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Design of Mini Latissimus Dorsi Flap Based on
Thoracodorsal Vascular Patterns
Ehab Mostafa Elzawawy, MD,* Melad Naim Kelada, MD,* and Ahmed Farouk Al Karmouty, MD†
Introduction: Latissimus dorsi (LD) flap has been used for reconstructive pur-
poses in oncoplastic breast surgery. Using large part of the muscle as a flap leads
to a residual functional loss. Muscle sparing and mini LD flaps can be used with
no functional sequelae. However, the design of such flap presents a challenge.
Methods: Twenty cadavers were dissected on both sides to identify the differ-
ent vascular patterns of the thoracodorsal (TD) pedicle. The vessels were
counted, and the following measurements were taken: diameter, length, dis-
tance from inferior angel of scapula, and vertebral level. Data were collected
and entered into the personal computer. Statistical analysis was done using
(SPSS/version 20) software.
Results: Five vascular patterns of TD pedicle were found. Type 1: a long verti-
cally descendingpedicle giving 3 to 4 transverse medial branches to LD in 40%.
Type 2: a short pedicle terminating into 1 to 2 serratus anterior collaterals and 1
to 2 transverse lateral branches to LD in 10%. Type 3: a long vertically descend-
ing pedicle giving 2 to 3 small lateral branches to upper part of LD and termi-
nating into medial and lateral branches in the lower part of LD in 10%. Type
4: a short pedicle that gives 4 to 5 terminal branches to LD, one of them is a
long vertically descending branch to lower part of LD in 20%. Type 5: a short
pedicle that terminates into a transverse medial and a long vertical branch to
LD in 20%.
Conclusion: The classically described pattern of TD pedicle (type 5) was found
in 20% of cases, whereas the most commonly found pattern was type 1. This
means that the pattern of TD branching is unpredictable, and apreoperative ultra-
sound is essential to define the existing pattern and plan the best LD flap design
for each patient. In types 1 and 5, the flap can be designed using the transverse
medial branch or branches. In type 2, one of the lateral transverse branches can
be used. In types 3, 4, and 5, the long descending vertical branch can be used.
It has a sizeable diameter (1.80.23 mm), length (12.31.64 cm), and can be located
6.50.96 cm below the inferior angle of scapula.
Key Words: mini flap, TD pedicle, breast reconstruction, muscle sparing flap
(Ann Plast Surg 2018;80: 607–615)
Through many years, latissimus dorsi (LD) flaps have been used for
many reconstructive purposes as reconstruction of the breast,
1
upper
limb,
2
face,
3
and hypopharynx.
4
Breast reconstruction with standard LD flap maintains the natu-
ral consistency of tissue but causes loss of muscle function.
5
It can be
used for salvage of failed implant reconstructions,
6
and it is a good op-
tion after failed breast conservative therapy.
7
Repairing a segmental defect differs from reconstruction after
modified mastectomy. Latissimus dorsi mini flap (LDMF) may suffice
to fill a segmental defect. It involves harvesting LD muscle with or
without the overlying skin.
8
It is often recommended for patients who
are candidates for breast conservative therapy.
9
It allows wide local
excision of large tumours with preservation of the breast envelope
and nipple-areola complex.
10
The skin overlying the lateral thoracic area has a rich blood
supply from three rows of perforators. From anterior to posterior:
(1) direct cutaneous perforators from the lateral thoracic, (2) fasciocuta neous
perforators form thoracodorsal (TD) pedicle, and (3) musculocutaneous
perforators from TD pedicle. All these perforators are reliable as a
flap pedicle.
11
The TD pedicle provides the dominant blood supply to LD in
addition to segmental perforating branches from the posterior intercos-
tal and lumbar arteries (Mathes and Nahai type V circulatory pattern).
TD pedicle divides into transverse and descending branches.
12
The TD
pedicle gives off musculocutaneous and fasciocutaneous perforators
with a ratio of 3:2.
13
We would like to consider all modern flaps related to LD as mini
flaps. They only utilize part of the muscle and/or its fat and vessels.
Received October 16, 2017, and accepted for publication, after revision January 10,
2018.
