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144
Fig. 14.21 Pedicled LD
myocutaneous ap tunnelled
through the axilla to reach
shoulder defect
M. Farid et al.
LD muscle
tunnelled via
axilla to reach
shoulder defect
Fig. 14.22 LD
myocutaneous ap inset and
closure to cover shoulder
defect
LD muscle
inset and
closure over
shoulder defect
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
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145
Case 2 Amputated contralateral left forearm stump resurfaced with Free myocutaneous LD ap. This 37-year-old
man had a crush avulsion injury to the arm during an industrial accident. His forearm was avulsed and he sustained segmental fractures of the radius, ulna and humerus. Replantation
was not feasible due to the poor condition of the amputated
part and the signicant crush avulsion mechanism. To sal-
vage his exposed radius and ulna and to preserve function of
his elbow joint, a contralateral free myocutaneous LD ap
was performed. This was anastomosed to the brachial artery
and associated venae comitantes. He made an excellent
recovery and was tted with an upper limb prosthesis
(Figs.14.23, 14.24, 14.25, 14.26, 14.27, 14.28, 14.29, and
14.30).
Fig. 14.23 Left forearm avulsion/amputation injury
Fig. 14.24 Left forearm
post-debridement with
exposed radius
Fig. 14.25 LD myocutaneous ap raised demonstrating superior
insertion
Radius
Elbow
146
Fig. 14.26 Preparation of
recipient vessels in right
forearm showing brachial
artery
M. Farid et al.
Brachial artery
Fig. 14.27 Intraoperative LD
ap inset and covered with
SSG and skin paddle to cover
radius
LD skin paddle
LD muscle cover with SSG
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
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Fig. 14.28 Intraoperative check for US Doppler signal on skin paddle
for LD ap
Fig. 14.29 Post-operative
SSG take and early results for
LD myocutaneous ap
LD skin paddle
147
LD muscle cover with SSG
148
a b
Fig. 14.30 (a) Post-operative follow-up showing SSG take and LD skin paddle (b) Post operative appearance if LD over arm
Fig. 14.31 Right lower limb
open tibial fracture, soft tissue
debridement and ex-x
stabilisation
M. Farid et al.
Ex-Fix
Case 3 Right lower limb open fracture resurfaced with a
free LD ap. This 57-year-old man had a right lower limb
injury from a road trafc accident. The right leg had open
tibia fracture (Gustilo- Anderson IIIB) with compromised
posterior compartment muscles. The initial operation
involved debridement of devitalised muscles and bony stabilisation with an external xator. This was followed by
Tibia
Lateral
Compartment
Muscles
denitive fracture xation, soft tissue coverage with LD
muscle ap and split thickness skin graft. The extensive
nature of the wound with bony exposure and large soft tissue defect necessitated the need for LD muscle ap. A
three-vessel run-off conrmed on CT-A and anastomosis
was performed end to end (thoracodorsal to posterior tibial
artery) (Figs.14.31, 14.32, and 14.33).
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
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Fig. 14.32 LD muscle free
ap inset into right lower limb
defect
149
LD muscle free flap
Fig. 14.33 LD muscle
covered with SSG
post-operatively
LD muscle cover with SSG
150
M. Farid et al.
14.8 Pearls and Pitfalls
Incision The orientation of the scar should be attempted to be
covered by clothes. A horizontal scar can be hidden along bra
straps for women allowing a better cosmetic result of donor site.
Vascular Pedicle Dissection The pedicle is identied and
protected when progressing into caudal LD insertion.
Identify the branch to the serratus anterior to prevent injury
to the vascular pedicle to the LD ap. The vascular pedicle
can expand to include branch to the serratus anterior or tip of
the scapula when raised as a chimeric ap.
Anatomy Preservation The surgeon should ensure there is
clear identication of the surrounding muscles and vasculature
throughout dissection. Allow orientation of bres to orientate
LD from other muscles.
Donor Site Towel clips are used to help facilitate closure
sequentially (Fig.14.18). Drains are to be kept until output
volume <30 mls in each. Quilting is recommended to reduce
the risk of seroma formation on donor site [22].
Flap Harvest The LD ap can be raised in an extended
fashion recruiting subcutaneous tissue to increase volume.
