Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 822e829
Intercostal artery perforator propeller flap for reconstruction of trunk defects following sarcoma resection Mengqing Zang a, Shengji Yu b, Libin Xu b, Zhenguo Zhao b, Shan Zhu a, Qiang Ding a, Yuanbo Liu a,* a Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China b Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
Received 16 December 2014; accepted 3 February 2015
KEYWORDS Intercostal artery perforator flap; Propeller flap; Trunk reconstruction; Sarcoma
Abstract Trunk defects following soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities and some trunk regions lack reliable recipient vessels. The intercostal arteries give off multiple perforators, which distribute widely over the trunk and can supply various pedicle flaps. Our purpose is to use various intercostal artery perforator propeller flaps for trunk oncologic reconstruction. Between November 2013 and July 2014, nine intercostal artery perforator propeller flaps were performed in seven patients to reconstruct the defects following sarcoma resection in different regions of the trunk, including the back, lumbar, chest, and abdomen. Two perforators from intercostal arteries were identified for each flap using Doppler ultrasound probe adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel. An elliptical flap was raised and rotated in a propeller fashion to repair the defects. There were one dorsal intercostal artery perforator flap, four dorsolateral intercostal artery perforator flaps, three lateral intercostal artery perforator flaps, and one anterior intercostal artery perforator flap. The mean skin paddle dimension was 9.38 cm in width (range 6e14 cm) and 21.22 cm in length (range 13e28 cm). All intercostal artery perforator flaps survived completely, except for marginal necrosis in one flap harvested close to the previous flap donor site. The intercostal artery perforator propeller flap provides various and valuable options in our reconstructive armamentarium for trunk oncologic reconstruction. To our knowledge, this is the first case series of using intercostal artery perforator propeller
* Corresponding author. Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing 100144, China. Tel.: þ86 1088771985; fax: þ86 1088964137. E-mail address: [email protected] (Y. Liu). http://dx.doi.org/10.1016/j.bjps.2015.02.009 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Intercostal artery perforator propeller flap for oncological reconstruction of trunk
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flaps for trunk oncologic reconstruction and clinical application of dorsolateral intercostal artery perforator flaps. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction As soft tissue sarcomas often occur (10%) in the trunk,1 plastic surgeons are frequently asked to deal with problem wounds following soft tissue sarcoma resection in the back, lumbar, chest, and abdomen. Extensive removal of tissue is required in most of the cases, and primary closure is not usually possible. In addition, as more patients present with sarcoma recurrences, the re-resections further deplete the nearby tissues of redundancy and the transferring of healthy tissue from areas of excess is necessary. The complexity of the wounds following soft tissue sarcoma resection has increased, as more patients now receive preoperative radiotherapy. Radiation decreases the chance for a successful skin graft, and it also renders the wound edges ischemic. Therefore, well-vascularized tissues are required for reconstruction.2,3 Regional myocutaneous flaps, such as latissimus dorsi flaps, can usually repair the wounds resulting from sarcoma resection of the trunk.4 However, the muscles have to be sacrificed, which results in great donor-site morbidities. Distal free flaps can provide well-vascularized tissues for wound restoration. However, finding a reliable recipient vessel to support the microvascular transfer can be a real challenge in the torso region. Moreover, some regions, such as the lumbosacral region, are beyond the comfortable reach of most local flaps and also lack reliable recipient vessels.2 Since Koshima and Soeda in 1989 first introduced the perforator flap,5 the use of perforator flaps has increased with advantages of sparing of the underlying muscle with resultant decreased donor-site morbidity and its versatility. With a substantial number of perforators in the body, the pedicled perforator flap provides the surgeons more reconstructive options and can be a simpler alternative to free flaps.6 Hallock further improved the technique of the pedicled perforator flap with the introduction of a perforator-based propeller flap design.7 Some difficult clinical scenarios, previously relying on free flap and regional musculocutaneous flap, now can be easily managed using this technique. The intercostal vessels form the largest angiosome in the torso by means of their extensively distributed perforators to the skin.8,9 Various pedicled perforator flaps can be raised on these perforators to cover defects on the trunk, including dorsal intercostal artery perforator flap (DICAP), dorsolateral intercostal artery perforator (DLICAP) flap, lateral intercostal artery perforator (LICAP), and anterior intercostal artery perforator (AICAP) flap.10 These flaps provide versatile options for challenging defects on the trunk without sacrifice of the underlying muscle as well as concerns of the unavailability of reliable recipient vessels for free flap transfer.
