Thoracoacromial Artery Perforator Flap Research Articles

228. THORACOACROMIAL ARTERY PERFORATOR FLAP REPAIR OF ACQUIRED INTRATHORACIC NONMALIGNANT TRACHEOESOPHAGEAL FISTULAS THROUGH A MIDSTERNAL INCISION APPROACH

Abstract Background Acquired intrathoracic nonmalignant tracheoesophageal fistulas (TEFs) are rare and challenging surgical problems. They can constitute a life-threatening condition due to severe pulmonary complications and poor nutrition. The current treatment strategy for TEFs is controversial, and postoperative mortality and complication morbidity have been ignored in recent studies. Here, we introduce our innovative experience repairing acquired tracheoesophageal fistulas with a thoracoacromial artery perforator flap, in which no mortality or complications were observed within 180 days after the operation. Methods Surgical repair with a thoracoacromial artery perforator flap through a midsternal incision approach was performed in 3 patients. During the procedure, a midsternal incision was made. After the thymus and anterior mediastinal fat were resected, and the left innominate vein was transected, the trachea and esophagus were mobilized. The trachea was incised and pulled to the cranial and caudal sides. Then, the thoracoacromial artery perforator flap was harvested and transferred into the superior mediastinum for esophageal reconstruction. Subsequently, the trachea was anastomosed end to end after debridement, and the left innominate vein was either anastomosed or not. Results Two patients developed esophageal anastomotic leakage postoperatively and healed well after nonsurgical treatment. No mortality or other complications were observed at 180 days after the operation. Conclusion Repair of acquired tracheoesophageal fistulas using a thoracoacromial artery perforator flap through a midsternal incision approach is an effective, safe surgical treatment.

Pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction.

Total laryngeal and hypopharyngeal resection remained to be the mainly treatment option for advanced hypopharyngeal cancer, which resulted in complicated reconstructive challenge for circumferential hypopharyngeal defect. The pedicled thoracoacromial artery compound flaps included Thoracoacromial artery perforator (TAAP) flap and pectoralis major myocutaneous (PMMC) flap. This study is to evaluate the clinical application of the pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction. From May 2021 to April 2022, four hypopharyngeal cancer patients with circumferential hypopharyngeal defects were reconstructed by the pedicled thoracoacromial artery compound flaps. All patients were males. Patient age ranged from 35 to 62years (average, 50years). The Shoulder function were evaluated by SPADI. The average follow-up was 10.25months (range from 4 to 18months). All of the pedicled thoracoacromial artery compound flaps in our study survived. The defect length between tongue base and cervical esophagus ranged from 8 to 10cm after total laryngeal and hypopharyngeal resection. The TAAP flap size ranged from 6 × 7cm to 7 × 10cm, and the PMMC flap size ranged from 6 × 7cm to 9 × 12cm. The pedicle length of TAAP and PMMC flaps varied, respectively, from 5 to 8cm (mean 6.5cm) and 7cm to 11cm (mean 8.75cm). The mean time of TAAP and PMMC flaps harvest was, respectively, 82min and 39min. All patients were able to resume soft diet in the fourth week of postoperation, but one patient was operated by gastrostomy in the second month of postoperation because of pharyngeal cavity stenosis, and the patient successfully resumed oral soft diet by endoscopic balloon dilation after postoperation radiotherapy. All patients have resumed oral feeding at last. There were mild dysfunction for our patients according to SPADI during the mid-long follow-up. The pedicled thoracoacromial artery compound flaps have stable blood supply and provide adequate muscle coverage for greater protection during radiotherapy, and the microsurgical skills have no requirement. Therefore, the compound flaps provide a good choice for the reconstruction of circumferential hypopharyngeal defect, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

Anatomical study and clinical application of thoracoacromial artery perforator flap

