Pedicled Thoracodorsal Artery Perforator Research Articles

610. NOVEL HYBRID TECHNIQUES FOR DELAYED RECONSTRUCTION OF THE CERVICAL PART OF A LEFT COLON INTERPOSITION: A CASE REPORT

Abstract Conduit necrosis following colon interposition for esophageal replacement is a devastating complication with a high morbidity and mortality rates. Survivors often face a challenging journey of complex reconstructive procedures. A multi-disciplinary approach is paramount to tailor the management according to the patient's anatomy, nutritional and psychological status, conduit alternatives and routes. This case report provides a series of novel reconstructive techniques, each of which could be helpful for esophageal surgeons facing such difficult situation. A 36 years old female, with a history of corrosive ingestion at the age of 5 years, who was subjected to series of regular dilatation since then, presented with a tight stricture not passing a wire. She underwent a subcutaneous isoperistaltic left colon interposition. The postoperative course was complicated with necrosis of the cervical part of the graft with infection of the subcutaneous tunnel. Resection was done with esophagostomy and colostomy in the neck. The patient survived the acute stage, feeding was established through the colostomy opening in the neck. Delayed reconstruction was planned 6 months later. The skin between the two openings in the neck was considered posterior wall of the conduit, and transaxillary pedicled thoracodorsal artery perforator flap (TDAP) was used to reconstruct the anterior wall (1,2). Partial flap loss occurred (3). Debridment and gastrostomy were done. The result was two gaps on both ends of the flap (3). The food regurgitated upwards from the gastrostomy. An antireflux stent was placed inside the flap to bridge the defects and allow oral intake (4). The TDAP-colon side was closed using a local flap from TDAP and skin graft (5,6). The esophageal side was closed primary and covered by a supraclavicular flap (7-12). Management of graft failure should focus on controlling sepsis and nutrition. Attempts should be made to preserve any surviving part of the conduit as long as it doesn’t add to sepsis. A combination of Myocutaneous flaps could be used to replace the cervical part of the conduit as TDAP and supraclavicular flaps. Stent could be used successfully to bridge a failure in a skin flap. Finally, a dedicated team is paramount for a successful outcome.

Cubital fossa defect- our reconstructive experience with pedicle flaps

IntroductionCubital fossa wounds can be complicated by the non-availability of reliable, well-vascularized donor tissue. Closure with pliable and readily available donor tissue for cubital defect and early mobilization of the elbow joint is essential for better results. The authors did this study to see how best the results of cubital fossa defect cover can be achieved by pedicle flaps in a single stage without compromising the donor areas. Material and methodPatients having deep elbow wounds in which vital structures were lying exposed in the cubital region were included in this study. The patients were assessed for the availability of tissue for cover, reliability of flaps, flap pliability, the functional outcome of the elbow and donor site morbidity. ResultsA total of 17 cases of cubital region defects are presented wherein closure of the wound by means of primary closure was not possible. Out of these, eight were covered with Pedicled Thoracodorsal Artery Perforator (TDAP) flaps, five with Pedicled split Latissimus Dorsi Muscle (SLDM) flaps and four with reversed lateral arm flaps (RLA). Post-operatively all the flaps were healthy, patients attained a good range of elbow joint movements with no clinically evident morbidity of the donor site. ConclusionCubital fossa defect coverage needs dedicated planning to obtain a sturdy tissue for cover. In the presence of local tissue damage or scarring, we have looked elsewhere to bring pliable and well-vascularized tissue which is reliable. The flaps we used have allowed single-stage reconstruction and early mobilization of the elbow joint with good functional recovery.

