Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, e5ee8

CASE REPORT

Lateral intercostal artery perforator-based reversethoracic flap for antecubital reconstruction

Tahsin Oguz Acarturk*

Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University School of Medicine,Adana 01330, Turkey

Received 13 February 2007; accepted 30 November 2007

KEYWORDSPerforator flaps;Lateral intercostalartery perforator;Upper extremityreconstruction

* Tel.: þ90 532 609 6409; fax: þ90 3E-mail address: toacarturk@yahoo

1748-6815/$-seefrontmatterª2007Britdoi:10.1016/j.bjps.2007.11.050

Summary Pedicled flaps distant from the trunk are often used to reconstruct defects of theupper extremity. For this, various flaps have been described, with the groin flap being the mostcommon. Recently, perforator flaps and perforator-based pedicled flaps have been described,that can be raised from the trunk for reconstruction of various defects. The lateral intercostalartery perforator (LICAP) flap, raised from the lateral and posterior thorax, has been used forchest reconstruction. Also LICAP flaps from the abdominal area were described in reconstruc-tion of the upper extremity. In this paper we report a case where a LICAP-based thoracic flapwas used for the reconstruction of the antecubital area of the upper extremity. This is the firstreport of the application of this flap to the upper extremity. The advantages of reverse LICAPflap from the posterolateral thoracic area are: (1) no kinking in the pedicle as it is not folded,especially for antecubital defects, (2) hairless skin from the midaxillary line area, (3) thinnerflap compared to the abdominal area and (4) the scar is on the back of the patient in a moreacceptable area.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Pedicled flaps from the trunk have often been used in thereconstruction of the upper extremity. The groin flap haslong been the workhorse in hand reconstruction. Variousrandom abdominal flaps have been used to reconstructmore proximal forearm and arm defects. Recently, perfo-rator flaps have gained popularity and are taking the placeof random as well as muscle flaps. They have a wide variety

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of applications both as pedicled and free flaps. Many typesof perforators have been described throughout the body.

The intercostal artery gives off perforators at three mainlocations. These are the posterior perforator at the lumbararea, the lateral perforator at the midaxillary line and theanterior perforator at the anterior chest line. The areawhere the lateral intercostal artery perforator (LICAP)emerges at the midaxillary line roughly corresponds tothe anterior border of the latissimus dorsi muscle. Fromhere on the perforator continues anteriorly and superficial

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 Soft tissue defect at the distal humeral area.

Figure 2 (A) Marking of the flap. Two lateral intercostal perforaline. (B) Flap raised from the posterolateral thoracic wall. The latisperforator at the base of the flap arising at the anterior edge of t

e6 T.O. Acarturk

to the abdominal musculature as an axial vessel until thelateral edge of the rectus muscle. The lateral intercostalartery perforator-based abdominal flap has also beendescribed and used to reconstruct upper arm defects.1,2

Hamdi et al. have used a LICAP flap raised from the postero-lateral thoracic wall to reconstruct a breast deformity.3

However, a LICAP-based flap raised from the thoracicarea to reconstruct an upper extremity defect has neverbeen described in the literature.

In this paper we describe a case of antecubital defectwhich was reconstructed with a LICAP-based flap raisedfrom the thoracic region, which we will name as the reversethoracic posterolateral intercostal artery perforator flap(rt-LICAP flap).

Case report

A 51-year-old male patient was seen in our departmentwith a chief complaint of an open soft tissue defect in theanterior distal arm with exposed bone (Figure 1). Twentydays prior, the patient had an accident with an industrialmachine. He sustained a mid-humeral fracture, and frac-tures of the proximal radius and ulna. A rod was placed inthe humerus and an external fixator was placed for theradio-ulnar fractures. On examining the patient there wasa 10� 8 cm soft tissue defect just proximal to the antecu-bital area. On the proximal aspect of the wound the distalfractured segment of the humerus was exposed. Afterapplication of dressing changes with Dakin’s solution for

tors are found with the Doppler examination at the midaxillarysimus dorsi muscle is visible at the base. (C) Lateral intercostalhe latissimus dorsi muscle.

Figure 4 (A) Postoperative view. (B) Donor area.

LICAP-based reverse thoracic flap for antecubital reconstruction e7

several days, vacuum-assisted closure was applied to thedefect for 6 days. After this treatment the wound was readyfor definite closure.

The posterolateral cutaneous perforators of the 7th and8th intercostal artery were found at the midaxillary lineusing Doppler examination (Figure 2A). Based on these per-forators an 18� 7 cm flap was marked in the posterolateralthoracic region parallel to the ribs. At its base the flap was5 cm (distance between two perforators). The flap wasraised subfascially from posterior to anterior (Figure 2B).At the anterior border of the latissimus dorsi muscle theperforators were isolated and preserved. After the flapwas raised Doppler examination was used to confirm theblood flow in the perforators and there was good bleedingat the distal end of the flap (Figure 2C). The donor areawas closed primarily. The arm was brought in adductionto the trunk to a comfortable position and the flap wassutured to the wound bed using interrupted 2/0 prolenesuture (Figure 3). The stalk of the flap was loosely suturedto close any raw surfaces.

Starting from the 7th day postoperatively the pedicle ofthe flap was intermittently strangulated. On the 13th daypostoperatively the pedicle was cut and definitively suturedto the wound bed. The patient had an uneventful recoveryand did not have any complications (Figure 4A, B).