Subcutaneous tissue fat pads are distributed in the posterolateral thoracic region in ve zones. This corresponds to area
under cutaneous crescent of LD skin paddle (Zone 1), the
entire ap between the muscle and fascia (Zone 2), scapular
hinge ap above superomedial of LD muscle (Zone 3), anterior hinge ap on the external forward part of LD (Zone 4)
and suprailiac fat zone above iliac crest on lower aspect of
LD ap (Zone 5) [23]. This is particularly useful in breast
reconstruction for a satisfactory volume replacement, avoidance of implant and better cosmetic appearance.
Flap Inset Aim for tensionless inset of pedicled ap by
releasing any fascial attachment that prevents advancement
of the ap. Observe the ap for any evidence of venous congestion once inset into defect.
Patient Positioning The lateral position with arm up on the
LD side harvest allows good planning. Patients may need to
be repositioned to allow ap inset into defect. Nonetheless, a
trans-axillary approach is feasible with the patient in a supine
position also described to harvest a portion of LD muscle
ap in facial reanimation [24]. The option for prone
positioning is noted for bilateral breast reconstruction or
even unilateral [25].
Flap Size The broad size of LD muscle and its thickness
allow coverage for large defects in the lower or upper limb,
head and neck or trunk defects. The LD muscle can provide
a better option than fasciocutaneous aps particularly in
overweight patients where fasciocutaneous aps would be
bulky in comparison to the more slender LD muscle.
14.9 Selected Readings
• Watanabe K, Kiyokawa K, Rikimaru H, Koga N, Yamaki
K, Saga T.Anatomical study of latissimus dorsi musculocutaneous ap vascular distribution. J Plast Reconstr
Aesthetic Surg. 2010; 63:1091–1098.
This cadaveric study provides the basis for safe myocutaneous LD ap harvest based on vascular angiosomes
to prevent skin necrosis in peripheral areas. First vascular territory is by direct anastomosis of perforating
branches of the thoracodorsal artery and branches of the
ninth, tenth and eleventh intercostal and scapular circumex arteries. A second vascular territory is based on perforating branches of the subcostal artery and perforating
branches of the rst and second lumbar arteries. If the
skin above LD muscle is recruited, this would extend into
a third vascular territory caudally from the inferior border of the twelfth rib. These vascular territories are connected with choke vessels for overlapping angiosomes.
We advocate the use of intraoperative adjuncts to further
illustrate the vascular territories intraoperatively.
• Winter R, Steinböck M, Leinich W, Reischies FMJ,
Feigl G, Sljivich M, et al. The reverse latissimus dorsi
ap: An anatomical study and retrospective analysis of
its clinical application. J Plast Reconstr Aesthetic Surg.
2019;72:1084–90.
This is an interesting anatomical and clinical study
demonstrating a new concept based on reverse LD ap
harvest. Blood supply is based on perforators from sixth
intercostal to subcostal area, dened as a “hotspot” as
7cm broad area over eighth to eleventh intercostal vessels. Reconstruction of the lateral thoracic chest wall and
sacral area is deemed feasible based on this concept.
• Clemens MW, Kronowitz S, Selber JC.Robotic-assisted
latissimus dorsi harvest in delayed-immediate breast
reconstruction. Semin Plast Surg. 2014;28:20–5.
The innovative concept of robotic microsurgery is demonstrated in LD ap harvest for delayed and immediate
breast reconstruction following radiotherapy. Minimal
donor site morbidity with three port sites access required
for instruments without an incisional site. Long-term
outcome (>1year) is part of future research for robotic
LD ap in breast reconstruction. The senior author rst
described the technique in 2012 and advocates the need
to be selective in choosing suitable patients for this
technique.
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
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151
• Lu J, Chavanon V, Margulies I, Yao AS.Cross-leg latissimus dorsi free ap with chimeric serratus anterior bridge
for lower extremity trauma: Case report and reconstructive algorithm. J Clin Orthop Trauma. 2019;10(5):867–72.
Lower limb defects for Gustilo-Anderson IIIB and
IIIC open fractures require complex reconstruction. Due
to vascular injury, limited reconstructive options were
available from the ipsilateral leg. Limb salvage was subsequently achieved with a chimeric cross-leg latissimus
dorsi-serratus anterior (LD-SA) free ap based off the
contralateral healthy leg.