From the *Department of Anatomy and Embryology, Faculty of Medicine, and †Department
of Breast Surgery, Medical Research Institute, University of Alexandria, Egypt.
This article was presented as a poster in ABS (Association of Breast Surgery)
conference on 15–16 may 2017 in Belfast, UK and the abstract was published
in the EJSO 2017; volume 43 (5), page: S12.
Conflicts of interest and sources of funding: None declared.
Reprints: Melad Naim Kelada, MD, Anatomy and Embryology, Faculty of Medicine,
University of Alexandria, Alexandria, Egypt. E-mail: meladkelada@ymail.com.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-70 43/18/8006–0607
DOI: 10.1097/SAP.0000000000001403
FIGURE 1. Left long TD pedicle accompanied by thoracodorsal
nerve (n). It gives SAC to SA, CS to S and LD collateral (arrow)
which gives 3 large transverse medial perforators (1–3) and
2 small transverse lateral perforators (4, 5) to LD. It continues
downward as a small perforator (6). SAC, serratus anterior
collateral; S, subscapularis; SA, serratus anterior; CS,
circumflex scapular.
BREAST SURGERY
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They spare its function. They include LDMF, thoracodorsal artery
perforator (TAP) flap and muscle sparing LD (MSLD) flap.
Angrigiani et al
14
designed LDMF without muscle. They based
it on 2 to 3 fasciocutaneous perforators of TD pedicle at the lateral bor-
der of LD. Actually, this was the first TAP flap.
15
It is a cutaneous flap
based on specific cutaneous perforators of TD pedicle. They originate
from the transverse or descending branches of the pedicle. It can be
used for reconstruction if the perforators are of sufficient calibre.
16
The MSLD flap is not based on specific perforators. It involves
harvesting skin paddlewith or without the underlying LD.It can be used
instead of TAP flap if no perforators of sufficient calibre are present.
17
OBJECTIVE
The objective of the present study was to study the vascular pat-
terns of the TD pedicle to put an anatomical basis for the design of the
best possible LD flaps to improve the outcome of breast and other re-
constructions to avoid functional loss or necrosis of the flap with its
bad sequelae.
MATERIALS AND METHODS
Twenty adult cadavers were injected with lead oxide, latex and
water, and then cooled to 4°C for 1 week before dissection. Cadavers
were dissected on both sides to identify the different vascular patterns
of TD pedicle. The vessels were counted and the following measure-
ments were taken using Vernier caliper: diameter, length and distance
from inferior angle of scapula (IAS). The site of the perforators
was described as medial, lateral and central zones in relation to the
posterior surface of LD and their vertebral levels were recognized.
Data were collected and entered into the personal computer. Sta-
tistical analysis was done using Statistical Package for Social Sciences
(SPSS/version 20) software. For comparison between groups, analysis
of variance test was used for parametric data, followed by post hoc test
FIGURE 2. Right long TD pedicle. It gives a SAC to SA and
LD collateral (arrow) to supply LD. LD collateral gives 3 large
transverse medial perforators (1–3) to LD. Perforator (2) divides
into (A, B, C, D). LD collateral ends as a small perforator (4).
The AA, AV, LT, and the right Br are noted. AA, axillary artery;
AV, axillary vein, Br, breast; LT, lateral thoracic artery.
FIGURE 3. A, Diagrammatic illustration of type 1 TD pedicle. It covers mainly medial perforator zone (1, 2, and 3). Small inconstant
perforators (4, 5) are in the lateral zone. TD pedicle continues as a small fasciocutaneous perforator (6). Note IAS and thoracic spines
(T6–T12). B, Diagrammatic illustration of possible flap designs in type 1 TD pedicle. Best flap design is LDMF based on one or more of
the large medial perforators. MSLD flap can be based on the small lateral fasciocutaneous perforators (4, 5, 6) in the lateral zone.
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and Waller-Duncan method. The level of significance was 0.05. The
same small letters indicate that there was no significant difference,
while different letters indicate that there was a significant difference.
