The angular branch of the thoracodorsal artery and its blood supply to the inferior angle of the scapula: an anatomical study

An anatomical study of the thoracodorsal arterial system was performed; it focused on the angular branch. The aim of the study was to document the anatomical variations of this pedicle and to delineate the area of supply to the inferior angle of the scapula with a view to free bone transfer. A total of 81 cadaver dissections were performed; they revealed the constant presence of the thoracodorsal artery and four vascular patterns of origin of the angular branch. Selective India ink perfusion studies performed on 11 sides in six fresh cadavers demonstrated a reliable supply to the inferior angle of the scapula to the extent of 6 cm of the vertebral margin and 3 cm of the lateral margin of the scapula. Histologic analysis of sections of this region of the scapula confirmed the presence of ink within the periosteal, cortical, and medullary vascular channels, implying the viability of this area of bone if transferred based on the angular branch.     

Clinical and basic research on occipito-cervico-dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels

The authors have carried out a clinical study of all the patients who underwent reconstructions with occipito-cervico-dorsal flaps in their department between 1994 and 2003 and analyzed the outcomes of the surgery. The reconstructed areas ranged from the cheek to the anterior chest. Twenty-eight cases underwent reconstruction with microvascular augmented occipito-cervico-dorsal flaps, and four were reconstructed with single pedicle occipito-cervico-dorsal flaps. In five cases, distal partial necrosis was observed. The largest flap size was 43 x 23 cm (5 x 5-cm pedicle). In the microvascular augmented occipito-cervico-dorsal flaps, the circumflex scapular artery and veins were used in 28 cases, and dorsal intercostal perforators were used together with circumflex scapular artery and veins in five cases. The follow-up term was between 1 and 8 years. Neck scar contractures were released in all cases, and good results were obtained not only functionally but also aesthetically. In an anatomical study, the authors used 20 preserved cadavers and took angiograms of the dorsal region. Five cadavers were used to confirm the territory of each of the vessels that have close relations to the occipito-cervico-dorsal flap (the occipital artery, transverse cervical artery, circumflex scapular artery, and dorsal intercostal perforator artery). Each anatomical territory was clearly seen and its area identified.     

The osteocutaneous scapular flap for mandibular and maxillary reconstruction

Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.     

Use of circumflex scapular vessels as a recipient pedicle for autologous breast reconstruction: a report of 40 consecutive cases

The use of the circumflex scapular pedicle as a recipient vessel for breast reconstruction in a series of 40 consecutive cases in 37 patients is reported. There were 3 bilateral reconstructions and 34 unilateral reconstructions. Twenty-one cases were immediate reconstructions, and 19 cases were secondary reconstructions. The diameter of the artery varied from 1.5 mm to 3 mm and systematically matched with the diameter of the epigastric artery. The artery was a branch of the subscapular system in 82.5 percent of cases (33 of 40). In 17.5 percent of cases (7 of 40), the artery was a direct branch of the axillary artery. The length of available pedicle between the axillary vessel and the distal part where it can be divided (on its division between scapular and parascapular artery) was of 76 +/- 13 mm for the artery and 72 +/- 12 mm for the vein. The vein was unique in 77.5 percent of cases. The diameter was similar to the artery diameter when unique. There was a dual venous system in 21 of 40 cases (52.5 percent) but in 15 cases (37.5 percent), one of the two veins was dominant. In the seven cases for which the veins were dual and of equivalent diameter, the epigastric veins were also dual and allowed a second anastomosis. Clinically, the anastomosis was always possible on the artery. In one case of reconstruction after Halstedt mastectomy, no vein could be found, because all the veins had been ligated previously. One venous thrombosis (2.5 percent) and one arterial thrombosis were experienced. Both were treated by revised anastomoses and did not compromise late results. The circumflex scapular pedicle is a reliable and simple recipient site for breast reconstruction. It allows a unique site of dissection in immediate reconstruction and avoids division of the thoracodorsal pedicle. The technique is now used exclusively at this institution.     