Our objective was to demonstrate the versatility of propeller flaps based on the intercostal artery perforator (ICAP), which can become an alternative for reconstruction following soft tissue sarcoma resection in the different regions of the trunk.
Patients and methods Between November 2013 and July 2014, nine ICAP propeller flaps were performed in seven patients for reconstruction of trunk defects secondary to excision of malignant tumors. Patient demographics, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions, and operative records were reviewed. Outcome variables included complications and flap survival.
Operative technique Preoperative flap design (Figure 1A) Before the surgery, the extent of the soft tissue wounds following the tumor ablations was estimated. Doppler ultrasound probe was used to identify at least two large perforators adjacent to the defects at different intercostal spaces. The perforator can be the perforator of dorsal, dorsolateral, or lateral branches of the posterior intercostal artery or those of anterior intercostal artery, depending on the location of the defects. Then the one with the most prominent Doppler signals was selected as the preferred supply for the flap. The location of the selected perforator denoted the pivot point of the flap. An elliptical skin island was then designed so that the distance between the perforator and the distal portion of the flap was slightly longer than the distance between the perforator and the furthest part of the defect. Flap width allowing for primary closure of the donor site was determined by a pinch test. DICAP flap DICAPs are found about 5 cm lateral to the midline posteriorly from the third through 11th thoracic vertebrae.9 DLICAP flap DLICAPs are present within 2 cm of the midscapular line in intercostal spaces 8 through 11.11 LICAP flap LICAPs are found at the junction of the midaxillary line and the lower border of the corresponding rib in intercostal spaces 3 through 11.12
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Figure 1 Case 3. A. The design of an LICAP for abdominal defect reconstruction. At least two perforators were identified adjacent to the potential defect. B. A reliable LICAP was identified intraoperatively and employed as the pedicle vessels. C. The perforator was skeletonized and ICAP flap was rotated 150 to cover the abdominal defect. D. The flap was inset and donor site was closed directly.
AICAP flap AICAPs are usually located 1e3 cm from the lateral sternal border in intercostal spaces 1 through 9.12
Flap elevation and rotation An opening incision facilitating all perforators’ exploration was made down to the deep fascia. Dissection proceeded subfascially from caudal to cranial and distal to proximal until the previously marked perforators were visualized. The perforator with visible pulsation was finally selected as the pedicle perforator (Figure 1B). The flap design might have to be modified based on the location of the selected perforator. The flap was incised like an island, and all other perforators were ligated. The pedicle was skeletonized to obtain sufficient rotation. The rotation direction (clockwise Table 1
or counterclockwise) resulting in less twisting or kinking of the pedicle was chosen. The flap could be rotated with the versatile swing arc up to 180 (Figure 1C). Circulation was verified with capillary reaction after rotation. If it appeared obviously hyperemic with slow capillary refill, the pedicle was skeletonized or retrograde-dissected intramuscularly longer to reduce the effect of twisting on vascular patency. Then, the flap was inset and the donor sites were directly closed (Figure 1D).
Results Demographics (Table 1) Wide excision was performed in all patients. The mean age of patients was 34.85 years (range 19e52 years). Five
Summary of the patients.
Case No
Sex/Age (yr)
Cause of wound
Location of defect
Size of defect (cm)
1 2 3 4 5 6 7
f/52 m/41 m/36 m/24 f/42 f/19 m/30
Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Fibromatosis Malignant fibrous histiocytoma Malignant peripheral nerve sheath tumor Dermatofibrosarcoma protuberans
Back Chest Abdomen Lumbar Back Lumbar Chest
6 15 15 26 20 26 30
6 13 10 13 12 13 20
Intercostal artery perforator propeller flap for oncological reconstruction of trunk patients underwent tumor resection before and suffered tumor recurrence. Three patients underwent radiation therapy before the surgery. Two patients underwent radiation therapy intraoperatively. The defects were located at the back (two patients), lumbar (two patients), chest (two patients), and abdomen (one patient). The size of the defects ranged from 6 6 cm to 30 20 cm.
