Lateral Thoracic Perforator Research Articles

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

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. 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. 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. 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.

The Ultrasound Evolution of Lateral Thoracic Perforator Flaps Design and Harvest for Partial and Total Breast Reconstruction.

The lateral thoracic area is a known source for perforator flaps for partial breast reconstruction. In this paper, we report our experience in designing and harvesting lateral thoracic perforator flaps for partial and total breast reconstruction with the introduction of the "propuller" concept. Between September 2013 and August 2021, 95 flaps were performed for immediate, partial and total breast reconstruction. On a total of 95 flaps, 30 (19 thoracodorsal artery perforator(TDAP) flaps, 10 lateral intercostal artery perforator(LICAP) flaps and 1 lateral thoracic artery perforator(LTAP) flap) were harvested in the traditional fashion (control group) and 65 (57 LICAP, 2 LTAP and 6 TDAP flaps) according to the propeller concept (study group). All cases were preoperatively planned with Color-Coded Duplex Ultrasound. No flap losses were experienced in both groups. The mean operative time was 156 minutes (range 118-234) for the control group and 75 minutes (range 53-125) for the study group (p<0.0001). A significantly higher number of LICAP flaps were chosen in the study group compared to control group. None of the patients had donor site complications. Patients' and Surgeons' satisfaction was high to very high. The ultrasound preoperative planning led to the development of an easier and safer method of local perforator flap harvesting, that we named as propuller design. Its novelty lies in that perforator intraoperative selection and fully skeletonization are not needed and a more efficient flap movement (propeller plus advancement) which transfers more tissue into the new breast can be achieved safely, faster and easier.

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

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. 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. 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. 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.

Repair of skin and soft tissue defects in shoulder and elbow with rotator scapular artery perforator flap, lateral thoracic perforator flap, or medial brachial artery perforator flap

From January 2014 to June 2018, 12 patients with skin and soft tissue defects in shoulder and elbow were admitted to General Hospital of Ningxia Medical University with skin and soft tissue defect size of 6 cm×5 cm to 11 cm×8 cm, including 9 males and 3 females aged 15-56 years. Wounds of 5 patients were repaired with rotator scapular artery perforator flap (flap area of 8 cm×7 cm to 12 cm×6 cm), and the donor flap area was sutured directly. Wounds of 3 patients were repaired with lateral thoracic perforator flap (flap area of 8 cm×7 cm to 13 cm×9 cm). The donor flap area of two patients was sutured directly, the majority of the donor flap area of one patient was sutured directly, and a small part was covered by split-thickness skin graft from ipsilateral thigh. Wounds of 4 patients were repaired with medial brachial artery perforator flap (flap area of 6 cm×5 cm to 12 cm×10 cm). The donor flap area of two patients was sutured directly, and two patients were covered with split-thickness skin graft from left chest wall. The flaps of 11 patients survived after surgery. Blood flow disorder at the distal end of the flap was observed in one patient. After treatment, the distal end of the flap presented 3 cm×2 cm necrosis, and the skin graft survived after second skin grafting and debridement. During the follow-up of 6 to 24 months post surgery, all patients had good texture of flap, with light scar hyperplasia in the donor flap area, and good recovery of elbow and shoulder joint function. The rotator scapular artery perforator flap, lateral thoracic perforator flap, and medial brachial artery perforator flap with the advantages being of relatively simple operation, high survival rate, and good surgical outcome, are good choices for repairing the skin and soft tissue defects in shoulder and elbow.

Application of Tissue Expansion with Perforator Flaps for Reconstruction of Challenging Skin Lesions

One set of perforators can supply its own perforasome as well as the adjacent perforasome. The process of tissue expansion can mimic the effect of surgical delay to include more perforasomes into the perforator flap. By combining the perforasome theory with the technique of tissue expansion, large and various expanded perforator flaps can be achieved. From July 2007 to July 2014, we performed eight different types of expanded perforator flaps in a total of 83 cases: 41 supraclavicular artery perforator flaps, 11 superficial cervical artery perforator flaps, 15 lateral thoracic perforator flaps, 6 internal mammary artery perforator flaps, 6 thoracoabdominal perforator flaps, 2 facial artery perforator flaps, 1 posterior interosseous perforator flap, and 1 ulnar collateral artery perforator flap. During the follow-up period, the survival rate, color, texture, and retraction of the flaps were assessed. The dimensions of the flaps ranged from 8 × 6 to 25 × 25 cm. Minor flap necrosis occurred in 20.5% of the cases, and severe flap necrosis developed in 2.4% of the cases. The donor sites were closed primarily in all but three cases. During the follow-up period (average, 13 months; range, 8-18 months), no flap contracture was observed with a good color and texture match. By combining the concept of perforasome with the technique of tissue expansion, flaps with large dimensions and reliable blood supply can be achieved, allowing a more flexible design to reconstruct various and challenging skin lesions.