The parascapular flap for treatment of lower extremity disorders

The parascapular flap was used as a free microvascular transfer for soft-tissue resurfacing of 11 lower extremities. The diagnoses included four cases of osteomyelitis, three cases of vascular ulceration, one case of combined osteomyelitis and vascular ulceration, two cases of posttraumatic heel defects, and one case of extensive soft-tissue contracture overlying a posttraumatic defect of the femur. All cases were successful clinically. Anatomically, the parascapular flap is supplied by the cutaneous parascapular artery, a branch of the circumflex scapular artery, which itself derives from the subscapular artery. Flap territory may reach 15 x 30 cm, and the vascular pedicle can extend 14 cm if the subscapular artery is taken. Advantages of this flap include the constancy, length, and caliber of the vascular pedicle; the length and width attributes, which allow both coverage of large wounds and primary closure of the donor defect; and an absence of disruption of musculoskeletal function.     

Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation

Thirty-seven consecutive free anterolateral thigh flaps in 36 patients were transferred for reconstruction of head and neck defects following cancer ablation between January of 1997 and June of 1998. The success rate was 97 percent (36 of 37), with one flap lost due to a twisted perforator. The anatomic variations and length of the vascular pedicle were investigated to obtain better knowledge of anatomy and to avoid several surgical pitfalls when it is used for head and neck reconstruction. The cutaneous perforators were always found and presented as musculocutaneous or septocutaneous perforators in this series of 37 anterolateral thigh flaps. They were classified into four types according to the perforator derivation and the direction in which it traversed the vastus lateralis muscle. In type I, vertical musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 56.8 percent of cases (21 of 37), and they were 4.83 +/- 2.04 cm in length. In type II, horizontal musculocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 27.0 percent of cases (10 of 37), and they were 6.77 +/- 3.48 cm in length. In type III, vertical septocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 10.8 percent of cases (4 of 37), and they were 3.60 +/- 1.47 cm in length. In type IV, horizontal septocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 5.4 percent of cases (2 of 37). They were 7.75 +/- 1.06 cm in length. The average length of vascular pedicle was 12.01 +/- 1.50 cm, and the arterial diameter was around 2.0 to 2.5 mm; two accompanying veins varied from 1.8 to 3.0 mm and were suitable for anastomosis with the neck vessels. Reconstruction of one-layer defect, external skin or intraoral lining, was carried out in 18 cases, through-and-through defect in 17 cases, and composite mandibular defect in two cases. With increasing knowledge of anatomy and refinements of surgical technique, the anterolateral thigh flap can be harvested safely to reconstruct complicated defects of head and neck following cancer ablation with only minimal donor-site morbidity.     

The vascular anatomy and dissection of the free scapular flap

This article refers to the author's personal experience with a new scapular flap based on the dissection of 35 cadavers. In total, 70 free flaps were dissected. Its main advantages are the following: constancy of vascular anatomy; adequate size, length, and diameter of its vascular pedicle (which is formed by the cutaneous scapular artery and two veins); easy surgical dissection; primary closure of the donor site; and limited scar. However, this technique is not recommended in cases in which a large loss of substance is to be replaced. The first successful surgical application of the microsurgical scapular flap was performed in Paris in October of 1979.     

Reconstruction of a complex defect of the hand with two distinct segments of the scapula and a scapular fascial flap transferred as a single transplant.

To repair multiple defects of the metacarpal bones in combination with skin defects, a combined scapular free flap on a single vascular pedicle--the subscapular artery and the accompanying veins--can be used successfully. This flap includes two distinct bone segments of the lateral border of the scapula and a scapular fascial flap. Because of its long and mobile vascular pedicle, such a transplant can be used for one-stage reconstruction of the first and other metacarpal bones of the long fingers of the hand. The scapular fascial flap included in the transplant provides good functional and aesthetic results in combined injury of the skin of the hand.     

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.     