Outcome (Table 2) There were one DICAP flap, four DLICAP flaps, three LICAP flaps, and one AICAP flap. All flaps were based on one perforator except one. The mean skin paddle dimensions were 9.38 cm in width (range 6e14 cm) and 21.22 cm in length (range 13e28 cm). In three patients, the ICAP flap was combined with another flap, which consisted of a deep inferior epigastric artery perforator (DIEAP) flap in one patient, a superior epigastric artery perforator (SEAP) flap in one patient, and a superficial circumflex iliac artery perforator (SCIAP) flap in another patient. In two patients, the defects were reconstructed using two ICAP flaps.
Complications (Table 2) There were no flap losses. One ICAP flap exhibited marginal necrosis. The distal 2 cm of the flap required debridement and was repaired with advancement of the combined DIEAP flap. The remaining ICAP flaps healed without complications. In two patients, the combined flaps, including an SCIAP flap and an SEAP flap, had partial necrosis. The secondary defects following debridement were repaired with a superior gluteal artery perforator propeller flap and an AICAP propeller flaps, respectively. No functional loss related to flap harvesting was recognized.
Case reports Case 1 A 42-year-old woman underwent wide resection of the recurrent malignant fibrous histiocytoma at her central back (Figure 2A). A part of the trapezius and latissimus
Table 2
Perforator
Orientation Size (cm) Type
6 7
dorsi muscle was ablated with tumor. The defect measured approximately 20 12 cm (Figure 2B). Two ICAP flaps were designed to reconstruct the huge defect together. Perforators from dorsolateral branch and dorsal branch of the posterior intercostal artery were identified adjacent to the defect in the ninth intercostal space. A 20 14-cm elliptical DLICAP flap was harvested on the right back extending to the anterior axillary line and rotated to the defect. A small flap, measuring 13 6.5 cm, based on the DICAP was harvested on the left back and rotated to aid repairing the large defect (Figure 2C). The donor sites were closed primarily (Figure 2D). The flaps survived without any complications.
Case 2 A 30-year-old man with a recurrent dermatofibrosarcoma protuberans underwent wide resection of the tumor on his anterior chest wall. The resultant defect measured 30 20 cm (Figure 3A). A 28 10-cm elliptical flap based on the eighth lateral intercostal artery was harvested on the left side of the defect and rotated 180 to repair the upper portion of the defect (Figure 3B). The lower portion was reconstructed with an SEAP propeller flap. The distal one-fourth of the SEAP flap was lost (Figure 3C) and subsequently repaired with a 20 10-cm flap based on two fourth AICAPs, which were harvested on the right chest (Figure 3D). Both the ICAP flaps healed uneventfully (Figure 3E).
Discussion Perforator flaps based on any of the cutaneous branches of the posterior or anterior intercostal arteries are generally called ICAP flaps.12 In 1984, Badran et al. described the free flap based on the cutaneous branch of the posterior intercostal artery without any muscle, creating the first true ICAP flap.13 Since then, the ICAP flaps have been described by several authors, more often as a pedicle flap, which are most often based on the dorsal and lateral branches of the posterior intercostal artery (PICA).14,15
Summary of the results.
Case No Flap
1 2 3 4 5
825
Horizontal Horizontal Horizontal Oblique Horizontal Horizontal Vertical Horizontal Horizontal
16 26 17 28 20 13 23 28 20
6 10 10 8 14 6.5 10 10 10
DLICAP LICAP LICAP DLICAP DLICAP DICAP DLICAP LICAP AICAP
Flap rotation degree Combined flap Complications
Location (ICS) 11th 7th 8th 9th 9th 9th 9th 8th 4th
180 180 150 150 150 150 180 180 180
None None None DIEAP flap ICAP flap
None None None Marginal necrosis of ICAP flap None
SCIAP flap SEAP flap
Partial necrosis of SCIAP flap Partial necrosis of SEAP flap
Abbreviation ICS: Intercostal space; DLICAP: Dorsolateral intercostal artery perforator; LICAP: lateral intercostal artery perforator; DICAP: Dorsal intercostal artery perforator; AICAP: Anterior intercostal artery perforator; DIEAP: deep inferior epigastric artery perforator; SCIAP: superficial circumflex iliac artery; SEAP: superior epigastric artery perforator.