Pedicled thoracodorsal artery perforator flap in the soft-tissue reconstruction of an acute traumatic cubital fossa defect

Complex cubital fossa injuries with bony and vascular injuries are not an uncommon clinical presentation after trauma to the elbow. The revascularization of the upper limb by brachial artery repair with the venous graft is paramount, followed by immediate cover with a sturdy flap to salvage the limb. The use of local muscle and fasciocutaneous flaps is limited in the setting of vascular injury. The pedicled latissimus dorsi muscle flap and abdominal flaps are routinely used with few advantages. This article describes the use of a pedicled thoracodorsal artery perforator flap in the management of acute traumatic cubital fossa defect. A retrospective observational study was performed from September 2015 to December 2020 with patients who underwent the pedicled TDAP flap as a soft-tissue cover of cubital fossa injuries primarily. Patient variables, including the size of defect and flap, the number of perforators, the complications, and the outcome, were recorded. Eleven patients were included in the study. The majority of the patients were males (n=10) and presented with a history of trauma in a road traffic accident (n=6) or because of a fall from height (n=4). All of them (n=11) had some form of bony injury. Seven patients in this group required brachial artery repair with an interposition vein graft successfully covered with a TDAP flap. There was a constant dominant musculocutaneous perforator about 10-13cm from the apex of the axilla. At discharge, all flaps had settled well. On follow-up ranging from 2 months to 2 years, the patients reported satisfactory outcomes.

The Value of Dynamic Infrared Thermography in Pedicled Thoracodorsal Artery Perforator Flap Surgery.

Background:Dynamic infrared thermography (DIRT) is a noninvasive imaging technique that can provide indirect and real-time information on skin perfusion by measuring skin temperature. Although used in flap surgery, there are no reports on its value in procedures using a pedicled thoracodorsal artery perforator (TDAP) flap. The aim of this study was to assess the usefulness of DIRT in preoperative perforator mapping and in monitoring intra- and postoperative flap perfusion of pedicled TDAP flaps.Methods:This prospective study comprised 21 patients (21 flaps) scheduled for reconstructive surgery with a TDAP flap. Perforator mapping was done by DIRT, handheld unidirectional Doppler ultrasound, and computer tomography angiography. Intra- and postoperative flap perfusion was assessed by clinical signs and with the use of DIRT and handheld unidirectional Doppler ultrasound.Results:Perforator mapping with DIRT showed that first-appearing bright hotspots were always associated with arterial Doppler sounds and suitable perforators intraoperatively. Computer tomography angiography presented useful information on the thoracodorsal artery branching pattern but was less beneficial for perforator mapping. Intra- and postoperative flap monitoring with DIRT was more useful than handheld unidirectional Doppler ultrasound and clinical signs to detect early arterial and venous perfusion problems. DIRT demonstrated that TDAP flap perfusion is a dynamic process with an increase in perfusion during the first operative days. Nineteen flaps survived, of which 3 sustained distal necrosis. Two flaps were lost due to inadequate blood perfusion.Conclusion:DIRT provides valuable real-time information for perforator mapping and for monitoring TDAP flap perfusion intra- and postoperatively.

Effect of pedicled thoracodorsal artery perforator flap on the repair of moderate to severe axillary scar contracture deformity

Objective: To investigate the effect of pedicled thoracodorsal artery perforator (TDAP) flap on the repair of axillary moderate to severe scar contracture deformity. Methods: From January 2012 to January 2017, 29 patients with axillary moderate to severe scar contracture deformity were admitted to the the Second Xiangya Hospital of Central South University, including 18 females and 11 males, aged 14-42 years. There were 3 patients with cicatricial contracture deformity of bilateral axillas and 26 patients with cicatricial contracture deformity of unilateral axilla. After relevant preoperative examinations were completed and basic diseases were controlled, axillary scar was removed or released under the anesthesia of endotracheal intubation. The areas of wounds ranged from 7.5 cm×5.0 cm to 21.0 cm×8.5 cm after the operation. The pedicled TDAP flaps were used to repair the defects, which were thinned based on demand of the recipient sites before being transferred. The areas of flaps ranged from 9.0 cm×6.0 cm to 22.0 cm×10.0 cm. The donor sites were sutured directly. The status of thinned flaps, the survival of flaps after the operation and during follow-up, and the shoulder joint function during follow-up were observed. Results: Thirty-two pedicled TDAP flaps were harvested for repairing the defects. Among them, 14 flaps were transferred directly without thinning and the thickness of the flaps ranged from 9.0 mm to 15.0 mm, with average thickness of 13.6 mm.While the other 18 flaps were thinned, and the thickness of the thinned flaps ranged from 5.0 mm to 8.0 mm, with average thickness of 7.5 mm. The distal parts of 3 flaps in 3 patients showed small size of blackening or necrosis within 72 hours after the operation, and 2 of them were thinned and the other one was not. Finally, the 3 flaps were healed after hyperbaric oxygen therapy, dressing change, or other treatments. One flap occurred vein congestion 8 hours after the operation caused by pressure on the pedicle, and the color of the flap turned back to normal after the pressure was relieved. The rest of the flaps survived well. All the patients were followed up for 9 to 36 months, with an average of 18 months. All the flaps survived well, the color of the flaps was nearly the same as the recipient sites, and none of the flaps developed obvious contraction. The shoulder joint function of all patients was significantly improved compared with that before operation, with abduction angles of shoulder joints ranged from 90.0-145.0°, with an average of 130.0°. Conclusions: Pedicled TDAP flap is an relatively ideal choice for the repair of moderate to severe axillary scar contracture deformity, and better results will be achieved if the flaps are thinned to a appropriate thickness according to the condition of axillary defects.