Osteocutaneous flap prefabrication based on the principle of vascular induction: an experimental and clinical study

Conventional osteomyocutaneous flaps do not always meet the requirements of a composite defect. A prefabricated composite flap may then be indicated to custom create the flap as dictated by the complex geometry of the defect. The usual method to prefabricate an osteocutaneous flap is to harvest a nonvascularized bone graft and place it into a vascular territory of a soft tissue, such as skin, muscle, or omentum, before its transfer. The basic problem with this method is that the bone graft repair is dependent on the vascular carrier; the bone needs to be revascularized and regenerate. The bone graft may not be adequately perfused at all, even long after the transfer of the prefabricated flap. This study was designed to prefabricate an osteocutaneous flap where simply the bone nourishes the soft tissues, in contrast to the conventional technique in which the soft tissue supplies a bone graft. This technique is based on the principle of vascular induction, where a pedicled bone flap acts as the vascular carrier to neovascularize a skin segment before its transfer. Using a total of 40 New Zealand White rabbits, two groups were constructed as the experimental and control groups. In the experimental group, a pedicled scapular bone flap was induced to neovascularize the dorsal trunk skin by anchoring the bone flap to the partially elevated skin flap with sutures in the first stage. After a period of 4 weeks, the prefabricated composite flaps (n = 25) were harvested as island flaps pedicled on the axillary vessels. In the control group, nonvascularized scapular bone graft was implanted under the dorsal trunk skin with sutures; after 4 weeks, island composite flaps (n = 15) were harvested pedicled on the cutaneous branch of the thoracodorsal vessels. In both groups, viability of the bony and cutaneous components was evaluated by means of direct observation, bone scintigraphy, measurement of bone metabolic activity, microangiography, dye injection study, and histology. Results demonstrated that by direct observation on day 7, the skin island of all of the flaps in the experimental group was totally viable, like the standard axial-pattern flap in the control group. Bone scintigraphy revealed a normal to increased pattern of radionuclide uptake in the experimental group, whereas the bone graft in the control group showed a decreased to normal pattern of radioactivity uptake. The biodistribution studies revealed that the mean radionuclide uptake (percent injected dose of 99mTc methylene diphosphonate/gram tissue) was greater for the experimental group (0.49+/-0.17) than for the control group (0.29+/-0.15). The difference was statistically significant (p<0.01). By microangiography, the cutaneous component of the prefabricated flap of the experimental group was observed to be diffusely neovascularized. Histology demonstrated that although the bone was highly vascular and cellular in the experimental group, examination of the bone grafts in the control group revealed necrotic marrow, empty lacunae, and necrotic cellular debris. Circulation to the bone in the experimental group was also demonstrated by India ink injection studies, which revealed staining within the blood vessels in the bone marrow. Based on this experimental study, a clinical technique was developed in which a pedicled split-inner cortex iliac crest bone flap is elevated and implanted under the medial groin skin in the first stage. After a neovascularization period of 4 weeks, prefabricated composite flap is harvested based on the deep circumflex iliac vessels and transferred to the defect. Using this clinical technique, two cases are presented in which the composite bone and soft-tissue defects were reconstructed with the prefabricated iliac osteomyocutaneous flap. This technique offers the following advantages over the traditional method of osteocutaneous flap prefabrication. Rich vascularity of the bony component of the flap is preserved following transfer (i.e. (ABSTRACT     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

