Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 372e379

Transverse thoracodorsal artery perforator flaps:experience with 31 free flaps*

Soo-Hyang Lee, Goo-Hyun Mun*

Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine,Irwon-dong 50, Gangnam-gu, Seoul 135-710, South Korea

Received 26 January 2007; accepted 31 October 2007

KEYWORDSThoracodorsal arteryperforator flap;Transverse design

* Partly presented at the 9th InternFlaps on October 7, 2005, Barcelona,

* Corresponding author. Tel.: þ82 20036.

E-mail address: gh.mun@samsung.

1748-6815/$-seefrontmatterª2007Bridoi:10.1016/j.bjps.2007.10.050

Summary The conventional design of free thoracodorsal artery perforator (TDAP) flaps isorientated vertically along the long axis of the latissimus dorsi muscle, i.e. along the courseof the descending branch of the thoracodorsal artery. However, this method does not considerperforators derived from the transverse branch of the thoracodorsal artery, and leaves a longscar that runs perpendicular to the relaxed skin tension line. Accordingly, scar widening andhypertrophy are frequently encountered problems.

From April 2004 to December 2005, 31 free TDAP flap transfers were performed in 29patients for reconstruction of the lower extremity (16 flaps), head and neck (12 flaps), andupper extremity (three flaps). Flap long axes were laid transversely following the relaxed skintension line and paddles were designed to include proximal perforators from both branches ofthe thoracodorsal artery. Flap sizes ranged from 7� 5 cm to 22� 12 cm with a mean thicknessof 7.5 mm (range 3e13 mm). Among the 40 perforators employed as pedicles, 34 were derivedfrom the descending branch and six were from the transverse branch of the thoracodorsalartery. Except for a single case of total flap loss, the other flaps were successfully transferred.Donor scars ranged from 6 to 28 mm in width after a minimum follow-up period of 10 months.The transverse design may be preferred whilst planning free TDAP flap transfer, becausethe surgeon has a wider choice of perforators and the final donor scar has a less disfiguringappearance.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

ational Course on PerforatorSpain.3410 2233; fax: þ82 2 3410

com (G.-H. Mun).

tishAssociationofPlastic,Reconstruc

The thoracodorsal artery perforator (TDAP) flap is an attrac-tive donor in various situations because its generousdimensions and thinness and its superb versatility for thereconstruction of complex defects.1e5 Low donor sitemorbidity with a relatively hidden scar below the posterioraxillary fold is also a consequential benefit of this flap.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Transverse thoracodorsal artery perforator flaps 373

Conventionally the free TDAP flap has been orientatedvertically along the long axis of the latissimus dorsi muscle,i.e. along the course of the descending branch of thethoracodorsal artery. In order to localise reliable perfora-tors and dissect the pedicle, a long exploratory incisionwith its arc skirting the free lateral muscle border is madealong the lateral boundary of the skin paddle with proximalextension of varying length to the posterior axillary fold.Using this method, medially located perforators derivedfrom the transverse branch of the thoracodorsal arterywere not usually considered during the flap planning. Asreported in two studies,6,7 the transverse branch of thethoracodorsal artery also provides valuable perforators forthe TDAP flap pedicle.

In the current era of the perforator flap, in addition toreduced donor site morbidity by only taking tissues that areneeded and consequently sparing underlying fascia, mus-cles and nerves, cosmesis has become an important issue atdonor sites. The traditional donor scar of the TDAP flap runsperpendicular to the relaxed skin tension line (RSTL) of theback, and thus frequent scar widening and hypertrophyhave been problems, especially in Orientals.

To improve cosmetic morbidity of the same donor terri-tory, a modification of design was conducted for pedicledlatissimus dorsi musculocutaneous8 and free parascapularflaps.9 Recently in the pedicled TDAP flap transfer forbreast augmentation and reconstruction, transverselyorientated design and its advantages were reported.10,11

However, preferential use of a transverse design in a freeTDAP flap series has not been reported to date. Moreover,the authors used different harvesting techniques, includingconsiderations of perforators, paddle locations, explora-tion incision and intramuscular dissection, and others.Here, the authors present the results of using this designand of the refined harvest technique used for free TDAPflap transfer.

