Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1596e1603

Lateral thoracic perforator flap: Additionalperforator flap option from the lateralthoracic region

Jeong Tae Kim a,*, Siew-Weng Ng b, Shenthilkumar Naidu c,Jong Do Kim a, Youn Hwan Kim a

aDepartment of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, 17 Haengdang-Dong,Seongdong-Gu, Seoul 133-792, South KoreabDepartment of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Outram Road,Singapore 169608, SingaporecDivision of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, Tan Tock Seng Hospital, Singapore

Received 25 April 2011; accepted 28 June 2011

KEYWORDSLateral thoracic;Perforator flap;Latissimus dorsiperforator flap;Thoracodorsalperforator flap;Flap option;Universal donor site;Head and neckreconstruction;Lower limbreconstruction

* Corresponding author. Tel.: þ82 2E-mail address: ps360@hanmail.ne

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.06.048

Summary Background: Perforator flaps from the lateral thoracic region have not been aspopular as other donor sites because of the misconception that the vascular anatomy in thisregion is less than predictable. However, the skin over the lateral thoracic region is vascu-larised by three rows of perforators of varied vascular dominance. Two perforator flaps fromthis region based on the middle and the posterior row of perforators from the thoracodorsalartery have been described. The lateral thoracic perforator flap based on the anterior rowof perforators is another useful option.Patients and results: Nine patients underwent reconstructions using the lateral thoracic perfo-rator flap for various defects in the head and neck region and lower limbs as a result of tumourextirpation, crush injury and chronic wound with osteomyelitis. All flaps were raised in thesupine position. Three flaps were raised in a chimaeric fashion. The largest flap was 20 � 12 cmand the mean size was 106 cm2. All flaps survived without major complication.Conclusion: The lateral thoracic perforator flap is a reliable reconstructive option. It can bereadily configured in terms of size, thickness and tissue composition. However, it is not thefirst-choice flap from this region because the resultant donor scar tends to extend visiblybeyond the anterior axillary fold and the arterial and venous pedicles frequently have separatecourses. The lateral thoracic region has become a versatile and universal donor site for free-style flap harvest with this additional flap option.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

2290 8563; fax: þ82 2 2295 7671.t (J.T. Kim).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region 1597

Reconstruction with a perforator flap has become common-place because of its lower donor-site morbidity. Some ofthese flaps, for example, the lateral thigh flap, havebecome the workhorse flap in many centres because of itspredictable anatomy and ease of harvest. Although a perfo-rator flap from the lateral thoracic region has beendescribed since 1995,1 it has not enjoyed similar popularityas its counterparts have.

One explanation may be the preconceived notion thatdissection in the lateral thoracic region is difficult because ofthe steep learning curve required for vascular dissection. Theseniorauthorprefers a free-style approach toflapharvest andhas provided two options of perforator flaps in this region.2

Based on the senior author’s new classification,3 a perforatorflap is named after the source vessel which gives rise to theseptocutaneous perforator, for example, the thoracodorsalperforator flap based on septocutaneous perforators fromthe thoracodorsal artery. The flap is named after the musclein the case of a flap based on amusculocutaneous perforator,for example, the latissimusdorsi (LD) perforator flapbasedonthe musculocutaneous perforators. These two flaps havebeen applied in various reconstructions ranging from thehead and neck region to the limbs.

We further introduce the lateral thoracic perforator flap asa third perforator flap option in the lateral thoracic region.This flap shares similar versatility as the other two perforatorflaps based on the thoracodorsal system. This option alsoprovided further justification for ourpreferred supinepositionof flap harvest. With this added option, the lateral thoracicregion could readily become a universal flap donor site.