Objective:To study the anatomical characteristics of thoracoacromial artery perforator flap（TAAP）, and to explore the advantages and disadvantages of TAAP in head and neck reconstruction. Methods: Four fresh cadavers （8 hemichests） were collected for anatomical observation, the blood supply of chest skin was observed through autopsy, the presence, number, location, caliber, and landmark on the chest surface of all thoracoacromial artery perforators per hemichest were recorded, including the distance of each from the midpoint of the clavicle. The diameters of the thoracoacromial artery and perforating vessels were measured with vernier calipers （accuracy 0.05 mm）, the pedicle length and thickness were measured with a cm scale （accuracy: 1 mm） after the flap was obtained, and the retained photos were recorded. Results:No perforating branch （12.5%） was found on one side of the 8 hemichests, two perforating branches （12.5%） were found on one hemichest, and one perforating branches （75.0%） were found on the rest of the hemichests. The perforating point was about between the clavicular head of pectoralis major （clavicular part） and the sternocostal head （sternocostal part）. The vessels at the beginning of perforation were generally bulky, with an average diameter of 2.25 mm, however, the vessel diameter was significantly reduced after the perforation of the flap. The pedicle length of thoracoacromial artery perforator flap ranged from 5.43 cm to 9.03 cm, with an average length of 7.14 cm. The pedicle length from the exit point of perforator muscle gap to the flap was 2.32-4.63 cm, with an average length of 3.28 cm. The distance between the exit point of perforator muscle space and the lower edge of the midpoint of the clavicle was 3.31-4.52 cm, with an average distance of 3.77 cm. Conclusion:The thoracoacromial artery perforator flap has some advantages such as similar color as head, neck and maxillofacial region, stable blood supply, relatively consistent vascular pedicle length and caliber size, relatively larger flap, less damage to pectoralis major muscle, and protection of chest shape, thoracic movement and shoulder joint movement function. Although the clinical application of this flap is limited by the uncertainty of perforating vessels, postoperative asymmetry of the nipple and residual chest scar, it still has a broad application prospect in head and neck reconstruction.

LETTER TO THE EDITOR: THORACO-ACROMIAL ARTERY PERFORATOR (TAAP) FLAP FOR RECONSTRUCTION OF A RECURRENT DERMATOFIBROSARCOMA PROTUBERANS OF THE CLAVICULAR REGION

Dermatofibrosarcoma Protuberans is a rare mesenchymal tumor, highly infiltrative and with a high recurrence rate. Despite its localization may vary, the trunk is widely recognized as the most common interested site. We read with interest the recent article published by Longo et al. “Recur-rent dermatofibrosarcoma protuberans of the clavicular region: radical excision and reconstruction with Latissimus Dorsi myocutaneous flap”; since their case is very similar to one we faced in 2016. In this letter, we present our experience with the Thoraco-acromial artery perforator flap (TAAP) for reconstruction of a recurrent DFSP of the clavicular region.

Pitfalls in the management of subglottic paragangliomas at unusual location: a case report and literature review

BackgroundSubglottic paragangliomas (PGs) are exceptionally rare and unpredictable, occasionally presenting at an atypical location. There are three different clinical forms of subglottic PGs: intraluminal (tracheal PGs), extraluminal (thyroid PGs) and the mixed type (both intraluminal and extraluminal, mixed-subglottic PGs). These tumors are usually misdiagnosed as other relatively common primary thyroid or laryngotracheal tumors, and the treatment is troublesome.Case presentationA 22-year-old male patient with subglottic PGs has been successively misdiagnosed as thyroid tumors and subglottic hemangiomas, and lastly underwent local extended lumpectomy and laryngotracheal reconstruction with a pedicled thoracoacromial artery perforator flap (PTAPF). The patient was decannulated successfully after the second-stage tracheal reconstruction with a local flap, and no evidence of local recurrence and distant metastasis of the tumor until now.ConclusionSubglottic PGs can be easily misdiagnosed as laryngotracheal or thyroid tumors when presented at an atypical location. It is essential for otolaryngologists and head and neck surgeons to remain vigilant against these tumors. If the tumor is not diagnosed or removed completely, patients may encounter a risk of lethal paroxysm, which is incredibly troublesome.

Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction

BackgroundLarge or complex trachea defects often require some tissue to reconstruct, various flaps have been reported for reconstructing this defect. However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction. Therefore, this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction.MethodsEight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed.ResultsAll of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm × 5 cm to 4 cm × 10 cm, and the size of each island of one double-island flap was 2 cm × 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities, such as diabetes, hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis. Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment.ConclusionPedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

A Sequential Thoracoacromial Artery Perforator Flap for Reconstructing the Donor Site of Sternocleidomastoid Myocutaneous Flaps: Extended Indications and Technical Modifications.