Flap prefabrication in the head and neck: a 10-year experience

Tissue neovascularized by implanting a vascular pedicle can be transferred as a "prefabricated flap" based on the blood flow through the implanted pedicle. This technique potentially allows any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive options. During the past 10 years, 17 flaps were prefabricated and 15 flaps were transferred successfully in 12 patients. Tissue expanders were used as an aid in 11 flaps. Seven flaps were prefabricated at a distant site and later transferred using microsurgical techniques. Ten flaps were prefabricated near the recipient site by either transposition of a local vascular pedicle or the microvascular transfer of a distant vascular pedicle. The prefabricated flaps were subsequently transferred as island pedicle flaps. These local vascular pedicles can be re-used to transfer additional neovascularized tissues. Common pedicles used for neovascularization included the descending branch of the lateral femoral circumflex, superficial temporal, radial, and thoracodorsal pedicles. Most flaps developed transient venous congestion that resolved in 36 to 48 hours. Venous congestion could be reduced by incorporating a native superficial vein into the design of the flap or by extending the prefabrication time from 6 weeks to several months. Placing a Gore-Tex sleeve around the proximal pedicle allowed for much easier pedicle dissection at the time of transfer. Prefabricated flaps allow the transfer of moderate-sized units of thin tissue to recipient sites throughout the body. They have been particularly useful in patients recovering from extensive burn injury on whom thin donor sites are limited.     

Reconstruction of mandibular and floor of mouth defects using the trapezius osteomyocutaneous flap

The trapezius osteomyocutaneous island flap has evolved in postablative head and neck reconstruction as a versatile and hardy local flap which can provide intraoral lining, well-vascularized bone, and muscle bulk for the reconstruction of a complex defect. This investigative study examines the anatomy of 20 osteomyocutaneous flaps in 10 fresh cadavers and in 8 clinical patients. In our series, 80 percent (type I) of the major vascular pedicle arose from the thyrocervical trunk. In 20 percent (type II), the major pedicle arose separately from the subclavian artery. The regions perfused by the vascular trunk were further examined with microopaque and Prussian blue injections through the transverse cervical artery. Consistent areas of cutaneous staining as well as bony staining were noted over the shoulder, arm, and back and into the scapula itself. Experience with eight clinical applications of this osteomyocutaneous flap resulted in successful healing with an excellent aesthetic and functional result. Long-term follow-up was maintained on the patients for up to 36 months. Panorex radiographs and biopsies of the grafted bone were obtained on several patients. These disclosed evidence of bony remodeling and viable bone tissue. Tetracycline labeling also revealed evidence of active bony turnover.     

Distally based anterolateral thigh flap: an anatomic and clinical study

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 x 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 +/- 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.     

Vascularization of the myocutaneous latissimus dorsi flap. Injection study on the thoracodorsal artery

This study reports on investigations of the thoracodorsal artery by injection studies. This artery has a long proximal extramuscular course before it enters the muscle. A consistent neurovascular hilum was found at a considerably constant location on the inferior muscle surface, 2-3 cm medial to its lateral edge and about 5 cm distal to the inferior scapular border. A constant branching pattern of the thoracodorsal artery into a lateral and a medial vessel stem was found. A high number of muscle-perforating arteries from a dense network in the cutaneous and subcutaneous layer. The thoracodorsal artery supplies the whole cutaneous area adjacent to the latissimus dorsi muscle plus a streak of about 2 cm at the medial and distal muscle borders. The presented anatomical landmarks are useful for locating the neurovascular hilum, and the intramuscular course of the thoracodorsal artery for exploration of the vessel by Doppler sonography or dissection. The length of the pedicle and the relatively big vessel gauge are good anatomical markers for the free transfer of a latissimus dorsi flap.     

Superficial circumflex iliac artery perforator flap for reconstruction of limb defects

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

The vascular supply of the extended tensor fasciae latae flap: how far can the skin paddle extend?