Discussion

The intercostal artery has four anatomical segments.4 Thefirst is the vertebral segment which comes directly fromthe aorta and is the source artery to the dorsal paraverte-bral perforator. The second part is the costal groovesegment. From this come numerous musculocutaneousbranches including the large lateral intercostal perforator.This branch is the origin of the subcutaneous branch whichcourses over the anterior abdominal wall ending lateral tothe rectus muscle. Clinically an axial flap can be raisedfrom the anterior abdominal wall on this artery.5 The thirdsegment is the intermuscular segment and as the nameimplies it courses within the oblique abdominal musclesending at the lateral border of the rectus abdominis. Thefinal segment lies under the rectus abdominis muscle andconnects to the epigastric vascular system. At intercostal

Figure 3 The pedicle of the flap before division.

segments higher than the 6th rib the vessels anastomosewith the internal mammary artery system.

LICAP-based abdominal flaps have been described toreconstruct upper arm defects.1,2 Yunchuan et al. har-vested this flap with a pedicle dimension of 3� 4 cm andflap dimensions up to 12� 16 cm. The location of theharvest site on the abdominal wall varied from obliqueto perpendicular depending on the location of the defecton the distal forearm or hand. One flap was used to covera defect on the elbow. However, their flap was not a pureperforator flap, but rather an axial flap as it included thesubcutaneous branch which runs over the anterior abdom-inal wall. Gao et al. have used the same flap to recon-struct burn injuries in hands. The flap was thinned downto the subdermal vascular plexus in order to obtaina more cosmetically pleasing flap, converting it intoa pure perforator-based flap.2 The rt-LICAP flap describedin our study is a true perforator-based flap as it does notcontain an axial vessel.

Compared with its anterior abdominal counterpart,which was used by Yunchuan et al. and Gao et al., the rt-LICAP flap comes from an area with a lesser amount ofsubcutaneous fat, making it ideal for reconstructions re-quiring thinner resurfacing.1,2 The posterolateral thoracicarea also contains less to no hair compared to the abdomenor back in many subjects, when a hairless flap is desired.When applied to the antecubital region the pedicle doesnot kink, unlike its abdominal counterpart. For defects atvarious levels the LICAP-based flaps from different levels

e8 T.O. Acarturk

of intercostal perforators may be used, from the 7th to the12th intercostal perforator. For hand defects the contralat-eral flap may be used.

Hamdi et al. used intercostal artery perforator flapsarising from the dorsal (DICAP), lateral (LICAP) and anterior(AICAP) branches in reconstruction of various trunk de-fects.3 The largest LICAP flap from the thoracic area was20� 10 cm with primary closure of the donor site.6 Levineet al. used a de-epithelialised LICAP flap from the lateralthoracic area to augment and reconstruct partial mastec-tomy defects.7 Van Laduyt et al. used the same flap to aug-ment breasts either for congenital breast asymmetry ordeficiency following massive weight loss.8 Kwei et al. usedan AICAP flap to perform augmentation mastopexy follow-ing massive weight loss.9 Badran has used the lateral inter-costal artery flap as a free flap for hand, foot, neck andfacial defects.10,11 We describe the first case where theLICAP flap from the posterolateral thoracic area is used toreconstruct an upper extremity defect.

The advantages of a rt-LICAP flap from the posterolat-eral thoracic area are: (1) no kinking in the pedicle as it isnot folded, especially for antecubital defects, (2) hairlessskin from the midaxillary line area, (3) thinner flapcompared to the abdominal area and (4) the scar is placedin the back of the patient in a more acceptable area.

References

1. Yunchuan P, Jiaqin X, Sihuan C, et al. Use of the lateral inter-costal perforator-based pedicled abdominal flap for upper-

limb wounds from severe electrical injury. Ann Plast Surg2006;56:116e21.

2. Gao JH, Hyakusoku H, Inoue S, et al. Usefulness of narrow ped-icled intercostal cutaneous perforator flap for coverage of theburned hand. Burns 1994;20:65e70.

3. Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforatorflaps in breast reconstruction: a new concept. Br J Plast Surg2004;57:531e9.

4. Daniel RK, Kerrigan CL, Gard DA. The great potential of the in-tercostal flap for torso reconstruction. Plast Reconstr Surg1978;61:653e65.

5. Spear SL, Kroll SS, Little 3rd JW. Bilateral upper-quadrant(intercostal) flaps: the value of protective sensation in pre-venting pressure sore recurrence. Plast Reconstr Surg 1987;80:734e6.

6. Hamdi M, Van Landuyt K, de Frene B, et al. The versatility ofthe inter-costal artery perforator (ICAP) flaps. J Plast ReconstrAesthet Surg 2006;59:644e52.

7. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breastreconstruction for partial mastectomy defects. Plast ReconstrSurg 2005;116:762e7.

8. Van Landuyt K, Hamdi M, Blondeel P, et al. Autologous breastaugmentation by pedicled perforator flaps. Ann Plast Surg2004;53:322e7.

9. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmen-tation after massive weight loss: the intercostal artery perfora-tor (ICAP) flap. Ann Plast Surg 2006;57:361e5.

10. Badran HA, El-Helaly MS, Safe I. The lateral intercostalneurovascular free flap. Plast Reconstr Surg 1984;73:17e26.

11. Badran HA, Youssef MK, Shaker AA. Management of facialcontour deformities with deepithelialized lateral intercostalfree flap. Ann Plast Surg 1996;37:94e101.