The current study introduces and demonstrates our experience of using a sequential thoracoacromial artery perforator (TAAP) flap to repair the sternocleidomastoid (SCM) flap donor site in this context. The aims of this technique are to optimize both esthetic and functional outcomes and to reduce postoperative complications for patients. Between September 2013 and March 2017, the SCM flap combined with sequential TAAP flap was used for reconstruction postradical parotidectomy in 12 patients. Flap characteristics, patient outcomes, and postoperative complications were monitored and objectively measured, with 10 to 24 months of follow-up. There were no incidences of total flap loss. All TAAP flap donor sites were closed directly, and all healed without any complications. The SCM flap and TAAP flap donor areas were esthetically acceptable, with good esthetic and functional outcomes achieved in all 12 patients. The sequential TAAP flap has a consistent vascular supply and provides a reliable surgical approach to reconstruct the SCM flap donor site with good esthetic and functional outcomes.

Anatomical Study and Clinical Application of Free Thoracoacromial Artery True-Perforator Flap for Reconstruction of the Face.

The clavicular region is acknowledged as one of the most suitable donor sites for reconstruction of the face or neck. Recently, a free thoracoacromial artery (TAA) perforator (TAAP) flap was reported as a new option for reconstruction of the face. However, the TAAP flap has several drawbacks including tedious intramuscular dissection of the pedicle and loss of availability of a pectoralis major flap as a bailout option in case of cancer recurrence. We performed an anatomical study of the TAAP and developed a novel TAA "true-perforator" flap, in which we can preserve the main trunk of the TAA. Anatomical study of the TAAPs was performed in 6 patients while elevating a deltopectoral flap or a pedicled TAAP flap. Location and diameter of the perforators were recorded. Based on these anatomical findings, we developed a novel free TAA true-perforator flap, which we used for the reconstruction of a facial defect after cancer resection. The most dominant TAAP was identified 4.8-cm (4 to 7-cm) caudally from the upper border of the deltopectoral triangle along the cephalic vein and 1.7-cm (0.5 to 2-cm) medially from the cephalic vein. The diameter of the TAAPs at the level of fascial penetration was 0.78-mm (0.6 to 1.0-mm). The pedicle could be elongated up to 3-cm with proximal dissection. Clinical case showed a satisfactory aesthetic result with minimal donor-site morbidity. A free TAA true-perforator flap can be a new option for the reconstruction of the face with many advantages including reduced donor-site morbidity and satisfactory aesthetic outcome.

Clinical application of pedicled chimeric thoracoacromial artery perforator flap for circular hypopharyngeal reconstruction

To explore the effectiveness of pedicled chimeric thoracoacromial artery perforator (TAAP) flap as a reconstructive option for circular hypopharyngeal defects. Between January 2013 and December 2014, the pedicled chimeric TAAP flap was used to repair oncologic circular hypopharyngeal defects in 8 patients, included 6 males and 2 females, with an average age of 57 years (range, 45-80 years). All patients were treated in other hospitals before and recurrence was noted. The duration between latest treatment and recurrence ranged from 3 to 28 months (mean, 16.5 months). According to Union for International Cancer Control (UICC) TNM staged, 3 cases were T 2N 1M 0, 2 cases were T 3N 1M 0, 1 case was T 3N 2M 0, 2 cases were T 4N 1M 0. After laryngectomy, the size of circular hypopharyngeal defect ranged from 9.0 cm×8.5 cm to 12.0 cm×10.5 cm. The size of TAAP flap ranged from 7.0 cm×4.0 cm to 9.5 cm×6.0 cm．The size of pectoralis major flap ranged from 9.0 cm×5.0 cm to 14.5 cm×6.0 cm．The donor sites were closed directly in all cases. Postoperatively all flaps survived smoothly, and all defects healed by first intention. No early complication was noted. The mean hospital stay period ranged from 12 to 22 days (mean, 14.5 days). All patients were followed up 12-45 months (mean, 18.7 months). Patients possessed good appearance of surgical sites. No recurrence, fistulas, stenosis/strictures, dehiscence, or swelling occurred. Only linear scars were left on the donor sites, and the pectoralis major muscle function was completely preserved in all patients. Patients with high comorbidities may not be suitable candidates for free flap reconstruction, especially when the recipient vessels are affected from disease or radiotherapy. Pedicled chimeric TAAP flap is a good choice for the reconstruction of hypopharyngeal defects in such conditions．.