Patients and methods

From April 2004 to December 2005, a total of 31 consecu-tive TDAP free flaps were transferred in 29 patients. Thepatient group was composed of 14 females and 15 males,with a mean age of 36.3 years (range, 6e74 years). Theflaps were used for the reconstruction of various wounds ofthe lower extremity (14 patients), head and neck (12patients), and upper extremity (three patients).

Surgical technique

With the patient lying in the lateral decubitus position,medial and lateral borders of the latissimus dorsi muscleand scapular angle are marked. Using a sterile Dopplerprobe (8 MHz; Hadeco, Japan), lateral perforators are map-ped out with the aid of the ‘perforator compression test’12

at about 6 to 12 cm below the posterior axillary fold and 1to 3 cm inside the lateral free muscle border and, then,medial perforators are searched for within a circular areaof 3.5 cm radius centred at the tip of the scapular angle.A TDAP flap is designed along the axis lying parallel to theRSTL, starting high posteriorly and running anteriorly inan oblique fashion (Fig. 1A). If a female patient requires

a horizontal scar for better concealment by a brassiere,the design is adjusted accordingly.

If the paddle size permits, the flap is outlined to includeboth perforators deriving from the descending and trans-verse branches of the thoracodorsal artery. When we pre-pared a small paddle, it was placed over the perforator withthe louder sound on Doppler examination. Initial incision ismade at the central portion of the superior border of theflap and dissection is then deepened to identify the looseareolar plane above the dorsal thoracic fascia (Fig. 1B).After the location of the marked perforator is confirmedby suprafascial elevation of the flap inferiorly, entire inci-sion is made along the flap margin. When multiple perfora-tors were identified, we selected the pedicle perforatorbased on considerations of its size and location. For sensateflaps, the posterior ramus of the lateral cutaneous branch ofthe intercostal nerve hitchhiking the perforator is harvestedby tracing it anteriorly between slips of the serratus ante-rior muscle. Superior to the upper border of the flap,a suprafascial pocket is created over the proximal portionof the latissimus dorsi muscle. Retracting this underminedupper back skin then enables complete pedicle dissectionwithout extension of the incision beyond flap boundaries.We dissected the perforator intramuscularly with generoususe of a bipolar forceps. Sufficient muscle cleavage, diligentopposing retraction perpendicular to muscle fibres, and in-advance intramuscular nerve branch dissection are indis-pensable manoeuvres for accurate and safe perforatordissection. When the pedicle dissection has been completedand transected at the desired level, the whole pedicle isdrawn between the dissected nerve branches remaining inthe muscle cleft (Fig. 1C, D). Customised flap thinning isperformed on the side table with scissors whilst preservingthe subdermal fat layer, and final adjustment with bleedingcontrol is made after vascular anastomosis.

The cleaved muscle edges are approximated with anabsorbable suture and a suction drain is placed. Generallyclosure of the donor wound proceeds in the usual fashionand, for small defects, we apply the purse-string closuremethod to minimise donor site scarring (Fig. 2AeC).

Results

Patient data are summarised in Table 1. One flap wastotally lost due to arterial insufficiency. Two flaps were suc-cessfully salvaged by vascular revision. Two patients under-went staged bilateral TDAP flap transfers; one for bilaterallower limb reconstruction (cases 16 and 25) and the otherfor failed first TDAP transfer (cases 7 and 30). Twenty-fiveflaps (75.8%) were thinned, and the average flap thicknessafter customised sculpturing was 6.4 mm (range 3e10 mm). A single perforator was selected for the pediclein 22 flaps and double perforators were included in nineflaps. Among a total of 40 perforators included as pediclesof 31 flaps, 33 (82.5%) perforators were located in the lat-eral region near the lateral muscle border and six (15%)were in the medial region near the medial muscle border.A perforator derived from the descending branch was foundin the central region, more than 4 cm distant from bothmuscle borders. Average length of the pedicle was 9.4 cm(range, 5e14 cm).

Figure 1 (A) The flap was designed with a long axis corresponding to the RSTL. The exploration incision line (red line) is marked.(B) During exploration, a perforator originating from the transverse branch (arrow head) and a lateral branch of the intercostalnerve (arrow) were visualised. The perforator derived from the descending branch (asterisk) is hidden behind the nerve. (C) Dis-sected transverse branch (arrow head) joins descending branch (arrow) at the neurovascular hilum of the latissimus dorsi muscle.(D) A sensate TDAP flap was harvested completely.