18
RESULTS
Five vascular patterns of TD pedicle were found:
Type 1: A long pedicle that gave 3 to 4 large transverse medial
and occasionally 1 to 2 small transverse lateral perforators to LD. The
first and second medial perforators were the largest and usually gave
several smaller perforators. Their length reached up to 8 cm and their
diameter reached up to 2 mm. They were located at the level of spines
of T7 and T8.TD pedicle continued downward as a small fasciocu-
taneous perforator at the lateral edge of LD. This type was found in
40% of cases (Figs. 1, 2, 3A, B).
Type 2: A short pedicle that terminated into 1 to 2 serratus ante-
rior collaterals and 2 to 3 large transverse lateral branches to the upper
and lower lateral parts of LD. LD branches gave 1 to 2 small medial
musculocutaneous perforators at level of spine of T8 or T9 and contin-
ued downwards on the edge of LD as lateral fasciocutaneous perfora-
tors. This type was found in 10% of cases (Figs. 4, 5A, B).
Type 3: A long pedicle that gave 2 to 3 serratus anterior collat-
erals and 2 to 4 small transverse lateral perforators to upper lateral part
of LD. It continued as a long vertically descending vessel and termi-
nated into medial musculocutaneous and lateral fasciocutaneous per-
forators in the lower part of LD. This type was found in 10% of cases
(Figs. 6, 7, 8A, B).
Type 4: A short pedicle that divided in a star-like fashion. It gave
4 to 5 terminal perforators to LD, one serratus anterior collateral and
occasionally a branch to teres major. The LD perforators were divided
into 2 to 4 small transverse lateral perforators, 1 to 2 large transverse
medial perforators and one long vertically descending branch to the
lower part of LD. This descending branch may divide into long medial
FIGURE 5. A, Diagrammatic illustration of type 2 TD pedicle. It covers lateral perforator zone (1, 2). Note IAS and thoracic spines
(T6–T12). B, Diagrammatic illustration of possible flap designs in type 2 TD pedicle. Best flap design is TAP flap based on the large
lateral perforators (1, 2). LDMF can be based on the small medial perforator.
FIGURE 4. Left short TD pedicle accompanied by thoracodorsal
nerve (n). It gives 2 serratus anterior collaterals (SAC) to supply
serratus anterior (SA), and gives 2 large transverse lateral
perforators (1, 2) to supply LD. Perforator (1) divides into (A, B).
Perforator (2) divides into (C, D, E). Perforator (C) is
musculocutaneous; it passes medially and divides inside the
muscle (arrows). Perforators (A, B, D, E) end as fasciocutaneous
perforators on the lateral edge of LD. The left Br is noted.
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and lateral terminal branches (type 4a in 10%) (Figs. 9A and B), or
continued downward and laterally and gave 2 to 3 medial side
branches (type 4b in 10%) (Figs. 10A and B, 11A, B). This type was
found in 20% of cases.
Type 5
A short pedicle that gave one serratus anterior collateral and
terminated into a transverse medial and a long vertical descending
branch to LD. The long branch gave 1 to 2 small transverse lateral
perforators to the upper lateral part of LD and divided into short medial
and lateral terminal perforators. This type was found in 20% of the
cases (Figs. 12, 13A, B).
According to these 5 types, there were 3 perforator zones: medial
zone based on medial perforators, lateral zone based on lateral perfora-
tors, and central zone based on the vertical descending branch and its
side branches or terminal perforators (Fig. 3A). Perforators in type
1 supply mainly the medial zone, type 2 supplies mainly the lateral
zone, type 3 supplies mainly lateral and central zones, and types 4
and 5 cover all zones (Table 1).
The location of these perforator zones compared with the pos-
terior surface of LD can be illustrated as follows. Medial perforators'
zone can be located between spines of T6 to T9 below and medial to
IAS (Fig. 3A). Lateral perforators' zone can be located between
spines of T6 to T12 below and lateral to IAS (Fig. 5A). Central
perforators' zone can be located between spines of T9 to T12 below
and medial to IAS; it is based on the descending branch which can
be located 6.5 ± 0.96 cm below and in line with IAS at level of
spine of T9 (Figs. 8A, 11A, 13A).