Chimeric thoracoacromial artery perforator flap for one-staged reconstruction of complex pharyngoesophageal defects: A single unit experience.

Circumferential hypopharyngeal defects with anterior neck skin loss often require double-stacked or chimeric flaps to achieve good surgical outcomes. The thoracoacromial artery perforator (TAAP) flap is a simple and reliable method for hypopharyngeal defect reconstruction. From March 2012 to February 2015, 19 male patients with an average age of 62 years (range 42-81 years) underwent complex pharyngoesophageal defect reconstruction with chimeric TAAP flaps. All 19 male patients who underwent reconstruction with TAAP flaps achieved optimal functional outcomes. All donor sites were closed primarily. The average length of hospital stay was 12.5 days (range 10-19 days). All patients returned back to normal nutrition after 8 weeks postoperatively. The average follow-up period was 19.3 months (range 14-48 months). The chimeric TAAP flap is an innovative local alternative solution for reconstruction of complex circumferential hypopharyngeal defects when free tissue transfer is contraindicated or neck vessels are depleted.

Outcome of thoracoacromial artery perforator (TAAP) flap for reconstruction of defect after oral tumor radi-cal resection

Objective To observe the outcome of free TAAP flap in the reconstruction of defect after oral tumor radical resection. Methods From June, 2010 to April, 2015, 12 patients with oral tumor underwent radical resec-tion, including 4 cases of gingival carcinoma, 3 cases of tongue carcinoma and 5 case of buccal cancer. The cause ranged from 2 to 12 months. The radical resection left defects with size ranged from 4.5 cm×3.5 cm to 6.0 cm×4.5 cm which were reconstructed by free TAAP flaps with size ranged from 7.0 cm×4.0 cm to 12.0 cm×8.0 cm. The length of TAAP flap was (6.5±0.6) cm. The width of flap was (4.3±0.5) cm. And the thickness of flap was (1.1±0.3) cm. The length of pedicle was (8.4±0.2) cm. All the arteries of TAAP were anastomosed with superior thyroid arteries, while the venae comitans were anastomosed with superior thyroid venae or internal jugular venae. Results The perforators existed consistently. All 12 flaps survived uneventfully. The donor sites were closed directly in all cases. All patients were followed up for 14-38 months with satisfied esthetic and functional results in reconstructed tongue. No local recurrence happened. The shoul-der function was not affected. Conclusion The TAAP flap has consistent blood supply, good color match and texture, while leaving minimal morbidity at donor site, is an ideal choice for buccal tumor reconstruction. Key words: Thoracoacromial artery, perforator flap; Buccal tumor; Flap transplantation; Microsurgical technique

Clinical application of free thoracoacromial artery perforator flap in reconstruction of tongue and mouth floor defects after resection of tongue carcinoma

To investigate the clinical outcome of free thoracoacromial artery perforator (TAAP) flap in the reconstruction of tongue and mouth floor defects after radical resection of tongue carcinoma. Between May 2010 and February 2015, 11 cases of tongue carcinoma underwent radical resection and reconstruction of tongue and mouth floor defects with free TAAP flaps. The locations of tongue carcinoma were the lingual margin in 7 cases, the ventral tongue in 2 cases, and the mouth floor in 2 cases. According to Union for International Cancer Control (UICC) TNM stage, 3 cases were classified as T 4N 0M 0, 3 cases as T 4N lM 0, 2 cases as T 3N 1M 0, 2 cases as T 3N 2M 0, and 1 case as T 3N 0M 0. The disease duration ranged from 3 to 28 months, 10.6 months on average. The tumor size ranged from 6.0 cm×3 cm to 10 cm×5 cm. The TAAP flap ranged from 7.0 cm×4.0 cm to 11.0 cm×5.5 cm in size, and 0.6-1.2 cm (0.8 cm on average) in thickness, with a pedicle length of 6.8-9.9 cm (7.2 cm on average). All 11 flaps survived, the donor site was closed directly and healed primarily in all cases. The patients were followed up 12-24 months (17.2 months on average). The reconstructed tongue had satisfactory appearance and good functions of swallowing and language. No local recurrence was observed during follow-up. Only linear scar was left at the donor site, and the function of pectoralis major muscle was normal. The TAAP flap is an ideal choice in the reconstruction of tongue defect after resection of tongue carcinoma, which has good texture, appearance, and function results.