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.

Axillary Reconstruction Using a Pedicled Thoracodorsal Artery Perforator Flap Including Latissimus Dorsi Muscle Strip

For axillary reconstruction, most reconstructive surgeons use the latissimus dorsi flap because of its usefulness and reliability. However, the latissimus dorsi musculocutaneous flap poses complications such as donor site morbidity and poor aesthetic results. Moreover, the thoracodorsal artery perforator (TDAP) flap, without muscle, presents difficulties for the delicate procedure of dissecting the perforators separately. Therefore, we propose the use of a pedicled TDAP flap including a latissimus dorsi muscle strip for axillary reconstruction, as it is believed to be easier and safer to perform.

Giant congenital melanocytic nevus of the upper extremity: Coverage with a pre-expanded pedicled thoracodorsal artery perforator flap and re-expanded transferred flap

Giant congenital melanocytic nevus of the upper extremity: Coverage with a pre-expanded pedicled thoracodorsal artery perforator flap and re-expanded transferred flap

Versatility of the Pedicled Thoracodorsal Artery Perforator Flap (TDAP) Anatomic Basis and Clinical Application in breast reconstruction

Background: the thoracodorsal artery perforator (TDAP) flap is relatively new member of perforator flap family in reconstructive surgery. TDAP flap used as pedicled flap in breast reconstruction. Advantages of the TDAP flap include homogenous flap thickness, minimal donor-site morbidity, and constant vascular anatomy with a long pedicle. Aim: to study versatility of the pedicled thoracodorsal artery perforator flap and evaluate its role in breast reconstruction. Methods: This prospective cohort study was conducted in Zagazig university Hospitals during the period from January 2018 till January 2019 on 20 patients with breast cancer who have been subjected to breast surgery and immediate breast reconstruction. Results: the mean time taken for flap elevation was 266 ± 18 minutes, flap elevated with single perforator in 85 % of the cases and with double perforators in the remaining 15%. The mean skin paddle diameters were 15.6 ± 3.3 cm in length and 7.2 ± 2.1 cm width. The donor side was closed by primary closure in 90% while two cases (10%) needed grafting for closure. Objective and subjective assessment for the post procedure satisfaction showed that around 90% of the population was satisfied by the result. Conclusion: The TDAP has several advantages that make it a work horse for many soft tissue reconstructions in appropriately selected patients. The drawback of the TDAP can be manipulated by some technical modification.

Pedicled Thoracodorsal Artery Perforator Flap to Resurface Locoregional Soft Tissue Defects-A Prospective Study

Pedicled Thoracodorsal Artery Perforator Flap to Resurface Locoregional Soft Tissue Defects-A Prospective Study

Pedicled Thoracodorsal Artery Perforator and Muscle-Sparing Latissimus Dorsi Flaps in the Axillary Reconstruction After Hidradenitis Suppurativa Excision: Functional and Aesthetic Issues.