Medial perforators are mainly musculocutaneous, whereas
lateral perforators are mainly fasciocutaneous with few direct cuta-
neous perforators. Medial terminal perforator of the descending branch
is mainly musculocutaneous, whereas lateral terminal perforator of
the descending branch is mainly fasciocutaneous (Tables 1, 2).
Medial musculocutaneous perforators passed between LD mus-
cle layers. They were especially large in types 1, 3, 4, 5 and can be used
in LDMF (Figs. 3B, 8B, 11B, 13B). All these perforators were in the
medial zone except in type 3; small medial intramuscular perforators
took origin from the medial terminal branch and were located in the
central zone (Tables 1, 2).
All perforators were accompanied by venae comitantes ensur-
ing good venous return of any flap based on them. They were espe-
cially large in case of the descending perforator and its branches
(Figs. 6, 9, 12).
Large lateral fasciocutaneous perforators found in type 2 are
great for TAP flap. Despite the small size of the transverse medial
perforators in type 2, they were constant and LDMF can be designed
on them at the level of T8 and/or T9 (Fig. 5B).
In type 3, flap design is restricted to the lateral and central zones.
The LDMF can be based on the medial terminal musculocutaneous
perforator of the descending branch. The MSLD can be based on
the upper lateral perforators of the pedicle. The TAP flap can be based
on the lateral terminal fasciocutaneous perforator (Fig. 8B).
In type 4, any type and any design of flap is possible. The medial,
lateral, and vertical descending perforator and/or one of its branches
can be used in any of these flaps. They cover medial, lateral, and cen-
tral zones (Fig. 11B). In type 5, LDMF can be based on the transverse
medial branch. The TAP flap can be designed on the long vertical
descending branch which can be lengthened by including its medial
or lateral terminal branch. Lateral perforators though small, can be
FIGURE 6. Right long TD pedicle accompanied by
thoracodorsal nerve (n). It gives 2 SAC to SA. It continues
as a vertical descending vessel (arrow) which gives 2 lateral
transverse perforators (1, 2) to the upper lateral part of LD.
It terminates into M musculocutaneous and L fasciocutaneous
perforators at the lower part of LD. The AA and AV are noted.
M, medial; L, lateral.
FIGURE 7. Right long TD pedicle. It gives 3 serratus anterior
collateral branches (SAC) to SA, and 4 small transverse lateral
perforators (1, 2, 3, 4) to upper lateral part of LD. It gives a vertical
descending vessel (arrow) which terminates into M) and L
perforators at the lower part of LD. Branch (M) divides into
3 musculocutaneous perforators (A, B, C) to the lower medial
part of LD. Branch (L) is a large fasciocutaneous perforator
at the lower lateral edge of LD.
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FIGURE 9. A, Right short TD pedicle. It divides in a star-like fashion into a branch (arrow) to teres major muscle (TM) and 2 SAC to
SA and 4 terminal perforators (1–4) to LD. Perforators (1,2) are lateral and transverse. Perforator (4) is medial and transverse. Perforator
(3) is a vertical descending branch and divides into lateral fasciocutaneous terminal branch (L) and medial musculocutaneous terminal
branch (M). The AA, AV are noted. B, A close up photograph of the previous specimen. Perforator (4) is large and musculocutaneous.
It gives several perforators (arrows) to LD and terminates into 2 perforators (A, B).
FIGURE 8. A, Diagrammatic illustration of type 3 TD pedicle. It covers lateral zone(through perforators1–4, L)and central zone
(through perforator M). Note IAS and thoracic spines (T6–T12). B, Diagrammatic illustration of possible flap designs in type 3 TD
pedicle. Best flap design is TAP flap based on the descending branch and its lateral terminal perforator (L). Central zone LDMF
is possible through the lateral terminal perforator (M). MSLD flap can be based on the upper lateral perforators (1–4).
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FIGURE 10. A, Left short TD pedicle accompanied by thoracodorsal nerve(n). It gives SAC to SA and a lateral upper perforator (1) to LD.