Modified pedicled thoracoacromial artery perforator flap for the repair of complex pharyngocutaneous fistula: a retrospective review of 9 cases

Objective: To report our experience in the application of modified pedicled thoracoacromial artery perforator (TAAP) flap for the repair of complex pharyngocutaneous fistula. Methods: Between December 2011 and September 2015, modified pedicled TAAP flaps were used to repair pharyngocutaneous fistulas in 9 patients. All patients were males, and ranged in age from 28 to 72 years old. Fistula size ranged from 4.5 cm×2.5 cm to 6.5 cm×4.5 cm, and the TAAP skin paddle size ranged from 7.0 cm×4.0 cm to 8.0 cm×5.0 cm. Neck defect size ranged from 4.0 cm×3.0 cm to 6.0 cm×4.0 cm, and the TAAP skin paddle size ranged from 5.5 cm×3.5 cm to 7.0 cm×5.0 cm. Results: All 9 flaps survived smoothly and all the donor sites were closed directly, with no flap vascular crisis and necrosis. The mean hospitalization of patients was 10.4 days. Postoperative barium swallow showed no hypopharyngeal stenosis or fistula recurrence. The follow-up time ranged from 8 to 32 months. The appearance of neck was good and all patients accepted oral diet. Only linear scar was left on the donor site, with no significant impairment of the function of pectoralis major muscle. Conclusion: Modified pedicled TAAP flap is suitable for the repair of complex pharyngocutaneous fistula.

CLINICAL APPLICATION OF PEDICLED THORACOACROMIAL ARTERY PERFORATOR FLAP FOR PHARYNGOCUTANEOUS FISTULA REPAIR AFTER RADIOTHERAPY AND SALVAGE TOTAL LARYNGECTOMY

To explore the effectiveness of pedicled thoracoacromial artery perforator (TAAP) flap for pharyngocutaneous fistula repair after total laryngectomy and radiotherapy. Between February 2012 and January 2015, TAAP flap was used to repair pharyngocutaneous fistula after total laryngectomy and radiotherapy in 8 patients. The eight patients were male, aged from 46 to 72 years (mean, 51.8 years). The disease duration was 8-62 months (mean, 27.5 months). Fistula size ranged from 4.0 cm×2.5 cm to 6.0 cm×4.0 cm and the skin defect size ranged from 4.0 cm×3.0 cm to 6.0 cm×4.0 cm. The flap size ranged from 7.0 cm×4.0 cm×0.3 cm to 9.5 cm×6.0 cm×0.5 cm. The length of pedicle was (8.3±0.5)mm. The distance from pivot point of flap to central point of recipient site was (94.5±1.9) mm. All 8 flaps survived and all incisions healed smoothly. The hospitalization time was 7-14 days (mean, 9.6 days). The barium meal examination showed no fistula or stenosis. The patients were followed up 8-42 months (mean, 28.5 months). During follow-up, the neck appearance was good, and no fistulas or stenosis occurred. Only linear scars were observed at the donor sites, pectoralis major muscle function was normal in all patients. Pharyngocutaneous fistula should be repaired as early as possible after total laryngectomy. TAAP flap is suitable for the reconstruction of pharyngocutaneous fistula after total laryngectomy.