• Sarifakioglu N, Bingül F, TerzioĞlu A, Ates L, Aslan
G. Bilateral split latissimus dorsi V-Y aps for closure
of large thoracolumbar meningomyelocele defects. Br J
Plast Surg. 2003;56::303–6.
Neural tube defects including meningomyelocele
require careful choice of aps for adequate coverage.
This case illustrates the use of bilateral split LD muscle to cover a lumbar defect in a 2-month-old baby. The
aps are based on the thoracic and lumbar perforators
advanced towards midline without tension. Bilateral
LD aps were advanced along the orientation of muscle
bres with primary closure of donor site as V-Y advancement ap.
References
1. Neligan P. Chapter 19: Latissimus dorsi ap breast reconstruction. In: Gart M, Kim J, Fine N, editors. Plastic surgery (aesthetic),
vol. II, 4th ed, Section II: (reconstructive breast surgery). 2018.
p.300–20.
2. Bostwick J III. Latissimus dorsi ap: current applications. Ann
Plast Surg. 1982;9(5):377–80.
3. Tansini I.Sopra il mio nuevo processo di amputazione della mammella. Gazz Med Ital; 1906.
4. Olivari N.The latissimus ap. Br J Plast Surg. 1976;29(2):126–8.
5. Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi myocutaneous ap for breast reconstruction. Br J Plast Surg.
1977;30(4):277–81.
6. Bostwick J 3rd, Vasconez LO, Jurkiewicz MJ. Breast reconstruction after a radical mastectomy. Plast Reconstr Surg. 1978;61(5):
682–93.
7. Quillen CG, Shearin JC, Geogiade NG.Use of the latissimus dorsi
myocutaneous island ap for reconstruction in the head and neck
area. Plast Reconstr Surg. 1978;62:113–7.
8. Maxwell GP, Sueber K, Hoopes JE.A free latissimus dorsi myocutaneous ap. Plast Reconstr Surg. 1978;62:462–6.
9. May J, Lukash F, Gallico G. Latissimus dorsi free muscle
ap in lower-extremity reconstruction. Plast Reconstr Surg.
1981;68(4):603–7.
10. Bailey B, Godfrey A.Latissimus dorsi muscle free aps. Br J Plast
Surg. 1982;35(1):47–52.
11. Samir M, Fu-Chen W. Chapter:41: Latissimus dorsi ap. In:
German G, Reichenberger M, editors. Flaps and reconstructive surgery, 2nd ed. 2016. p. 446–63.
12. Wolfe S, Hotchkiss R, Pederson W, Kozin S, Cohen M.Chapter
45: Free aps to the hand and upper extremity. In: Jones N,
Lister G, editors. Green’s operative hand surgery, 7th ed. 2016.
p.1575–610.
13. Sood R, Easow J, Konopka G, Panthaki Z.Latissimus dorsi ap
in breast reconstruction: recent innovations in the workhorse ap.
Cancer Control. 2018;25(1):1–7.
14. Pu L, Karp N.Chapter 8: Latissimus dorsi ap breast reconstruction. In: Abraham J, Saint-Cyr M, editors. Atlas of reconstructive
breast surgery, 1st ed. 2019. p.94–104.
15. Heitmann C, Pelzer M, Kuentscher M, et al. The extended latissimus dorsi ap – revisited. Plast Reconstr Surg. 2003;111:
1697–701.
16. Myers E, Snyderman C. Chapter 172: Trapezius and latissimus
dorsi regional aps. In: Howard B, Hackman T, editors. Operative
otolaryngology: head and neck surgery, 3rd ed. 2017. p1199–207.
17. Kademani D, Tiwana P.Chapter 113: The latissimus dorsi free ap.
In: Bonin G, Makhoul NM, editors. Atlas of oral and maxillofacial
surgery, 1st ed. 2015. p.1174–82.
18. Mayer H, Buena P, Petersen M.The value of preoperative computed
tomography angiography (CT-A) in patients undergoing delayed
latissimus dorsi ap breast reconstruction after axillary lymph node
dissection or irradiation and suspicion of pedicle injury. J Plast
Reconst Aesth Surg. 2020;73(11):2086–102.