Preoperative color Doppler ultrasound assessment of the lateral thoracic artery perforator flap and its branching pattern

The anatomy of the lateral thoracic artery perforator flap remains controversial, but this region is extremely useful as a reconstructive donor site. In this report, we describe the usefulness of the preoperative color Doppler ultrasound evaluation for the harvesting of the lateral thoracic artery perforator flap, and we clarify its branching pattern. Twenty-seven patients underwent the preoperative color Doppler ultrasound assessment before perforator flaps were harvested. We evaluated the branching pattern and the diameter of the flaps by direct observation. All flaps were successfully transferred, and it was found that the branching pattern of the lateral thoracic perforator is divided into three groups: the superficial branch, the medial branch, and the deep branch. Their appearance ratios were 48.1% (13/27), 14.8% (4/27), and 81.5% (22/27), respectively. The lateral thoracic artery perforator flap has a great deal of anatomical variation, and vessels with relatively small diameters compared to those of other flaps. This is why flaps from this region are not currently popular. This study revealed the superiority of the color Doppler ultrasound for preoperative planning of the lateral thoracic artery perforator flap elevation. Furthermore, the branching pattern and the diameters of the different branches were specified.

Another option of perforator flap in the lateral thoracic area: lateral thoracic perforator flap.

The lateral thoracic donor site provides two types of perforator flap; the latissimus dorsi perforator flap based on the musculocutaneous perforator, and the thoracodorsal perforator flap based on the septocutaneous perforators from the thoracodorsal artery. In this article, we introduce a direct cutaneous perforator derived from the lateral thoracic artery, which provides another option for harvesting a perforator flap from the lateral thoracic region. Overall 17 patients underwent reconstructions using the lateral thoracic perforator flap for defects resulting from tumor-ablative surgery in the head and neck region, chronic osteomyelitis, and trauma or chronic wounds of the lower extremities. All flaps survived without major complications and six of the flaps were harvested in a chimeric pattern. When the latissimus dorsi and thoracodorsal perforator flaps are not suitable, the lateral thoracic perforator flap provides another option from the lateral thoracic region that is useful for a variety of reconstructions. However, anatomic variation and the shorter and smaller pedicle compared with the thoracodorsal vessels are drawbacks of the lateral thoracic perforator flap that make it difficult to approach. The combination of the versatility of the previous two perforator flaps based on the thoracodorsal system and this additional type of lateral thoracic perforator flap makes the lateral thoracic region a universal donor site.

A perforator-based dorsal flap's experimental research in the rat

To develop a new experimental animal model of different a single perforating vessel as its pedicle, and to investigate this vessel can captures how many adjacent angiosomes in different directions. Thirty-six Sprague-Dawly rats of both sexes were used. The rats were divided into group A, group B and group C. Group A: the unilateral deep circumflex iliac perforator artery- based flap. Group B: the unilateral posterior intercostal perforator artery-based flap. Group C: the unilateral lateral thoracic perforator artery-based flap. An extended dorsal perforator flap measuring up to 13 cm x 6 cm was designed in 36 rats to assess the viability of the flap. The upper margin was located at the level of the tip of the scapula and the lower margin at a level 1 cm below the iliac crest. All flaps were observed for 7 days postoperatively, 72 hours after flap elevation, observe flap dyeing conditions through the vivo fluorescein injection, the surviving flap area was calculated as a percentage of total flap dimensions and the angiosome's structure of the flap was displayed by radiopaque microangiography. No fluorescence was visible in the distal flap of groups A and C, the whole flap show bright fluorescence in group B. Survival rate of C, A, B were improved in order. Statistic difference is significant (P < 0.01) between group and group. In group A, lead oxide-gelatin angiography shows the cephalic flap necrosis occurred in the bilateral lateral thoracic territories, and the vascular architecture partly disappeared in the necrotic area. In group B, the vascular architecture of flap is unbroken. In group C, the caudal flap necrosis occurred in the bilateral deep circumflex iliac perforator artery territories, and the vascular architecture partly disappeared and disordered in the necrotic area. The perforator flap is based centrally on a single perforator, this vessel can capture multiple the second vascular territory. In a direction, the longest distance that the blood supply can reach is the point of the third perforator vessel puncture into skin, which can provide certain theoretical guidance for designing of perforator flap.

Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region

Perforator flaps from the lateral thoracic region have not been as popular as other donor sites because of the misconception that the vascular anatomy in this region is less than predictable. However, the skin over the lateral thoracic region is vascularised by three rows of perforators of varied vascular dominance. Two perforator flaps from this region based on the middle and the posterior row of perforators from the thoracodorsal artery have been described. The lateral thoracic perforator flap based on the anterior row of perforators is another useful option. Nine patients underwent reconstructions using the lateral thoracic perforator flap for various defects in the head and neck region and lower limbs as a result of tumour extirpation, crush injury and chronic wound with osteomyelitis. All flaps were raised in the supine position. Three flaps were raised in a chimaeric fashion. The largest flap was 20×12 cm and the mean size was 106 cm2. All flaps survived without major complication. The lateral thoracic perforator flap is a reliable reconstructive option. It can be readily configured in terms of size, thickness and tissue composition. However, it is not the first-choice flap from this region because the resultant donor scar tends to extend visibly beyond the anterior axillary fold and the arterial and venous pedicles frequently have separate courses. The lateral thoracic region has become a versatile and universal donor site for free-style flap harvest with this additional flap option.