Patients and methods

Nine patients underwent flap coverage with the lateralthoracic perforator flap (Table 1). The approach to the flapharvest was similar to that described by the senior authorfor the LD and thoracodorsal artery perforator flaps.3 Thepatient was place in supine position with the shoulderabducted at 90�. The anterior border of the pectoralismajor muscles and posterior borders of the LD musclewere marked. An incision is placed several centimetresanterior to the LD muscle border, centred at about 10 cminferior to the axillary apex, allowing access to both reli-able septocutaneous and the musculocutaneous perfora-tors. The presence of a direct cutaneous perforator from

Table 1 List of patients.

Sex/Age Diagnosis

M/31 Recurrent squamous cell carcinoma of neckM/60 Recurrent buccal squamous cell carcinoma.M/53 Hypopharyngealsquamous cell carcinomaM/37 Chronic wound with osteomyelitis of the lower limbM/73 Esophageal squamous cell carcinomaM/39 Left foot crush injuryF/51 Left leg chronic ulcerM/56 Tonsillar squamous cell carcinoma, rightM/57 Hypopharyngeal squamous cell carcinoma

the lateral thoracic vessels is a bonus because it providesthe third option for a flap from the lateral thoracic region.In this series, the lateral thoracic perforator flap was usedif the first trial of dissection was not able to locate a suit-able perforator from the thoracodorsal artery or if thelateral thoracic perforator was located at the outset bychance.

Results

We treated eight male and one female patients, ageranging from 31 to 73 years (mean age: 50.5 years). Thesize of flaps ranged from 4 � 2 to 20 � 12 cm (mean size:106 cm2). The indications for flap reconstruction in thesenine patients included post-tumour-ablation defects,chronic osteomyelitis and chronic and traumatic wounds.Six cases involved the head and neck region, the otherthree involved lower-limb reconstruction. Four of thereconstructions required chimaeric composition of theflap. One flap for hypopharyngeal squamous cell carcinomawas made sensate with the inclusion of intercostal nerves.

There were no complications, such as flap necrosis,haematoma, seroma or infection. There was one instanceof flap-margin wound dehiscence, which eventually healedafter postoperative radiotherapy. Another patient sufferedfrom hypertrophic scar over the donor-site wound.

Case reports

Case #1. A 53-year-old male patient with stage T3N1M0

squamous cell carcinoma in the right hypopharynx, under-went right hemilaryngectomy and radical neck dissection(Figure 1(a)). The resultant defect required reconstructionof two contiguous structures: the right vocal cord and rightlateral pharyngeal wall. A thin perforator flap from thelateral thoracic region was planned. During dissection, nosuitable thoracodorsal artery septocutaneous perforatorwas found. Before attempting to locate the musculocutane-ous perforators, the dissection proceeded anteriorly andthe direct cutaneous perforator from the lateral thoracicartery was traced (Figure 1(b)). The flap was centredmore anteriorly yielding an 8 � 6-cm thin skin paddle(Figure 2(a)). The posterior digastric tendon was used toreconstruct the right vocal cord by attaching it to the

Dimension Remarks

20 � 12 cm For thin resurfacing6 � 5 cm For controlled resurfacing8 � 6 cm Sensate flap

. 7 � 3, 4 � 2 cm Chimeric flap9 � 6 cm Bipedicled flap13 � 10, 12 � 7 cm Chimeric flap12 � 7 cm For thin resurfacing10 � 7, 8 � 7 cm Chimeric flap14 � 9, 3 � 2 cm Chimeric flap

(small paddle for monitoring)

Figure 1 a (left): Unilateral pharyngeal and hemilaryngeal defect after excision of right hypopharyngeal squamous cell carci-noma. b (right): Anterior dissection for lateral thoracic perforator flap was planned when a suitable perforators from the thoraco-dorsal system was not found.

1598 J.T. Kim et al.

thyroid and cricoid cartilages under suitable tension. Thethin portion of the flap was draped over the reconstructedvocal cord (Figure 2(b)) and the thicker portion was used toresurface the rest of the right pharyngeal defect. Thelateral thoracic artery and vein were anastomosed to thesuperior thyroid vessels. The postoperative recovery wasuneventful, with no leakage noted. Endoscopic examina-tion performed 3 weeks postoperatively showed good heal-ing and recovery of vocal cord function (Figure 2(c)). Therewas no recurrence during the 16-month follow-up period.The only drawback was a donor scar which extended tothe anterior chest area.