It divides into terminal perforators (2, 3, 4, 5, 6) at the upper part of LD. Perforators (2, 3, 4) are short lateral transverse and pass into
the upper lateral part of LD. Perforator (5) is a long vertical descending vessel (arrow) reaching the lower lateral part of the muscle
and gives 2 medial perforators (7, 8) passing into the lower medial part of LD. Perforator (6) passes into the upper medial part of LD.
The AA and AV are noted. B, A close up photograph of the previous specimen. Perforator (6) is a large medial musculocutaneous
perforator. It divides into 2 branches (A, B) that pass in between the muscle layers (arrows) of LD.
FIGURE 11. A, Diagrammatic illustration of type 4 TD pedicle. It divides in a star-like fashion and covers lateral zone (through perforators
1, 2, 3, L), medial zone (through perforators 4, 5) and central zone (through perforators 7, 8, M). Descending branch (arrow) divides
into terminal branches (L and M) (type 4a) or gives medial branches (7, 8) (type 4b). Note IAS and thoracic spines (T6–T12). B,
Diagrammatic illustration of possible flap designs in type 4 TD pedicle. All flap designs are possible especially LDMF and TAP flap.
LDMF is possible based on any medial perforator (4, 5, 7, 8, M). TAP flap can be based on the descending branch or its lateral
termination (L). MSLD flap can be based on the lateral perforators (1, 2, 3).
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used, along with the lateral terminal perforator of the descending branch
in MSLD flap (Fig. 13B).
DISCUSSION
Flaps have evolved from muscle based flaps to specific perfora-
tors based flaps. It can preserve underlying muscle, reduce donor site
morbidity and improve ability to design the flap. Better understanding
of the vascular anatomy of the skin, subcutaneous tissues, and muscle
can greatly advance and improve flap design.
19
Although there are many publications on the clinical uses of dif-
ferent LD flaps,
10,11
there is paucity of data concerning the detailed vas-
cular anatomy of TD pedicle. The detailed description of the anatomical
variations of this pedicle is crucial not only for the choice of the appro-
priate flap but also for the best design of the flap.
The number and location of perforators differ according to
TD vascular pattern. In the present study, 5 patterns were identified.
In types 1 and 5, medial zone musculocutaneous perforators were of
appropriate length and caliber. In type 1, the best LDMF design can
be based on any of the transverse medial perforators. They start at level
of T7 and continue downward till level of T10, although in type 5, the
flap can be based on the transverse medial branch present at level of T7.
The largest perforators were the first and second medial muscu-
locutaneous perforators found in type 1 at the level of the spine of T7
and T8, respectively. Thomas et al
13
and Mohan and Saint-Cyr
19
con-
firmed that the most proximal perforator of TD pedicle is usually the
largest. It is found at the level of inferior angle of the scapula (T7).
Schaverien et al
20
noted that in 53% of cadaveric dissections,
there is a large fasciocutaneous perforator from the TD pedicle running
over the lateral border of LD. In our study, type 2 pedicle (10%) showed
the largest lateral fasciocutaneous perforators; they started at T6 and
continued downwards on the edge of LD till T10. While in types 3
(10%) and 4a (10%), there were large terminal lateral fasciocutaneous
perforators. They were lengthy and of largecaliber and can be used for
TAP flap.
FIGURE 12. Left short TD pedicle accompanied by thoracodorsal
nerve (n). It gives SAC to SA; then divides into a medial
transverse branch (1) and a long vertical descending branch
(2) to LD. Branch (2) gives 2 small lateral transverse perforators
(3, 4) to the upper lateral part of LD and divides into medial M
and L fasciocutaneous terminal perforators at the lower lateral
edge of LD. The AV is noted.
FIGURE 13. A, Diagrammatic illustration of type 5 TD pedicle. It covers medial zone (through perforator 1), lateral zone (through
perforators 3, 4, L) and central zone (through perforator M). Note IAS and thoracic spines (T6–T12). B, Diagrammatic illustration of
possible flap designs in type 5 TD pedicle. All flaps are possible. LDMF is especially feasible on the transverse branch (1). TAP flap
can be based on the descending branch and its M or L terminal perforator. MSLD flap can be based on lateral perforators (3, 4, L).