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Figure 2 Case 5. A. The flap design of double LICAP flaps for repairing a large defect in the central back. B. The wide resection of the sarcoma resulted in a huge soft tissue defect. C. A large flap based on a DLICAP from the ninth intercostal space was raised and rotated 150 to cover the majority of the back defect and a small flap based on a DICAP from the ninth intercostal space was harvested to repair the rest of the defect. D. The dual flaps were inset and the donor sites were closed primarily.
The anatomy and course of intercostal vessels have been studied by Kerrigan and Daniel.16 The intercostal vessels form an arcade between the aorta and the internal mammary vessels, which gives numerous perforators during their long courses along the intercostal space. The course of the intercostal vessels can be divided into four segments: vertebral, costal groove, intermuscular, and rectus.16 Each segment gives off cutaneous branches to supply the overlying skin, for example, known as DICAP from the vertebral segment, or DLICAP and LICAP from the costal segment.10 These perforators distribute widely over the trunk, making the pedicled perforator flaps of the intercostal arteries a capable reconstructive tool for the defects in different regions of the torso. In 2006, Hamdi et al. presented a study of the versatile clinical use of the ICAP flaps for defects over the trunk.15 They demonstrated the ICAP flaps could be harvested to cover defects that extend on the trunk from the lower neck to lower abdomen and lumbosacral area. Soft tissue sarcoma can appear in any region of the trunk. In the back region, wound closure following the tumor resection can benefit from the use of a pedicled latissimus dorsi myocutaneous flap or the reverse latissimus dorsi myocutaneous flap.4 However, functional impairment of the shoulder could develop after latissimus dorsi muscle flap transfer.17 Nevertheless, the muscle-sparing latissimus dorsi showed low functional morbidity.17 In terms of donorsite morbidities, the ICAP flap has an advantage over the muscle flap. Furthermore, the pivot points and donor sites of the regional myocutaneous flaps are relatively fixed, lacking flexibility in flap design. By contrast, the ICAPs distribute widely over the back, along the midline
posteriorly and midscapular line, rendering versatile flap design.10 One can choose a DICAP or a DLICAP as the pedicle to harvest abundant skin close to a back wound. Because of their versatility, the ICAP flap can be used to deal with the challenging back wounds. In case 5, a large defect at the midline posteriorly was repaired by combining two ICAP flaps, that is, a DLICAP and a DICAP flap. The use of DICAP flaps to reconstruct posterior trunk defects has been widely reported.14 The DICAPs can be found about 5 cm lateral to the midline posteriorly from the third through 11th thoracic vertebrae.9 Minabe and Harii demonstrated that the dorsal perforators in intercostal spaces 4e6 and 10e11 were more dominant compared with the perforators in intercostal spaces 7e9. The upper DICAP flap can be designed extending from the midline to the midaxillary line, and the lower DICAP flap is extendible to the iliac crest.9 The largest reported DICAP flap measured 40 15 cm14 The DLICAP flap was rarely reported and we found no clinical application of the DLICAP in the literature. In 2012, Vani Prasad et al. described the vascular anatomy of the DLICAP.11 The anatomical study showed that DLICAPs were present within 2 cm of the midscapular line in intercostal spaces 8 through 11. Perforators were oriented perpendicular to the direction of the muscle fibers of the latissimus dorsi and present one or two intercostal spaces below their origin from the PICA. Moreover, because anastomoses were present between the dorsolateral, dorsal, and lateral branches, they suggested that the DLICAP flap could be extended transversely to include the territories of dorsal and lateral branches and used to reconstruct defects on the back.11 Four DLICAP flaps were performed in this series. To
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Figure 3 Case 7. A. The design of the LICAP flap and SEAP flap for the large chest defect reconstruction. B. The LICAP flap was used to repair part of the chest defect. C. The distal one-fourth of the SEAP flap was lost and a flap based on the perforator of IMA from the fifth intercostal space was planned to repair the resultant wound after debridement. D. The IMA perforator was not found intraoperatively. Fortunately, two AICAPs from the fourth intercostal spaces were identified and used to supply the propeller flap for the sternal defect reconstruction. Because both the perforators had small caliber, they were all included in the flap. E. Both the ICAP flaps survived completely. The symmetry of the bilateral nippleeareola complex was largely preserved.