Case #2. A 37-year-old man sustained Gustillo & Andersongrade IIIA open fracture of the distal tibia and fibula duringa game of soccer. He was referred for chronic osteomye-litis, with two resultant skin defects following openreduction and internal fixation, which was secondarilyinfected (Figure 3(a)). A lateral thoracic perforator flapwas harvested with two skin paddles (7 � 3and 4 � 2 cm)(Figure 3(b) and (c)). The draining comitantes veins werefound to be of insufficient diameter and the lateral thoracic

Figure 2 a (left): 8 � 6 � 3 cm lateral thoracic perforator flap. byngeal defect. The flap was draped over the resected right vocal cotrics tendon). c (right): Postoperative endoscopic examination. Thecord closure.

vein was included for better venous drainage (Figure 3(d)and 4). The postoperative recovery was uneventful andthere was no need for surgical revision (Figure 3(d)).

Case #3. A 73-year-old patient underwent cervical oeso-phagectomy and bilateral neck dissection for stage T3N2M0

squamous cell carcinoma, leaving only 3 cm width of theposterior cervical oesophagus intact (Figure 5(a)). A thincutaneous perforator flap was planned from the rightlateral thoracic region. The thoracodorsal septocutaneousperforator was initially dissected but its diameter wasrather small. Further dissection anteriorly yielded a reliableperforator arising from the lateral thoracic artery(Figure 5(b)). This 9 � 6-cm flap which was finally raisedwas based on two perforators but was termed the lateralthoracic perforator flap because the latter perforator wasmore reliable (Figure 6(a)). The lateral thoracic pediclewas anastomosed to the transverse cervical vessels andthe other pedicle was anastomosed to the facial vessels(Figure 6(b)). Postoperative recovery occurred withoutany complications and the patient remained disease freeat 3 years’ follow-up.

(middle): Flap coverage of unilateral pharyngeal and hemilar-rd (which was reconstructed using the transverse sling of digas-reconstructed right vocal cord is able to assist in normal vocal

Figure 3 a (top left): Two chronic wounds in the right leg associated with osteomyelitis as a result of infected open reduction andinternal fixation for Gustilo Grade IIIA fracture. b (top right) and c (bottom left) : Harvest of the lateral thoracic perforator flap withtwo skin paddles. d (bottom right): At 9 months follow-up.

Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region 1599

Discussion

Free flaps from the lateral thoracic area have beendescribed since the 1970s.4e6 However, compared withother donor sites, there are fewer publications of flapsfrom this region versus, for example, the thigh donor site.

Figure 4 Schematic diagram showing the configuration ofthe flap with two skin paddles. The venae commitantes weretoo small for sufficient drainage. The lateral thoracic veinwas included to improve drainage. (P: perforator, LTAp: lateralthoracic artery pedicle with small venae committantes, LTV:lateral thoracic vein).

One possible reason may be the perceived inconsistentanatomy. The other cited reason is the lateral positioningof the patient during flap harvest, which precludes a two-team approach in some cases of reconstruction.

The skin overlying the lateral thoracic region has a richblood supply from three rows of perforators which originatefrom the thoracodorsal and lateral thoracic vessels, whichin turn originate from the axillary artery. Anteriorly, thethoracodorsal artery gives off septocutaneous perforators(directly or via separate branches) and a muscular branchto the serratus anterior muscle. The thoracodorsal arterythen divides into horizontal (transverse) and lateral(descending) branches deep into the LD muscle approxi-mately 4 cm distal to the inferior scapular border and2.5 cm medial to the lateral LD muscle border.7 Thesebranches subsequently give off musculocutaneous perfora-tors, which traverse the LD muscle. Hence, from anteriorto posterior, the three groups of perforators in the lateralthoracic region are: (1) the direct cutaneous perforatorsfrom the lateral thoracic artery, (2) septocutaneous perfo-rators from the thoracodorsal artery and (3) musculocuta-neous perforators also from the thoracodorsal artery. Agreat deal of anatomic variations exits in terms of domi-nance of these perforators. In the lateral thoracic areabetween the two muscle borders of the pectoralis majorand the LD muscles, the predominant supply is from thethoracodorsal arterial system, with the lateral thoracicartery being dominant in a minority of cases.8