Annals of Plastic Surgery •Volume 80, Number 6, June 2018 Mini Latissimus Dorsi Flap
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Boucher et al
17
reported that the most reliable perforators of the
TD pedicle originate from its transverse and descending branches. They
reported the presence of 2 to 8 perforators, 50% are lateral, 30% are
medial, and 20% are central. However, they did not designate spe-
cific TD pedicle types or zones.
In the present study, there were 3 perforator zones: medial zone
based on medial perforators, lateral zone based on lateral perforators,
and central zone based on the vertical descending branch and its side
branches or terminal perforators. Perforators in type 1 (40%) supply
mainly the medial zone, type 2 (10%) supplies mainly the lateral
zone, type 3 (10%) supplies mainly lateral and central zones, types 4
and 5 (40%) cover all zones.
Disagreement among authors who studied TD pedicle can be
explained by the presence of several patterns. Colohan et al
21
stated
that the descending branch covers 87% of the musculocutaneous per-
fusion territory of TD pedicle. Boucher et al
22
reported that the aver-
age muscular surface vascularized by the transverse branch of TD
pedicle is 80% of the complete LD and that inter-muscular connec-
tions between the two branches of TD pedicle account for the overlap
in the covered areas.
Losken et al
23
noticed the variations in the location of TD per-
forators. They reported that in 7% of cases, the dominant perforator
originates from the transverse branch of TD pedicle. This perforator
is approximately 4 to 5 cm behind the anterior edge of the LD. They
also reported that few cases had several small perforators instead of
1 to 3 larger vessels and this calls for an alternative flap design. That
is why improved knowledge and understanding of the 5 patterns of
TD pedicle can enable better tailoring of LD flaps.
Controversies in LD flap design can be explained by the various
TD pedicle patterns. Schaverien et al
20
designed MSLD flap where the
most lateral edge of the skin paddle should be 1 to 2 cm anterior to the
lateral edge of LD, depending on lateral fasciocutaneous perforators.
Although Colohan et al
21
designed MSLD flap where the skin paddle
can be positioned at any level along the axis of the descending branch
of TD pedicle depending on its perforators.
Boucher et al
17
located perforators at 5, 10, and 15 cm from pos-
terior axillary fold, at, respectively, an average of 2.0, 2.4, and 2.9 cm
behind the anterior border of LD. Schaverien et al
20
reported that the
area of greater perforator density can be found between 9 and 15 cm
from the posterior axillary fold and within 4 cm from the lateral edge
of LD. Angrigiani et al
24
confirmed that perforators of TAP flap are
quite predictably localized in up to 80% of patients approximately
8 cm from the top of the axilla and close to the anterior edge of the
LD muscle.
Designing the flap based on perforators located at certain dis-
tances on the edge of LD or on posterior axillary fold or from top
of axilla is inaccurate and can lead to many fallacies, whereas using
vertebral levels is more accurate and can give confidence in perfora-
tors’presence and flap survival.
In our study, medial muscular perforators passing between LD
muscle layers were constantly seen in all vascular patterns. They are
small in types 2, 3, and especially large in types 1, 4, 5. These perfora-
tors are important when planning primary closure of the donor site in
the lateral thoracic area. Thin LDMF up to 20 cm in length and
10 cm in width can be safely designed.
11
These flaps can be used effec-
tively for resurfacing of the hand, tibia, or foot.
25
To ensure survival of
these flaps, they must be based on medial zone intramuscular perfora-
tors except in type 3, where they must be based on central zone
intramuscular perforators.
Saint-Cyr et al
26
prefer MSLD over TAP due to simplicity of
technical dissection, lack of need for adequately sized perforators
and better neurovascular pedicle protection due to the small muscle
cuff retained. Type of TD vascular pattern should be included in the
selection criteria of flap type. In case of types 2 and 3, a TAP flap is
preferred, whereas in type 1, MSLD flap is preferred because lateral
perforators are small in size. In types 4 and 5, there are equal chances
for both types of flaps.
Park et al
27
lengthened TD pedicle to reconstruct remote defects.