Wide axillary reconstruction after hidradenitis suppurativa (HS) excision still represents a great challenge. Thoracodorsal artery perforator flap is one of the most reliable local reconstructive techniques. Although its anatomy and harvesting technique have been well described, specific reconstructive criteria still lack. The aim of this study was to help surgeons in planning axillary reconstruction on flaps based on the thoracodorsal artery. Twelve patients affected by HS at Hurley stage III underwent wide "en block" excision and immediate reconstruction with 15 local thoracodorsal artery perforator flaps and 2 muscle-sparing latissimus dorsi flaps. A thorough chart review has been performed with preoperative and postoperative photographic documentations. Early and late complications have been analyzed. A total of 15 perforator flaps on thoracodorsal artery and 2 muscle-sparing latissimus dorsi flaps have been raised. The early complication rate was 29%, whereas the late complication rate was 35%. Except for one, all patients declared they were satisfied or highly satisfied from both aesthetic and functional points of view. Analyzing specific aspects, we have described several important details to consider for the reconstruction of the axilla. Through a retrospective analysis, we have classified HS axillary patients into 4 categories to better plan surgical reconstruction. Axillary reconstruction is still a plastic surgery challenge. Peculiar surgical details should be considered when approaching this area. This new classification may help young surgeons during the reconstructive phase.

Outcome of Pedicled Thoracodorsal Artery Perforator Flap in the Surgical Treatment of Stage II and III Hidradenitis Suppurativa of Axilla.

Hidradenitis suppurativa (HS) is a chronic, inflammatory disease affecting the apocrine glands of the axillary, groin, and mammary regions with significant physical and psychosocial sequelae. Surgical excision of the affected tissue is the criterion standard treatment. Advanced cases of axillary HS are associated with high rates of recurrence and require extensive surgical resection with challenging reconstruction associated with risk of postoperative complications. The most effective method for reconstruction of the axilla after excision of HS is yet to be identified. The aim of the study was to evaluate the results of the use of pedicled thoracodorsal artery perforator (TDAP) flap as a method of reconstruction for axillary efect result from wide surgical excision as a line of treatment for stage II and III HS of the axilla. The study included 20 patients with stage II and III (Hurley staging system) HS of the axilla, 18 male and 2 women treated by wide local excision and reconstruction by rotational TDAP flap. At the end of follow-up, outcome is judged by complete remission of disease, comparing preoperative shoulder function (using Constant-Murley shoulder outcome score), and quality of life (using dermatology life quality index) with postoperative results after 1 year, plus durability of reconstruction, donor site morbidity, overall aesthetic outcome, and patient's satisfaction. The mean ± SD follow-up period was 30 ± 5.2 months (range = 12-60 months). Four patients (20%) were treated for their right side, 8 patients (40%) for their left side, and 8 patients (40%) were treated bilaterally, so we perform 28 operations for 20 patients. The treated patients with stage II disease were 16 (57.14%) and with stage III disease were 12 (42.85%). The size of the defects was usually approximately 10 × 15 cm. By the end of follow-up period, all patient showed complete remission of the disease with improvement in both shoulder function and quality of life, whereas 1 flap (3.57%) was complicated by bleeding treated by reoperation, 2 flaps (7.14%) complicated by wound infection that was treated conservatively, 3 other flaps (10.71%) showed wide scare at insight of the flaps, and 1 flap (3.57%) developed hypertrophic scare at donor site of the flap. Surgical treatment of stage II and III HS of axilla and reconstruction by rotational TDAP flap provides good aesthetic and functional results with 100% success rate in eradicating and complete remission of the disease during follow-up period and accepted complication rate.

Breast-conserving surgery with immediate partial breast reconstruction using pedicled thoracodorsal artery perforator flap: a clinical analysis of 33 patients

Objective: To explore the application value of pedicled thoracodorsal artery perforator flap in immediate partial breast reconstruction for breast cancer. Methods: This study is a prospective case series studies. Totally 128 cases of primary breast cancer patients who prepared to receive the breast-conserving surgery combine with immediate partial breast reconstruction of pedicled thoracodorsalartery perforator flap were enrolled in Breast Cancer Prevention and Treatment Center of Peking University Cancer Hospital from June 2013 to March 2016. Finally, the operations had been completed successfully in 33 eligible cases. All patients were female with a median age of 40 years (ranging from 22 to 52 years). The perforator vessel location, the donor area design, the post-operative complications, the influence of radiation and chemotherapy had been evaluated. Results: The average diameter of thoracic dorsal artery perforators measured by Doppler ultrasound before the operation was (1.5±0.4) mm (ranging from 0.6 to 2.7 mm). The average size of flaps was 15 cm×6 cm. The average time of operations was (271±72) minutes (ranging from 120 to 245 minutes). Drainage tube removed on (4.7±2.1) days after operation (ranging from 3 to 12 days). All patients received follow-up, and there was no local recurrence and distant metastasis during a median follow-up of 17(12) months (M(Q(R))) (ranging from 5 to 38 months). All TDAP flaps were survival, the wound complication rates was 6% (2/33). Conclusions: The breast reconstruction of pedicled thoracodorsal artery perforator flap is a good choice of repairing local breast defect of breast conserving surgery.Its advantages are no-influence of latissimus dorsi function and little complications in donor area.