The vascular supply of the tensor fasciae latae flap and of the lateral thigh skin was studied in 10 cadavers to evaluate whether the lateral thigh skin toward the knee could be incorporated into an extended tensor fasciae latae flap. Within each cadaver, vascular injection of radiopaque material preceded flap elevation in one limb and followed flap elevation in the contralateral limb. Flaps raised after vascular injection were examined radiographically to evaluate the vascular anatomy of the lateral thigh skin independent of flap elevation. When vascular injection was made into the profunda femoris, the upper two-thirds of the flaps was better visualized than the distal third. When the injection was made into the popliteal artery, the vasculature of the distal third of the flaps was better visualized. Flaps raised before vascular injection were examined radiographically to delineate the anatomical territory of the vascular pedicle that had been injected. In these flaps, consistent cutaneous vascular supply was only seen in the skin overlying the tensor fasciae latae muscle, confirming that musculocutaneous perforators are the predominant means by which the pedicle of the tensor fasciae latae flap supplies the skin of the lateral thigh. Extended tensor fasciae latae flaps were elevated bilaterally in one cadaver, and selective methylene blue injections were made into the lateral circumflex femoral artery on one side and into the superior lateral genicular artery on the contralateral side. Methylene blue was observed in the proximal and distal thirds of the skin paddles, respectively, leaving unstained midzones. The vascular network of the lateral thigh skin could be divided into three zones. The lateral circumflex femoral artery and the third perforating branches of the profunda femoris artery perfuse the proximal and middle zones of the lateral thigh skin, respectively. The superior lateral genicular artery branch of the popliteal artery perfuses the distal zone. The middle and distal zones meet 8 to 10 cm above the knee joint, where the skin paddle of the tensor fasciae latae flap becomes unreliable. These data indicate that if the aim is to incorporate the skin over the distal thigh in an extended tensor fasciae latae flap without resorting to free-tissue transfer, then either a carefully planned delay procedure or an additional anastomosis to the superior lateral genicular artery is required.     

The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques

The thoracodorsal artery perforator flap is a relatively new flap that has yet to find its niche in reconstructive surgery. At the authors' institution it has been used for limb salvage, head and neck reconstruction, and trunk reconstruction in cases related to trauma, burns, and malignancy. The authors have found the flap to be advantageous for cranial base reconstruction and for resurfacing the face and oral cavity. The flap has been used successfully for reconstruction of traumatic upper and lower extremity defects, and it can be used as a pedicled flap or as a free tissue transfer. The perforating branches of the thoracodorsal artery offer a robust blood supply to a skin-soft-tissue paddle of 10 to 12 cm x 25 cm, overlying the latissimus dorsi muscle. The average pedicle length is 20 cm (range, 16 to 23 cm), which allows for a safe anastomosis outside the zone of injury in traumatized extremities; the flap can be made sensate by neurorrhaphy with sensory branches of the intercostal nerves. Vascularized bone can be transferred with this flap by taking advantage of the inherent vascular anatomy of the subscapular artery. A total of 30 pedicled and free flap transfers were performed at the authors' institution with an overall complication rate of 23 percent and an overall flap survival rate of 97 percent. Major complications, such as vascular thrombosis, return to the operating room, fistula formation, recurrence of tumor, and flap loss, occurred in 17 percent of the patients. Despite these drawbacks, the authors have found the thoracodorsal artery perforator flap to be a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction cases.     

Muscle-sparing latissimus dorsi myocutaneous flap with maintenance of muscle innervation,function, and aesthetic appearance of the donor site

In this report, the authors describe the application of a muscle-sparing technique to harvest a myocutaneous latissimus dorsi muscle flap, including only a tiny lateral muscle segment but carrying a large skin paddle, with the advantage of leaving intact innervation and function of the remaining latissimus dorsi muscle. According to the experiences and complications associated with the pure thoracodorsal artery perforator harvest at the authors' institution, the necessity of increasing the reliability of the vascular pedicle demands that a small muscle strip be left embedding the perforator vessels attached to the skin paddle. This procedure was applied in eight cases with only one minor complication, which was a distal flap tip necrosis in the largest flap used. The muscle function and aesthetic contour of the posterior axillary fold were preserved in every case. Harvesting a large skin paddle flap that is carried by a diminutive longitudinal segment of latissimus dorsi muscle circumvents thoracodorsal nerve damage and maintains muscle function. In contrast to a thoracodorsal artery perforator flap without muscle, the harvesting of which is a delicate procedure, this procedure is regarded as easier and safer.