In recent times, perforator flaps have become increas-ingly popular because of their lower donor-site morbidity.

Figure 5 a (left): Almost circumferential oesophageal defect after squamous cell carcinoma resection. b (right): Lateral thoracicperforator flap harvest.

1600 J.T. Kim et al.

Angrigiani et al.1 first described a perforator flap from thelateral thoracic area and named it the LD musculocutaneousflap without muscle. The senior author subsequentlyreported two options of perforator flaps from this region.2

These are the (1) thoracodorsal artery perforator flap,based on the middle row of septocutaneous perforatorsand (2) the LD perforator flap, based on the posterior rowof musculocutaneous perforators, both from the thoraco-dorsal system. This newer perforator flap nomenclature3

refines previous terminology9 and names the flap afterthe source vessel for a septocutaneous perforator. Theflap is named after the muscle for a musculocutaneousperforator. Both these perforator flaps can be raised ina free-style manner with varied composition and thicknessand in chimaeric pattern.10e12

Our preferred approach to perforator-flap harvest in thisregion is midway between the anterior border of thepectoralis major and the posterior border of the LD musclein the supine position. With this approach, we first dissectthe direct septocutaneous branch of the thoracodorsalartery yielding the thoracodorsal perforator flap.3 If thisperforator is unsuitable or less reliable, the dissectionproceeds posteriorly for the musculocutaneous perforatorsfrom the thoracodorsal artery which traverse the anteriorborder of the LD muscle. As a last alternative forperforator-flap harvest in this region, we dissect anteriorly

Figure 6 a (left): Lateral thoracic perforator flap. The main pediartery. There is a supplementary (smaller) perforator from the thanastomosed to the transverse cervical vessels and the other pedi

for the direct cutaneous perforator from the lateral thoracicartery. Our preference for harvesting a perforator flap fromthe lateral thoracic region in a supine position has allowednot only a two-team approach but also provided easy accessto all three rows of perforators in this region. Regarding thisorder of dissection of pedicles, we agree that the lateralthoracic perforator flap cannot be the flap of first choice.In the normal course of event, we adopt a fairly free-stylemanner by first searching for the septocutaneous or muscu-locutaneous perforators based on the thoracodorsal vascularsystem; if this is unsatisfying, we move anteriorly to harvestperforators based on the lateral thoracic vascular system. Toaid in the understanding of the anatomy of direct perfora-tors from the lateral thoracic artery, a picture of cadavericdissection is included (Figure 7).

There are several situations whereby the lateral thoracicperforator flap becomes the third flap option from thelateral thoracic donor site. While initially dissecting theseptocutaneous perforator of the thoracodorsal artery, onemay fortuitously meet a direct cutaneous perforator of thelateral thoracic artery first, instead. This may be a result ofeither making the lateral thoracic incision too anteriorly, ordue to anatomical variation. At this juncture, if a small flapis required, the flap is centred more anteriorly. Otherwise,another perforator from the same or another row can besought to improve the vascularity if a large flap is needed in

cle is the direct cutaneous perforator from the lateral thoracicoracodorsal artery. b (right): The lateral thoracic pedicle wascle was anastomosed to the facial vessels.

Figure 7 Cadaveric dissection of right lateral thoracic area.The lateral thoracic artery (red) and vein (blue) are posteriorto the free border of the pectoralis major muscle. The pinktriangular markers denote the direct cutaneous perforatorsfrom lateral thoracic vessels.

Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region 1601

a chimaeric fashion. In some rare instances, one may not beable to find a suitable middle or posterior row perforator inthe lateral thoracic region. This may be due to smallperforators, anatomical variation or inexperience.Changing the dissection anteriorly to look for the lateral

Figure 8 Algorithm of perforator flap di

thoracic artery perforators provides the third option. Analgorithm is proposed based on our proceedings of flapdissection (Figure 8).

In our experience, the lateral thoracic perforator flapshares the same characteristics and advantages as theother two perforator flaps based on the thoracodorsalvascular system.2 The abundant soft tissue in the lateralthoracic region (ranging from dermis to fascia) allows flex-ible composition of the lateral thoracic perforator flap intoadiposal, dermoadiposal and adipofascial flaps. Witha good-sized perforator, we managed to harvest flaps withsize up to 20 � 12 cm. When such a large flap is needed,we usually include another smaller perforator, be it fromthe thoracodorsal system, to improve reliability. Thisconstitutes a chimaera pattern.

Another advantage of this flap is its ability to be thinnedto 5e7 mm thickness safely by separating the superficialand deep adipose layer. This was illustrated in the first casestudy for pharyngeal and vocal-cord reconstruction. It isalso possible to harvest a sensate flap by incorporatingnearby intercostal nerves which are readily identified. Thedonor site is usually closed primarily. This versatility intissue composition, thickness, colour match and chimaericdesign makes the lateral thoracic perforator flap a goodcandidate for both head and neck as well as limbreconstructions.

The lateral thoracic perforator flap is not our first optionfor several reasons. Taylor and Daniel reported that the

ssection in the lateral thoracic region.

Figure 9 A postoperative 8 month view of a typical donorsite scar after a lateral thoracic perforator harvest. The scaris located more anteriorly than the thoracodorsal or LD perfo-rator flap.

1602 J.T. Kim et al.

lateral thoracic artery was not identified in 3 out of their 20dissections.13 Harii et al. noted the artery to be absent in 2of 11 cases.14 However, three rows of perforators wereconsistently demonstrated in five of our cadaveric dissec-tions. Another drawback is the small venae comitantes,which are usually too small to provide sufficient venousdrainage in our cases. Therefore, we routinely harvest thelateral thoracic vein with the flap.2,8 Pedicle dissectionfor this flap can occasionally be difficult because thepedicle is usually embedded in thick layer of fat, and thereliable lateral thoracic vein may have a separate coursefrom the artery. The lateral thoracic pedicle is also shorterand smaller compared with the thoracodorsal vessels. Areliable direct cutaneous perforator from the lateralthoracic artery can be sized between 1 and 2 mm in diam-eter. If there is size discrepancy to the recipient vessels,better size match can be achieved by: (1) harvestingmore proximally along the lateral thoracic artery, (2) usinga T anastomosis or (3) using end-to-side anastomosis. Goodpedicle length is an advantage for this flap. Eccentricplacement of the perforator pedicle and designing theflap more distally also helps in increasing the pediclelength. A portion of the donor scar tends to encroachbeyond the anterior axillary fold in contrast to a well-hidden scar in the lateral thoracic region if the flap wasraised on the thoracodorsal system (Figure 9). This consid-eration can limit the flap size, especially in femalepatients.

Conclusion

The lateral thoracic perforator flap is based on the directcutaneous perforator of the lateral thoracic artery, which is

part of the anterior of three rows of perforators in thelateral thoracic region. It is a reliable option for a variety ofreconstructions and can be readily configured in terms ofsize, thickness and tissue composition and in chimaericmanner. It provides yet another flap option apart from thethoracodorsal system. This makes it easier for free-styleflap harvest from this region. The lateral thoracic regionhas become a versatile and universal donor site.

Acknowledgements

There are no other sources of funds supporting the workand there is no financial interest in the methodologydescribed. We are grateful to the contribution of Se JinKim (Yeongdong High School).

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