaps. The flap was used for upper extremity reconstruction in 43 patients (49.4 percent), for head and neck reconstruction in 16 patients (18.4 percent), and for lower extremity reconstruction in 28 patients (32.2 percent). Of the 87 flaps, 48 (55.2 percent) were based on a single perforator, whereas 39 flaps (44.8 percent) were based on multiple perforators. The single- and multiple-perforator-based thoracodorsal artery perforator flaps were compared regarding clinical outcomes and morbidity. The morbidity rate was found to be significantly higher in the single-perforator-based group. Of the patients in the single-perforator group, seven patients had transient venous congestion, five were heparinized and treated with leeches for permanent venous congestion, six had partial necrosis, and one had total necrosis. In the multiple-perforator-based group, two patients had transient venous congestion, and no partial or total necrosis was observed. Despite the fact that dominant perforators may often be absent, this study showed that a multiple-perforator-based thoracodorsal artery perforator flap may be more reliable with safe vascularity compared with a single-perforator-based flap.

Postoperative leucocytoclastic vasculitis in free flap mimicking venous insufficiency

A 29-year-old man, who had been diagnosed with myelodysplastic syndrome 1 year before, developed a wound on his thigh and knee due to necrotising fasciitis. Forty h after a free thoracodorsal artery perforator flap transfer, the colour of the flap changed from pink to purple, starting from the peripheral margin and epitheliolysis proceeded. Within a week, the colour returned to normal spontaneously and the flap survived completely. On punch biopsy, the lesion was confirmed as leucocytoclastic vasculitis, necrotising inflammatory disease of the small vessels in the dermis. This case demonstrates that leucocytoclastic vasculitis mimics postoperative venous insufficiency of a free flap; hence, differential diagnosis by careful judgement of vascular status is required. This rare occurrence needs to be considered in free-flap monitoring, especially in immunosuppressed patients.

Impact of Perforator Mapping Using Multidetector-Row Computed Tomographic Angiography on Free Thoracodorsal Artery Perforator Flap Transfer

The preoperative localization of thoracodorsal artery perforators has been a challenge because of their topographic variation. From November of 2005 to January of 2007, 25 patients underwent free thoracodorsal artery perforator flap transfer for reconstruction of the lower extremities (22 flaps) and the head and neck (three flaps). All of the patients underwent multidetector-row computed tomographic angiography for preoperative perforator mapping. The computed tomographic findings were compared with the acoustic Doppler flowmetric and intraoperative findings. Surgical outcomes were compared with those of a historical group of patients treated before the adoption of computed tomography-based perforator mapping. The flap sizes ranged from 3 x 5 cm to 27 x 13 cm. One to four perforators (mean, 2.2) were marked on the three-dimensional computed tomographic image for each patient and the locations correlated with the handheld Doppler examination. Intraoperatively, all perforators marked were confirmed, and three additional perforators that had not been identified on the computed tomographic images were observed. All of the flaps survived, with the exception of two cases with marginal necrosis. Concrete planning based on knowledge of the precise location of the perforators allowed a shorter harvest time, minimized the incision for flap harvest, particularly with small flaps, and enabled the planned use of multiple perforators for better perfusion or complex designs. Perforator mapping with preoperative multidetector-row computed tomographic angiography is valuable for both planning and executing thoracodorsal artery perforator flap transfer. The targeted perforator flap harvesting allows a safe and straightforward harvest and an elegant reconstruction, with less donor-site morbidity.

Using a free thoracodorsal artery perforator flap for phallic reconstruction – A report of surgical technique

The free forearm flap and free fibular osteocutaneous flap are currently the most popular techniques used in phalloplasty. However, many complications at donor sites in both flaps have been reported. As an alternative, the thoracodorsal artery perforator flap is a versatile flap used for the resurfacing of various soft tissue defects and it has many advantages. We report the first phallic reconstruction using a free thoracodorsal artery perforator flap in a female-to-male transsexual. A 24-year-old female received phalloplasty and her major concerns included the location of the donor site scar, the appearance and sufficient size of the neophallus, and the ability to void while standing. We performed a three-stage operation. Preoperative colour Doppler sonography was executed to identify and mark the penetrating points of the skin perforators, which were derived from the descending branch of the thoracodorsal artery, and their suprafascial courses at her right side axillary and back region before the first stage operation. Three skin perforators were identified in all. During urethral prefabrication in the first stage operation, the sonographic information guided us to ward off injury to the suprafascial portions of the skin perforators. In the second stage operation, a 26 x 9.5 cm thoracodorsal artery perforator flap was designed and elevated. Glans sculpting with a modified Norfolk technique was performed in the third stage operation. No flap necrosis, donor site morbidity, urethral stricture or urethrocutaneous fistula developed in the patient. The neophallus was 14 cm in length and 3.5 cm in diameter. It allowed voiding while standing and the appearance met the expectation of our patient. The patient was satisfied with the donor site scar because it was not located at extremities and it could easily be hidden by the arm or by underwear. The thoracodorsal artery perforator flap is a good option when the patient desires an easily hidden donor site scar and covets a large-sized neophallus. Preoperative colour Doppler sonography is valuable in identifying the location of the penetrating points and the suprafascial courses of skin perforators. It facilitates prefabrication of the urethra, assists in the design of the flap, prevents injury to skin perforators during elevation of the flap, and decreases the risk of flap necrosis.