374 S.-H. Lee, G.-H. Mun

Primary closure of the donor site was achieved in allpatients. One wound dehiscence occurred after purse-string repair. No remarkable donor site haematoma orseroma was observed. In the present series, 22 donor sitesin 20 patients were adequately followed up for at least 10months and up to 29 months (mean 16.5 months) and wereincluded in the scar evaluation; widest points were definedas the width of the donor site scar at final follow up. Scarwidths ranged from 6 to 28 mm (mean 11.5 mm), and hyper-trophic change necessitating topical steroid injection de-veloped in one adult and four paediatric patients (Fig. 3A,B). No patient complained of contour deformity of theback and all showed rapid and complete recovery of shoul-der function. Seven flaps were transferred as sensate flaps.In five patients static two-point discrimination results at an

average of 14 months postoperatively showed 3e22 mm(mean 12.4 mm).

Case report

A 64-year-old man (case 15) with a long history of repeatedrecurrences of dermatofibrosarcoma protuberance on hisscalp presented at our clinic (Fig. 4A). The tumour was re-moved with a 3 cm resection margin including the perios-teum. An elliptical skin paddle of 22� 12 cm in size wasdesigned with its long axis following the RSTL (Fig. 4B). Be-cause the perforator near the lateral muscle border waslarger than one near the medial muscle border on explora-tion, we chose a perforator derived from the descendingbranch to perfuse the flap and another smaller nearby

Figure 2 (A) Donor site defect after flap harvest. (B) The de-fect was repaired by purse-string closure. (C) Donor scar at 70days postoperatively.

Transverse thoracodorsal artery perforator flaps 375

perforator. The donor site was closed primarily in the usualmanner, and the flap healed well without complication.The donor site scar was aesthetically favourable andmeasured 9 mm in width at 10 months postoperatively(Fig. 4C, D). The patient was unaware of any differencein shoulder function pre- and postsurgery.

Discussion

The lateral thoracic region had long been explored fora free flap donor and microsurgical transfer of thoracodor-sal axillary and lateral thoracic flaps was reported.13e15

However, this region had not generally been favoured be-cause of its anatomical variation of the pedicle until Angri-giani et al.16 first revealed the perforator anatomy andreported the use of the free TDAP flap.

Although the TDAP flap has not gained the same level ofpopularity as its competitor the anterolateral thigh (ALT)flap, partly due to the restricted decubitus position duringharvesting, TDAP flaps have unsurpassed advantages insome respects, and minimal donor site morbidity is one.In terms of donor site cosmesis, TDAP flaps show superiorresults by leaving scars accompanied by less contourdeformity, in relatively hidden areas.

Nonetheless, unattractive, widened donor site scarringorientated longitudinally is a principal drawback of theTDAP flap.17 Although width of the flap and donor laxity doaffect the result, vertical scars usually span several centi-metres or more in width based on our experience. More-over, breast mounds move laterally when widths of flapsare large, though most are temporary. The elasticity ofback skin has a preferential orientation along the longitudi-nal axis. Thus transverse cutaneous gain needed for longitu-dinal flap donor closure is limited due to the circumferenceof the thorax, as elastic reserve is poor in this direc-tion.18,19 This explains the frequent scar widening with orwithout hypertrophic change at donor sites of large longitu-dinal TDAP flaps.

According to our topographic study,7 there is a highchance (82.6%) of finding at least one reliable perforatornear the medial border of the latissimus dorsi muscle. In ad-dition, perforators in the central region, an area removedfrom the medial and lateral muscle borders, exist in about70% of patients. For the traditional flap of vertical design,only perforators near the lateral muscle border count aspossible pedicles and other perforators were not routinelyincluded in the flap design because of the lateralisationand vertical axis of the paddle. On the other hand, trans-versely orientated paddles span beyond the medial andlateral muscle borders and can incorporate most of the po-tential perforators derived from the thoracodorsal artery.When the flap size is large enough, included perforatorswere compared with each other during direct exploration,and then finally we chose the perforator for the flap pedi-cle. Because perforator size determines flap perfusionand its ultimate survival, selection of the largest perforatoris an important advantage. Actually in our 31 patients,seven patients had favourable perforators located in themedial or central region, which were chosen as pedicles;five as sole pedicles and two as pedicles for a second paddlein chimeric flaps.

