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Concept: Thoracodorsal artery

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BACKGROUND: Ablation of locally advanced head and neck cancers generally results in large composite oro-facial defects. Due to the often-large segment of mandible missing, as well as the need to provide skin coverage and oral lining, reconstructive options are limited. We present our experience in oncologic head and neck reconstruction using chimaeric subscapular system free flaps. METHODS: We performed a retrospective chart review of patients presenting important through-and-through oro-facial defects following ablation of T3, T4a or T4b tumours in two university centres between 2005 and 2011. All defects were reconstructed with a subscapular system free flap that was harvested in a dorsal decubitus position. RESULTS: Sixteen patients (15 M, 1 F; mean age = 60 years) underwent mandibular reconstruction with latissimus dorsi flaps with one or two skin paddles and one bony component based on the angular branch of the thoracodorsal artery. Fifteen patients received adjuvant radiotherapy. We experienced no flap loss. Donor-site complications were minimal, albeit a limitation of shoulder range of motion was found in four patients. Eight patients presented postoperative complications requiring re-intervention. Fourteen patients were able to recommence oral nutrition and their diction returned to normal in all but one. The mean follow-up period was 25 months. Aesthetic results were satisfactory upon atrophy of the latissimus dorsi muscle. CONCLUSIONS: In cases of extensive oro-facial defects involving a large mandibular segment, reconstruction with subscapular system free-tissue transfer is a safe and reliable technique that offers satisfactory functional and aesthetic results.

Concepts: Cancer, Oncology, Latissimus dorsi muscle, Iliac crest, Thoracodorsal nerve, Subscapular artery, Glenohumeral joint, Thoracodorsal artery

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The advent or micro-vascular free tissue transfer has facilitated the reconstruction of increasingly complex head and neck defects. There are multiple donor sites available, each with its' own advantages and disadvantages. However, the subscapular system, including the thoracodorsal system, provides the widest array of soft tissue and osseous flaps, as well as chimeric options. Its advantages include a long pedicle, independently mobile tissue components, relative sparing from atherosclerosis, and minimal donor site morbidity. The soft tissue flaps available from the thoracodorsal system include the Latissimus Dorsi, and Thoracodorsal Artery Perforator flaps, while the Tip of Scapula provides the osseous component. This review paper outlines the anatomical basis for these flaps, as well as describing their utility in head and neck reconstruction.

Concepts: Head and neck anatomy, Head and neck, Techno, Latissimus dorsi muscle, Free flap, Thoracodorsal nerve, Subscapular artery, Thoracodorsal artery

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Thoracodorsal artery perforator flap (TDAP) is one of the relatively new techniques in breast reconstruction. In this study, we try to evaluate the outcome of this flap in oncoplastic procedures.

Concepts: Plastic surgery, Thoracodorsal artery

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The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap.

Concepts: Fascia, Thoracodorsal artery

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The present study evaluated donor morbidities following the free TDAP flap harvest comprehensively and investigated patient- and operation-related factors that might contribute to adverse outcomes.

Concepts: Present, Time, Subscapular artery, Thoracodorsal artery

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The latissimus dorsi (LD) flap is considered one of the working horses within the field of breast reconstruction and it offers several advantages. However, donor-site morbidity may pose a problem. This article describes a new and modified technique for delayed breast reconstruction combining the use of a propeller thoracodorsal artery perforator (TAP) flap with an acellular dermal matrix (ADM) and an implant.

Concepts: Breast, Linear algebra, Latissimus dorsi muscle, Breast implant, Thoracodorsal nerve, Thoracodorsal artery, Flap consonant

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The reconstruction of oromandibular defects associated with extensive loss of external skin is surgically challenging. We describe 2 cases where such defects were reconstructed with a chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) free flap based on the subscapular system. The flap is a reliable option in the reconstruction of through-and-through oromandibular defects.

Concepts: Reconstruction era of the United States, Reconstruction, Subscapular artery, Arteries of the upper limb, Flapper, Dunning School, Thoracodorsal artery

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Background Perforator flaps have been used extensively in the field of reconstruction, and the thoracodorsal artery perforator (TDAP) flap is very popular. However, the perforator flap can be relatively bulky in some cases, depending on the defect’s location. Thus, several methods have been developed to address this bulkiness, including modification of the flap elevation, application of an ultrathin flap using microdissection, and the defatting technique. However, these methods have various disadvantages, so we developed an adjustable thin TDAP flap using modification of the flap elevation and defatting technique. Methods Between January 2012 and February 2015, 13 patients underwent reconstruction of defects of their upper and lower extremities using TDAP flaps. We measured all the flap dimensions, except for thickness, because it was adjusted for the target defect. Results The mean flap size was 94 cm(2) (range: 48-210 cm(2)), and all flaps were ≤10 cm wide to facilitate primary donor-site closure. Two subjects with a history of diabetes exhibited partial flap loss, so we performed secondary skin graft surgery. Conclusions The TDAP flap elevation was modified at the superficial fascia plane, and the defatting technique was used to adjust the flap volume. This technique provided more natural contours and minimized the need for secondary debulking.

Concepts: The Target, Wing, Flap, Flapper, Skin grafting, Thoracodorsal artery, Leading edge slats

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In toe reconstruction, amputation procedures are much more common than salvage procedures. However, toe resurfacing, rather than amputation, provides superior functional and aesthetic results. In this study, we report the clinical outcomes of toe resurfacing using a thin thoracodorsal artery perforator flap.

Concepts: Subscapular artery, Thoracodorsal artery

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High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts.

Concepts: Injuries, Injury, Wound, Physical trauma, Accident, Free flap, Subscapular artery, Thoracodorsal artery