Creation of a Large Adipose Tissue Construct in Humans Using a Tissue-engineering Chamber: A Step Forward in the Clinical Application of Soft Tissue Engineering

Tissue engineering is currently exploring new and exciting avenues for the repair of soft tissue and organ defects. Adipose tissue engineering using the tissue engineering chamber (TEC) model has yielded promising results in animals; however, to date, there have been no reports on the use of this device in humans. Five female post mastectomy patients ranging from 35 to 49years old were recruited and a pedicled thoracodorsal artery perforator fat flap ranging from 6 to 50ml was harvested, transposed onto the chest wall and covered by an acrylic perforated dome-shaped chamber ranging from 140 to 350cm3. Magnetic resonance evaluation was performed at three and six months after chamber implantation. Chambers were removed at six months and samples were obtained for histological analysis. In one patient, newly formed tissue to a volume of 210ml was generated inside the chamber. One patient was unable to complete the trial and the other three failed to develop significant enlargement of the original fat flap, which, at the time of chamber explantation, was encased in a thick fibrous capsule. Our study provides evidence that generation of large well-vascularized tissue engineered constructs using the TEC is feasible in humans.

Microsurgical Pedicle Lengthening for Pedicled Thoracodorsal Artery Perforator Flap Transfer

The pedicled thoracodorsal artery perforator flap has been shown to be an effective option for reconstruction of various regions, including the breast, axilla, upper arm, lateral chest, and shoulder area. However, the original length of the pedicle limits the flap's reach to remote locations. We devised a technique that involves microsurgical lengthening of the pedicle to extend the arc of rotation of the pedicled perforator flap. After exposure of the subscapular vascular tree, we divided the thoracodorsal vessel at the point of bifurcation to the serratus branch and then the pedicle was reconnected to the distal end of the serratus branch. Here, we present 2 cases in which this technique was effectively applied to reconstruct a defect of the elbow using a thoracodorsal artery perforator flap with a pedicle lengthening procedure.

Transaxillary thoracodorsal artery perforator flap: a versatile new technique for hypopharyngeal reconstruction.

Reconstruction of the hypopharynx and cervical esophagus after tumor resection remains a challenging problem. Different techniques of reconstruction have been described for such defects. Although free flap reconstruction, including jejunum and fasciocutaneous flaps, has gained popularity for this complex defect, regional flaps are still in use worldwide. We present our experience using the pedicled thoracodorsal artery perforator (TDAP) flap whereby only a small cuff of latissimus dorsi muscle around the perforators is harvested. The remaining muscle with its nerve supply is preserved. The flap is delivered to the neck through the cervicoaxillary tunnel. It was used as a complete tube in six patients and with an additional attached skin island for reconstruction of the neck skin in another four patients. A total of 11 TDAP flaps were used for reconstruction in 10 patients. All flaps survived except in one patient who suffered from a complete flap loss. This was salvaged by another TDAP flap from the contralateral side. Partial sloughing of the outer part of the pedicled TDAP occurred in one other patient. Pharyngeal fistulas developed in another two patients and eventually healed spontaneously. All patients resumed an oral diet within 2 weeks except two with fistulas. All patients resumed their shoulder active range of motion within 3 weeks. The transaxillary TDAP flap is an ideal technique for hypopharyngeal reconstruction. It offers the advantages of free fasciocutaneous flaps, has a wide arc of rotation, a relatively larger flap dimension, a reliable vascular pedicle, and acceptable donor site morbidity.