The transverse design requires a different approach forperforator exploration. We placed this limited incisionalong the superior border of the flap. Because occasionallythe perforator shows a long suprafascial course in theinferior direction before entering subcutaneous tissue,intraoperative adjustment of the lower border of theflap might be needed. Thus, placement of the exploration

Table 1 Patient demographics

No. Sex/age(yr)

Diagnosis Recipient site Flap size(cm2)

Flapthickness(mm)

Number ofincludedperforators

Sourcebranch

Pediclelength(cm)

Recipient artery & vein Complication Remarks

1 F/23 Burn scar contracture Neck 17� 8 7 1 Descending br. 10 Superior thyroid a.& v. Nil2 F/12 Trauma Foot, medial

malleolus13� 6 8 1 Descending br. 9 Anterior tibial a. & v. Nil

3 F/63 Venular malformation Lower lip 8� 6 3 1 Descending br. 8 Facial a. & v. Subflaphematoma

4 F/68 Squamous cellcarcinoma

Face, forehead 17� 8 8 1 Descending br. 9 Superficial temporal a. & v. Nil

5 F/10 Trauma Foot, medialmalleolus

13� 6 8 1 Transverse br. 8 Anterior tibial a. & v. Nil

6 F/17 Burn scar contracture Neck 16� 7 4 1 Descending br. 11 Facial a. & v. Nil7 M/12 Trauma Foot, dorsum 10� 6 8 1 Descending br. 11 Dorsalis pedis a. & v. Total flap loss8 M/25 Scar contracture Neck & lip 12� 8, 10� 4 7 2 Descending &

transverse br.14 Facial a. & v. Nil Two

paddles9 F/45 Malignant melanoma Hand, wrist 9� 5 5 1 Descending br. 7 Radial a. & v. Nil10 F/61 Malignant melanoma Hand, dorsum 9� 5 5 1 Transverse br. 10 Radial a. & superficial v. Nil11 F/50 Venular malformation Cheek & nose 8� 6, 6� 4 5 2 Descending &

transverse br.12 Superficial temporal a. & v. Nil Two

paddles12 M/29 Burn scar contracture Neck 22� 8 5 2 Descending br. 10 Facial a. & v. Nil13 F/55 Malignant melanoma Foot, heel 8� 5 8 1 Descending br. 11 Anterior tibial a. & v. Nil14 F/48 Arteriovenous

malformationFace, cheek 14� 7 13 1 Descending br. 11 Superior thyroid a. & v. Nil

15 M/64 Dermatofibrosarcoma Scalp 22� 12 10 2 Descending br. 9 Superficial temporal a. & v. Nil16 F/7 Amputated knee Knee 11� 5 12 1 Descending br. 7 Popliteal a. & v. Nil17 M/74 Malignant melanoma Foot, sole 10� 5 10 1 Descending br. 11 Posterior tibial a. & v. Nil S18 M/32 Myxofibroma Forearm 12� 7 4 2 Descending br. 9 Radial a. & vena comitantes Subflap

hematomaS

19 M/46 Scar contracture Popliteal area 20� 8 7 1 Transverse br. 10 Medial sural a. & v. Nil S20 F/8 Scar contracture Foot 12� 5 7 1 Descending br. 5 Anterior tibial a. & v. Nil S, P21 F/34 Scar contracture Foot, heel 10� 5 7 1 Descending br. 8 Anterior tibial a. & v. Nil P22 M/56 Malignant melanoma Foot, heel 9� 6 10 2 Descending br. 9 Anterior tibial a. & v. Nil S, P23 M/33 Buerger’s disease Foot, metatarsal

area8� 6 9 1 Descending br. 11 Anterior tibial a. & v. Nil P

24 M/7 Scar contracture Foot, dorsum 7� 5 5 1 Descending br. 6 Anterior tibial a. & v. Nil S, P25 F/8 Scar contracture Foot, dorsum 8� 5.5 10 2 Descending br. 5 Anterior tibial a. & v. Donor wound

dehiscenceS, P

26 M/6 Trauma Foot, dorsum ankle 15� 7 5 1 Transverse br. 7 Anterior tibial a. & v. Vein revision27 M/30 Burn scar contracture Neck 11.5� 8 5 1 Descending br. 9 Superior thyroid a. & v. Nil P28 M/21 Burn scar contracture Scalp 22� 12 7 2 Descending br. 12 Superficial temporal a. & v. Artery revision29 M/16 Trauma Foot 16� 9.5 10 1 Descending br. 10 Anterior tibial a. & v. Nil30 M/12 Trauma Foot, dorsum 13� 8 7 1 Descending br. 11 Posterior tibial a. & v. Nil P31 M/65 Radionecrosis Neck 15� 11 12 2 Descending br. 12 Transverse cervical a. & v. Nil

a., artery; v., vein; br., branch; S, sensate flap; P, purse-string donor closure.