19. Bonomi S, Settembrini F, Salval A, Gregorelli C, Musumarra G,
Rapisarda V. Current indications for and comparative analysis of
three different types of latissimus dorsi aps. Aesthetic Surg J.
2012;32(3):294–302.
20. Laitung JKG, Peck F.Shoulder function following the loss of the
latissimus dorsi muscle. Br J Plast Surg. 1985;38:375–9.
21. Engdahl R, Disa J, Athanasian EA, Healey JH, Cordeiro PG, Fabbri
N.Pedicled latissimus dorsi ap for shoulder soft-tissue reconstruction after excision of a musculoskeletal neoplasm. JBJS Essent
Surg Tech. 2016;6(2):e16.
22. Daltrey I, Thomson H, Hussien M, Krishna K, Rayter Z, Winters
Z. Randomized clinical trial of the effect of quilting latissimus
dorsi ap donor site on seroma formation. Br J Surg. 2006;93(7):
825–30.
23. Delay E, Gounot N, Bouillot A, Zlatoff P, Rivoire M.Autologous
latissimus breast reconstruction: a 3-year clinical experience with
100 patients. Plast Reconstr Surg. 1998;102:1461–78.
24. Leckenby J, Butler D, Grobbelaar A. The axillary approach to
raising the latissimus dorsi free ap for facial re-animation: a
descriptive surgical technique. Arch Plast Surg. 2015;42(1):
73–7.
25. Hammond D. Latissimus dorsi ap breast reconstruction. Plast
Reconstr Surg. 2009;124(4):1055–63.
Thoracodorsal Artery Perforator Flap
YounHwanKim andLanSookChang
15
15.1 Introduction
The conventional latissimus dorsi muscle or myocutaneous
ap is considered the workhorse ap for large defect coverage in the elds of reconstruction, and it has been welldescribed in numerous reports. However, sacrice of the
latissimus dorsi muscle can cause donor damage affecting
shoulder function. Recently, donor function effects and morbidities have been increasing where substantial amounts of
muscle are sacriced. Koshima and Soeda introduced the
“perforator ap” concept when using deep inferior epigastric
aps in 1989. The perforator concept reduces donor morbidities and creates thin aps without the need for any debulking
procedures. Angrigiani later described the thoracodorsal
artery perforator ap in the lateral thoracic region, and the
use of this ap was developed and expanded by the authors
Y.H.Kim and J.T.Kim.
Unfortunately, the thoracodorsal artery perforator ap has
not achieved the popularity of the anterolateral thigh ap due
to a lack of exact surface landmarks for perforator mapping
and the lateral position needed for ap harvesting. However,
accumulated knowledge of regional anatomy and clinical
experience has facilitated perforator mapping and provided
an easy route for obtaining thoracodorsal artery perforator
aps in a supine position. As a result, the thoracodorsal
artery perforator ap now provides as good an option for soft
tissue resurfacing as the anterolateral thigh ap.
15.2 Anatomy
15.2.1 Arterial Supply
Previously, two types of perforator, septocutaneous and musculocutaneous, were recognized at the same donor site of the
Y. H. Kim (*) · L. S. Chang
Department of Plastic and Reconstructive Surgery, School of
Medicine, Hanyang University, Seoul, South Korea
ank area, and two perforator aps based on these two perforators were clinically available. With more experience and
the accumulation of anatomical knowledge, it is clear that
more rows of perforators originate from the lateral thoracic
artery as direct cutaneous perforators in the lateral thoracic
region. Thus, three longitudinal rows of perforator groups in
the lateral thoracic region, the anterior, middle, and posterior
rows, run at intervals and parallel to the anterior border of the
latissimus dorsi muscle and lateral border of the pectoralis
major muscle, and these provide surface landmarks for ap
design (Fig.15.1).