Total Breast Reconstruction Using the Thoracodorsal Artery Perforator Flap without Implant

The thoracodorsal artery perforator flap was described mainly for partial breast reconstruction by Hamdi. The purpose of this article is to describe the use of the pedicled thoracodorsal artery perforator flap for total autologous breast reconstruction without using an implant. Between January of 2009 and December of 2011, seven patients underwent total breast reconstruction with a pedicled thoracodorsal artery perforator flap. The mean age of the patients was 53 years (range, 43 to 62 years), and the mean body mass index was 27 kg/m (range, 24 to 32 kg/m). The mean size of the harvested skin paddle was 23.7 × 8.8 cm (range, 15 × 7 cm to 39 × 14 cm). The flaps were based on one to three perforators and successfully transferred with an average operative time of 3 hours. No seroma occurred at the donor site. Average hospital stay was 4 days (range, 3 to 6 days). At an average follow-up of 21.5 months, two patients underwent additional revisions using autologous fat grafting, with overall fat injection volumes of 240 and 280 cc, respectively. The pedicled thoracodorsal artery perforator flap offers an alternative for total autologous breast reconstruction in small to medium breasted patients when abdominal tissues are not available. Therapeutic, IV.

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.

Clinical application of the thoracodorsal artery perforator flaps

Thoracodorsal artery perforator (TAP) flaps without latissimus dorsi muscle - have been used for reconstruction of the extremities, head and neck as free style flaps, and as pedicled flaps for reconstruction of the chest wall and axillary wounds. This retrospective study aimed to analyse the clinical applications and relevant anatomic findings of TAP flaps. From April 2007 to August 2011, 67 free or pedicled TAP flaps were transferred in 67 patients for reconstruction of wounds of the extremities, chest wall and axilla. Eight were used as free flaps for reconstruction of extremities, and 59 used as pedicled flaps for reconstruction of axillary or chest wounds. Patient ages ranged from 7 to 55 years (26.04±12.83). Perforator arteries were detected and identified with a hand-held Doppler. The size of flaps ranged from 6 by 9 to 14 by 18 cm ((8.66±2.05) by (12.62±2.03)). Flaps were designed with the perforator artery included, with all flaps based on one or two perforator arteries. All of the flaps survived. There were no problems with vascular spasm or occlusion. Significant venous congestion was not observed in any of the cases. Two cases developed minor wound dehiscence but healed with conservative therapy. None of the donor sites developed seromas. The thoracodorsal artery flap without associated latissimus dorsi muscle can provide a thin, large and reliable flap with robust blood supply. The TAP flap can significantly reduce donor site morbidity.

Elbow reconstruction with a pedicled thoracodorsal artery perforator flap after excision of an upper-extremity giant hairy nevus

The complexity of managing large soft-tissue defects at the elbow region byconventional techniques arises from the difficulty of providing sufficient tissue with adequate elasticity and durability. Reconstruction options that allow early mobilisation and avoid the risk of functional loss should be considered to achieve defect closure at the elbow region. A 21-year-old man presented with a congenital giant hairy nevus on his left upper extremity. The nevus was excised and the resulting raw surface after the excision was covered with a split-thickness skin graft except for the elbow region. The elbow was covered in one stage with an ipsilateral 24cm long pedicled thoracodorsal artery perforator (TDAP) flap. The follow-up examination 3 years after total reconstruction demonstrated durable elbow support provided by the TDAP flap. The patient revealed no complaint considering pain or sensitivity even when exposed to mechanical stress. Split-thickness skin grafting of the large superficial defects is almost always possible; however, impairment of the function on joint areas due to gradual contraction and skin graft propensity to ulcers under mechanical stresses can be devastating. The elbow is a weight-bearing area of the body. Elbow defects require durable and thin soft-tissue coverage and the tissue cover must possess excellent elastic properties to re-establish elbow mobility. The TDAP flap is an ideal choice for elbow soft-tissue defects. The longest pedicle length reported for the TDAP flap is 23cm. In our case, the pedicle length was 24cm and it was possible to transfer this flap to the elbow on its pedicle. A pedicled TDAP skin flap so as to provide elbow coverage in one stage is a useful choice to retain in one's armamentarium.