our knowledge, it is the first clinical report of the DLICAP flap. We found that the flap could be designed not only in a horizontal orientation but also in an oblique and vertical direction. In case 6, the vertically designed flap based on a DLICAP of the ninth intercostal artery extended from the ninth to third intercostal space. According to the angiosome theory, this DLICAP perfused its own angiosome as well as more than two adjacent perforasomes of ICAP, which is beyond the limit of one and a half angiosomes proposed by Taylor.18 We thought this phenomenon could be explained by the fact that each angiosome of the branches of the posterior intercostal arteries was linked to its neighbor by the true anastomoses without change in caliber.18 The lumbosacral region can pose especially difficult reconstructive challenges, because this region is beyond comfortable reach of most local flaps, and free tissue transfer in this area is often hampered by the lack of reliable recipient vessels.3 The perforator flaps provide
versatile reconstructive options for lumbosacral defects.19 The DICAP flap and the LICAP flap have been used for lumbosacral reconstruction.10,19 In our cases, two large lumbar defects following sarcoma resection were repaired with DLICAP flaps combined with other flaps. Traditionally, large torso defects were reconstructed by a multiple random pattern or local pedicled myocutaneous flaps.3 Currently, ICAP flaps provide flexible options to be combined with other perforator flaps for such clinical scenario. Four complicated torso wounds after tumor ablation were successfully managed in such a way in this series. One advantage of using the ICAP flap for oncologic reconstruction is that it saves the muscle for the subsequent reconstruction in recurrent cases. On the contrary, it also provides a valuable reconstructive option if the muscles have been damaged in the previous surgery. In case 4, the reverse latissimus dorsi muscle flap had been harvested for the lumbar lesion reconstruction. A DLICAP was
828 identified beside the previous incision and supplied an oblique flap for repairing the defect after the recurrent tumor resection. However, there is a risk to raise a perforator flap near the previous donor site, because the flap circulation might be injured in the previous surgery. We believe that this factor might contribute to the marginal necrosis of this ICAP flap. Because of the availability of large muscle units in the front torso, muscle or myocutaneous flaps are generally selected for complex defect reconstruction of the chest and abdomen.3 The ICAP flaps can provide coverage without sacrifice of the muscles. Badran et al. found that LICAPs were located at the level of the midaxillary line and flaps as large as 25 20 cm could be safely raised.13,16 However, these results were based on the anatomical investigation of only the last three intercostal arteries. The anatomical study of LICAP in upper intercostal spaces showed that the dominant perforators were located in the fourth to eighth intercostal spaces with a higher concentration in the sixth and seventh intercostal spaces, and located an average of 3.5 cm from the anterior border of the latissimus dorsi muscle.12 The recent study of lower ICAP exhibited that the lowest LICAP was located 2e5 cm cranially from a point 7e11 cm posterior to the anterior superior iliac spine along the iliac crest and the upper perforators were identified every 3 cm cranially with each being located 0.5 cm anterior to their immediate caudal counterparts.20 The largest application of LICAP flaps is in breast surgery,12 and the reports on employing LICAP flaps for trunk reconstruction are quite limited. The LICAP flaps have been used to cover defects in the chest, flank, groin, and back regions.20 We found that a flap based on the LICAP from the eighth intercostal space could be transferred in a propeller fashion to repair the defect in upper abdomen (case 3), which made an addition to the current literature on the possibility of torso reconstruction with pedicled LICAP flaps. The anterior intercostal artery derives from the internal mammary artery (IMA, first to sixth space) and from its musculophrenic branch (seventh to ninth space). It communicates with the PICA at about the anteromedial third of the ribs. The AICAPs can pierce anywhere between the IMA and PICA, usually within 1e3 cm lateral to the sternal border, but only through the upper fifth to sixth intercostal space.10 The caliber of the anterior intercostal arteries is small (about 1.0 mm in diameter) with their musculocutaneous perforators even smaller.10 In addition, there are no injection studies suggesting the safe dimensions of AICAP flaps. For these reasons, reports