Knowing the different TD pedicle patterns is important, it can give an
insight on whether the pedicle can be lengthened or not. Types 3, 4,
TABLE 1. Comparison Between Medial and Lateral Transverse Perforators of TD Pedicle
TD Vascular Pattern
Medial Perforators Lateral Perforators
Length Diameter Length Diameter P
Type 1 7.16 ± 1.08
a
1.82 ± 0.34
a
2.67 ± 0.25
b
1.11 ± 0.46
c
0.011*
Type 2 3.91 ± 0.24
b
1.13 ± 0.32
c
7.08 ± 0.63
a
1.71 ± 0.36
a
0.0136*
Ty p e 3 2.82 ± 0.44
b
0.83 ± 0.31
c
0.042*
Type 4 4.31 ± 0.36
b
1.43 ± 0.22
b
3.41 ± 0.93
b
0.96 ± 0.43
c
0.033*
Type 5 6.23 ± 0.71
a
1.53 ± 0.63
b
2.88 ± 0.74
b
1.03 ± 0.34
c
0.027*
*Significant difference.
The same small letters indicate that there was no significant difference between groups, whereas different letters indicate significant difference.
TABLE 2. The Descending Perforator of TD Pedicle and Its Terminal Branches
TD Vascular Pattern
Vertical Descending Perforator Medial Terminal Branch Lateral Terminal Branch
Length Diameter Length Diameter Length Diameter P
Ty p e 3 1 4 . 21 ± 1 . 4 2
a
2.13 ± 0.52
a
5.62 ± 0.78
b
1.47 ± 0.63
b
7.11 ± 0.43
b
1.53 ± 0.54
b
0.026*
Ty p e 4a Ty p e 4 b 7 . 7 3 ± 0 . 4 8
b
12.30 ± 1.64
a
1.87 ± 0.73
a
1.80 ± 0.23
a
5.33 ± 0.62
b
1.15 ± 0.33
c
5.86 ± 0.53
b
1.41 ± 0.27
b
0.031*
Ty p e 5 1 3 . 88 ± 1 . 5 2
a
2.21 ± 0.48
a
3.65 ± 0.43
c
0.93 ± 0.22
c
3.21 ± 0.58
c
1.13 ± 0.49
c
0.018*
*Significant difference.
The same small letters indicate that there was no significant difference between groups while different letters indicate significant difference.
Elzawawy et al Annals of Plastic Surgery •Volume 80, Number 6, June 2018
614 www.annalsplasticsurgery.com © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
and 5 are great candidates for pedicle lengthening especially when the
descending branch is dissected with its lateral terminal branch. In that
case, the length of the pedicle can reach up to 21 cm.
Thomas et al
13
reported that the length of TD pedicle when har-
vested along with the descending perforator was 14.0 cm. Boucher et al
17
reported that the average length of the descending branch was 15.2 cm.
Saint-Cyr et al
26
reported that the mean length of the descending branch
of TD pedicle was around 15 cm.
Nowadays, the location, size, blood flow inside the perforators,
and their venae comitantes can be easily mapped, thanks to the great
advances in imaging techniques as Doppler and color duplex ultraso-
nography, computed tomographic angiography (CTA) and magnetic
resonance angiography.Therefore, providing a 3-dimensional represen-
tation of the vascular anatomy of LD. It is mandatory to use these tools
preoperatively to outline TD pedicle pattern for better flap design.
28
The CTA and three-dimensional image post processing can be
used to show the number, size, course and location of TD pedicle and
its perforator arteries. This is crucial for the preoperative selection of
the best perforator to use for the flap which could shorten operative time
and decrease patient morbidity. The CTA is the preferred imaging mo-
dality for mapping arteries. It has better spatial resolution than magnetic
resonance angiography and is more sensitive than ultrasound.
29
CONCLUSIONS
It is essential to know all possible TD vascular patterns. The TD
perforators can be accurately located based on prior anatomical knowl-
edge and imaging techniques. This is crucial for the proper selection of
the type and design of LD flap.
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Annals of Plastic Surgery •Volume 80, Number 6, June 2018 Mini Latissimus Dorsi Flap
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