376S.-H

.Le

e,

G.-H

.M

un

Figure 3 (A) Postoperative view of the donor scar in a 50-year-old woman 21 months postoperatively. (B) The scar is concealedwith a brassiere.

Transverse thoracodorsal artery perforator flaps 377

incision along the superior border is desirable for the safeinclusion of the perforator within the flap territory.

Tedious intramuscular dissection of the perforator isa recognised shortcoming of TDAP flap harvest. A smallperforator size, a long intramuscular course (mean 5.3 cm),7

and numerous side branches and delicate nerve branchesare the causes of technical difficulties. According to thesurgeon’s taste various instruments are chosen as main in-struments for intramuscular dissection. Bipolar forceps usu-ally play a supplementary role, mainly for haemostasis. Incontrast, the authors have used bipolar forceps (Jewelersforceps, Valleylab�, Colorado, USA) extensively throughoutentire perforator dissection procedures.20 Immediatelyafter the reliable perforator has been identified, the wholeskin paddle was fully elevated to allow frequent change ofperforator position and direction during the dissection. Al-though this approach does not allow a technical error andseems risky, safer direction and space for bipolar electrodis-section could be maintained throughout the procedure,which improves security instead. Early paddle elevationalso permits intraoperative adjustment of the nerve-to-pedicle spatial relationship. A skin paddle with a vascularpedicle can sometimes be passed under dissected intramus-cular nerve branches to achieve a more favourable pedicleposition for easier proximal dissection with maximal preser-vation of the nerve branches. Moreover, because proximalpedicle exposure is much easier for the transverse thanthe vertical design, we were able to totally avoid extensionof the incision outside the flap boundaries in all study sub-jects. A long pedicle could be produced through this incisioneven for small flaps.

TDAP flap elevation produces donor site defects thatare round or oval in shape. Direct closure of this wound

inevitably elongates scar length and creates a dog-eardeformity. Experience of purse-string sutures for theclosure of various wounds was found to reduce scarlength.21e24 We used subcuticular purse-string suture ineight patients with flap sizes ranging from 35 to 104 cm2

(mean 60.9 cm2). Although wound revision was requiredfor an overweight patient, we achieved an acceptable cos-metic result. This closure method is most effective andbeneficial to the patient when a round small paddle isharvested.

The authors’ design and harvesting technique has thefollowing advantages: (1) various perforators can be in-corporated into flap pedicles, which increases flap versa-tility; (2) selection of the most suitable perforator byintraoperative comparison between perforators at variouslocations is possible; (3) incision beyond flap boundaries isunnecessary for elevation; (4) minimisation of muscle andnerve damage enables rapid functional recovery; (5) theresulting donor scar follows the RSTL and thus improvescosmesis and, if applicable, a purse-string suture could beused to shorten the donor scar.

However, transverse design requires accurate localisa-tion of perforators aided by Doppler examination; multi-detector CT angiography25 would be of practical value inthis regard. Moreover, dissection in the limited space avail-able when the flap paddle is small demands good assistanceand experience. Although possible contour deformity at thedonor site of a transversely orientated flap has beenmentioned by others,17 it has not become problematic toour patients from either the functional or the aestheticstandpoints.

In conclusion, a transverse design with a refined harvesttechnique proved to be valuable for free TDAP flap transfer.

Figure 4 Case 15. (A) Preoperative view of a 64-year-old man with a diagnosed dermatofibrosarcoma protuberance on the scalp.(B) A flap was designed to include two perforators derived from both branches of the thoracodorsal artery. (C) Postoperative viewof the recipient site at 10 months. (D) Donor site scar at 10 months postoperatively.

378 S.-H. Lee, G.-H. Mun

More perforators from the thoracodorsal artery can beconsidered as potential pedicles and donor site morbidity isfurther minimised using this method.