Clinical application of thoracoacromial artery perforator flap for hypopharyngeal reconstruction

To explore the clinical effect of thoracoacromial artery perforator (TAAP) flap as a reconstructive option for hypopharyngeal defects. Between June 2011 and November 2015,TAAP flap was used to restore oncologic hypopharyngeal defects in 13 patients with recurrence of hypopharyngeal carcinoma. The size of hypopharyngeal defects ranged from 7.0 cm× 4.5 cm to 8.5 cm × 5.5 cm. Doppler was used to detect the location of thoracoacromial artery perforator. The flap was designed on the line joining the acromion to the xiphoid process with the size 0.5-1.0 cm larger than the defect,the flap was passed under the clavicular head of the pectoralis major and under the clavicle bone and sternocleidomastoid to the recipient site for insetting. The donor site was closed directly. The size of TAAP flap is from 7.0 cm×5.0 cm to 9.5 cmu×6.0 cm. The length of pedicle is 7.5-9.0 cm. The distance from pivot point of flap to central point of recipient site was 9.0-10.5 cm. All 13 flaps survived completely, the defect at donor site was closed directly in all cases. Good appearance was achieved at 8 months to 42 months' follow up, with no recurrence, fistulas, stenosis/strictures, dehiscence, or swelling, only linear scars were left on the donor sites, pectoralis major muscle function was completely preserved in all patients. TAAP flap is a good choice for reconstruction of hypopharyngeal defects.

Thoracoacromial artery perforator flap based on the clavicular branch: A new option in regional reconstruction

AimThoarcoacromial artery‐based perforator flaps are rarely used in clinical practice, especially for the reconstruction of head, neck and axillary regions. In the present study, we present a case with an anterior chest wall soft tissue defect that was reconstructed using a thoarcoacromial artery‐based perforator flap based on the clavicular branch.Patients and MethodsA 65‐year‐old male patient presented with an anterior chest wall defect secondary to tumour resection, which was reconstructed using a thoarcoacromial artery‐based perforator flap.ResultsThe patient healed successfully without any early or late complications. To date, he is still followed up by plastic surgery and oncology departments.ConclusionAlthough there may be variable consistencies, the thoracoacromial artery perforator flap could be a good alternative to pectoralis major flap for upper chest wall, axilla and neck reconstructions.

Thoracoacromial Artery Perforator Flap

Concerns and criticism have been reported on the feasibility and vascular reliability of the thoracoacromial artery perforator flap because of the inconsistent size of the pectoral branch of the thoracoacromial artery and its cutaneous perforators. The authors have investigated its vascular basis through a cadaver dissection and described their clinical experience in the surgical strategy, range of application, and indications for the thoracoacromial artery perforator flap. Twelve fresh human cadavers were dissected to define the anatomy of the branches of the thoracoacromial artery and their perforators and the anatomical landmarks for clinical application. Single pectoral branch perforators were injected to measure the extension of the thoracoacromial artery perforator vascular territory. A constant thoracoacromial artery perforator was present in the septum between the clavicular and sternocostal heads of the pectoralis major muscle in 21 of 24 hemichests. The mean caliber of the perforator was 0.7 mm and the mean length of the vascular pedicle was 7.1 cm. The territory of the thoracoacromial artery perforator flap extended up to the fourth intercostal space inferiorly. Between 2006 and 2011, the thoracoacromial artery perforator flap was used to reconstruct head and neck defects in seven patients. All patients healed uneventfully. The authors' studies provide evidence of the vascular supply and the clinical application of the thoracoacromial artery perforator flap. The recruitment of the chest skin through a thoracoacromial artery perforator flap resulted in an adequate color match, texture, and pliability for local adjacent defect restoration and for head and neck reconstruction. Therapeutic, IV.

The Island Thoracoacromial Artery Muscle Perforator Flap

Descriptions of muscle perforator flaps incorporating the same skin territory of almost all known musculocutaneous flaps reflect their versatility. The pectoralis major musculocutaneous flap is a proven "workhorse" flap, especially for head and neck reconstruction. Yet, the corresponding thoracoacromial artery muscle perforator flap has been relatively overlooked, with few clinical experiences reported, presumably because of the highly variable and diminutive perforators emanating from this source vessel. However, in certain circumstances, this can be another alternative as a local muscle perforator flap for the transfer of chest skin to adjacent defects. Two clinical examples using the island thoracoacromial artery perforator flap prove that this can sometimes be a viable option also for head and neck reconstruction.

Thoraco-acromial artery perforator ‘propeller’ flap

Thoraco-acromial artery perforator ‘propeller’ flap

An assessment of the anatomical basis of the thoracoacromial artery perforator flap

Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap. A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels. THE PERFORATORS THROUGH THE PM MUSCLE TO THE OVERLYING SKIN INCLUDED THREE REGIONAL GROUPS: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery. The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.