The anterior row of perforators is located along the lateral
border of the pectoralis major and on the surface of the serratus anterior muscle. Most of these are derived from the lateral thoracic artery and are direct cutaneous perforators from
the axillary artery. In some cases the lateral thoracic artery
originates from the subscapular arterial system, but regardless of its origin, this artery is relatively small compared to
the other rows of perforators. Also the venous drainage is not
the same as the arterial drainage, and the unique lateral thoracic vein should be included once the lateral thoracic artery
perforator has been chosen. In addition, the pedicle is relatively short because of the absence of an intramuscular
course. Several reports highlight the usefulness of lateral
thoracic artery perforator aps. The ease of nding and dissecting these perforators is a great merit, but nevertheless
they are not necessarily the rst option since other reliable
musculocutaneous or septocutaneous perforators are known
to exist.
The middle row of perforators lies anterior to the latissimus dorsi muscle border and arises from branches of the thoracodorsal system. The thoracodorsal artery penetrates the
latissimus dorsi muscle about 8–14cm from the bifurcation
of the subscapular artery. Shortly before it enters the muscle,
a branch is given off to the serratus anterior muscle. The
latissimus dorsi muscle is supplied by two main muscular
branches from the thoracodorsal artery, horizontal or transverse branches of the thoracodorsal artery and descending
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_15
153
154
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Fig. 15.1 Schematic drawing of the right lateral thoracic area. The
anterior row of direct cutaneous perforators (DCp) is from the lateral
thoracic artery, while the middle rows of the septocutaneous perforators
(SCp) and direct cutaneous perforators originate from the cutaneous
branch, which are from the thoracodorsal artery or serratus anterior
branch. The posterior row of musculocutaneous perforators (MCp)
sprout from the latissimus dorsi muscle, and those three perforator rows
are horizontally connected with three perforator rows. Flaps based on
the three types of perforator are named lateral thoracic perforator aps
(LTp), thoracodorsal perforator aps (TDp) and latissimus dorsi perforator aps (LDp), respectively
branches of the thoracodorsal artery, and numerous musculocutaneous or septocutaneous perforators arise from each
branch. The descending branches run parallel to the anterior
border, and the horizontal branches run obliquely to the dorsal and medial part of the muscle.
The most posterior row is made up of musculocutaneous perforators passing through the latissimus dorsi muscle. These perforators often originate from posterior
horizontal branches of the thoracodorsal artery and are
widely distributed over the large area of latissimus dorsi
muscle. They are quite difcult to dissect intramuscularly
so it is better to choose a perforator near the muscle border
or in a thin area of muscle. Not all perforators can be dom-
Y. H. Kim and L. S. Chang
inant, and dominance is variable, but if a reliable perforator can be selected, it can provide nourishment to a 25cm
length of ap.
15.2.2 Venous Drainage
All venous branches drain into the axillary vein, except for
occasional branches draining into the subclavian or brachial
vein. The important thing about the venous anatomy is the
course of the lateral thoracic vein. All the perforators in the
lateral thoracic region except the lateral thoracic artery have
the same course as the arterial and venous branches. But the
lateral thoracic artery and vein often drain in a different way.
So venous dissection should be performed with care when
the lateral thoracic artery is selected as the dominant
perforator.
15.2.3 Nerves
The thoracodorsal motor nerve accompanies the pedicles,
and it is easy to preserve this nerve during dissection of a
pedicle. The intercostal nerves are the dominant sensory
nerves in this region and are useful for harvesting sensate
aps. The other sensory nerves of the proximal region of the
armpit, including the costo-brachial and lateral thoracic
nerves, should be saved.
15.3 Preoperative Investigation
The handheld Doppler provides a simple and easy way to
detect reliable perforators. However, it can get confused by
the source vessels and serratus anterior branches or lateral
intercostal perforators. Therefore the use of preoperative
mapping using a handheld Doppler is now decreasing.
High-resolution ultrasonograms have recently been used
to detect perforators. They provide the locations and sizes of
vessels and blood ow information. A skillful radiologist is
required to detect reliable perforators and a lot of time is
needed for preoperative mapping.
CT angiography requires less labor and time than sonograms, but radiation exposure and cost problems remain.
Preoperative CT angiography is mandatory for preparation
of recipient vessels in lower extremity reconstruction, while
it is not suitable for perforator mapping in the lateral thoracic
region. Mun et al. introduced multidetector-row computed
tomographic angiography for thoracodorsal artery perforator
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