Acknowledgements

The authors thank Miss J. E. Lee, a photographer in ourdepartment, for preparing the photographs used in thisarticle.

References

1. Guerra AB, Metzinger SE, Lund KM, et al. The thoracodorsal ar-tery perforator flap: clinical experience and anatomic studywith emphasis on harvest techniques. Plast Reconstr Surg2004;114:32e41.

2. Bidros RS, Metzinger SE, Guerra AB. The thoracodorsal arteryperforator-scapular osteocutaneous (TDAP-SOC) flap for recon-struction of palatal and maxillary defects. Ann Plast Surg 2005;54:59e65.

Transverse thoracodorsal artery perforator flaps 379

3. Van Landuyt K, Hamdi M, Blondeel P, et al. The compound thor-acodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot. Br J Plast Surg2005;58:371e8.

4. Mun GH, Lim SY, Hyon WS, et al. A novel reconstruction of 2distinct defects: concomitant use of a thoracodorsal arteryperforator flap and its corresponding muscle flap. Ann PlastSurg 2005;55:676e8.

5. Mun GH, Lim SY, Hyon WS, et al. Correction of temporo-masseteric contour deformity using the dual paddle thoraco-dorsal artery perforator adiposal flap. J Reconstr Microsurg2006;22:335e42.

6. Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsalartery perforator flap: anatomic basis and clinical application.Ann Plast Surg 2003;51:23e9.

7. Mun GH, Lee SJ, Jeon BJ. Perforator topography of the thora-codorsal artery perforator flap. Plast Reconstr Surg, in press.

8. Kelly MB, Searle A. Improving the donor site cosmesis of thelatissimus dorsi flap. Ann Plast Surg 1998;41:629e32.

9. Siebert JW, Longaker MT, Angrigiani C. The inframammaryextended circumflex scapular flap: an aesthetic improvementof the parascapular flap. Plast Reconstr Surg 1997;99:70e7.

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

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

12. Mun GH, Jeon BJ. An efficient method to increase specificity ofacoustic Doppler sonography for planning a perforator flap:perforator compression test. Plast Reconstr Surg 2006;118:296e7.

13. Baudet J, Guimberteau JC, Nascimento E. Successful clinicaltransfer of two free thoraco-dorsal axillary flaps. Plast Re-constr Surg 1976;58:680e8.

14. Irigaray A, Roncagliolo A, Fossati G. Transfer of a free lat-eral thoracic flap in a child. Plast Reconstr Surg 1979;64:259e63.

15. Harii K, Torii S, Sekiguchi J. The free lateral thoracic flap. PlastReconstr Surg 1978;62:212e22.

16. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocuta-neous flap without muscle. Plast Reconstr Surg 1995;96:1608e14.

17. Van Landuyt K, Hamdi M. Thoracodorsal artery perforator flap.In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, editors.Perforator Flaps: Anatomy, Technique, Clinical Application.St Louis: Quality Medical Publishing; 2006. p. 441e59.

18. Chretien-Marquet B, Bennaceur S, Fernandez R. Surgical treat-ment of large cutaneous lesions of the back in children by con-centric cutaneous mobilization. Plast Reconstr Surg 1997;100:926e36.

19. Aubert JP, Magalon G. Long term results of skin expansion.Scand J Plast Reconstr Surg Hand Surg 1995;29:233e8.

20. Mun GH, Lee SH. Efficient dissection of an intramuscularperforator using bipolar forceps. Ann Plast Surg 2007;58:591.

21. Peled IJ, Zagher U, Wexler MR. Purse-string suture for reduc-tion and closure of skin defects. Ann Plast Surg 1985;14:465e9.

22. Yuen JC. Versatility of the subcuticular purse-string suture inwound closure. Plast Reconstr Surg 1996;98:1302e5.

23. Tremolada C, Blandini D, Beretta M, et al. The ‘‘round block’’purse-string suture: a simple method to close skin defects withminimal scarring. Plast Reconstr Surg 1997;100:126e31.

24. Weisberg NK, Greenbaum SS. Revisiting the purse-string clo-sure: some new methods and modifications. Dermatol Surg2003;29:672e6.

25. Hamdi M, Van Landuyt K, Hedent EV, et al. Advances in autog-enous breast reconstruction: the role of preoperative perfora-tor mapping. Ann Plast Surg 2007;58:18e26.