of AICAP flap application are rare and it is usually considered as a secondary option for local reconstruction.21 The AICAP flaps can be used for repairing the sternal, breast, thoracic, and epigastric abdominal wounds.15,21 We employed the AICAP flap to cover a sternal defect secondary to the partial distal necrosis of an SEAP flap (case 7). We planned to use the perforator of IMA as the pedicle, but the perforator could not be found intraoperatively. Fortunately, two AICAPs were identified in the fourth intercostal space instead. We included both the perforators in the flap to guarantee the flap vascularity, owing to their small caliber. The flap healed uneventfully. Despite the clinical importance of ICAP flaps in breast surgery, their use has not become popular, possibly because
M. Zang et al. the ICAPs are relatively shorter than those of other regions of the body and dissection of the main pedicle for more length is difficult, with the potential for pneumothorax.21 The unique design of the propeller flap can resolve this problem. The large blade of the propeller flap is designed slightly longer than the distance between the pivot point of the flap and the furthest part of the defect.22 The adequate flap length can avoid the aggressive retrograde dissection of the perforator. In addition, the design of propeller flap uses a bridge segment of flap to cover the widest portion of the donor site, making the closure much easier.23 In our series, dissection for more pedicle length within the costal groove was not needed. However, pedicle skeletonization was necessary to avoid any twisting or kinking. Generally speaking, a 3-cm pedicle length is desirable for a 180 propeller rotation, and will not compromise the flap vascularity.24 Although the anatomy of the ICAP has been studied by many authors, the detailed description of the perforator distribution of the entire ICA system is still not available. In addition, there is variation of perforator location in the different intercostal spaces.10 Therefore, we complied with freestyle flap concept25e27 when we designed the ICAP flaps. We think it is important that at least two perforators should be located adjacent to the defect preoperatively and the flap should not be completely raised until a reliable perforator is identified. Further, surgeons should have a backup flap in mind. The exact dynamic territory perfused by a single ICAP perforator is still unknown. Because there are true anastomoses between the neighbor ICAP angiosomes,18 we think the ICAP flaps can be designed exceeding two angiosomes. However, further vascular anatomical studies are needed to investigate the maximum dimension of an ICAP flap.
Conclusions Because of their reduced morbidities and versatility, the ICAP propeller flap provides a valuable option in our reconstructive armamentarium for reconstruction of trunk defects following sarcoma resection.
Conflict of interest statement The authors have no conflict of interest or any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work.
Funding None.
References 1. Fletcher CMD. WHO classification of tumours of soft tissue and bone. 4th ed. Lyon: International Agency for Research on Cancer; 2013. p. 14. 2. Langstein HN, Robb GL. Reconstructive approaches in soft tissue sarcoma. Semin Surg Oncol 1999;17(1):52e65.
Intercostal artery perforator propeller flap for oncological reconstruction of trunk 3. Chang DW, Robb GL. Recent advances in reconstructive surgery for soft-tissue sarcomas. Curr Oncol Rep 2000;2(6):495e501. 4. Muramatsu K, Ihara K, Taguchi T. Selection of myocutaneous flaps for reconstruction following oncologic resection of sarcoma. Ann Plas Surg 2010;64(3):307e10. 5. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42(6):645e8. 6. Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 2010;126(5):1589e603. 7. Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006;56(5):540e2. 8. Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Reconstr Surg 1992;89(2):181e215. 9. Minabe T, Harii K. Dorsal intercostal artery perforator flap: anatomical study and clinical applications. Plast Reconstr Surg 2007;120(3):681e9. 10. Hamdi MVLK. Intercostal and lumbar artery perforator flaps. In: Blondeel PH N, editor. Perforator flaps: anatomy, technique, & clinical applications. St. Louis: Quality Medical Publishing; 2006. p. 513e22. 11. Prasad V, Almutairi K, Kimble FW, Stewart F, Morris SF. Dorsolateral musculocutaneous perforators of posterior intercostal artery: an anatomical study. J Plast Reconstr Aesthetic Surg 2012;65(11):1518e24. 12. Hamdi M, Spano A, Landuyt KV, D’Herde K, Blondeel P, Monstrey S. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg 2008;121(2):389e96. 13. Badran HA, El-Helaly MS, Safe I. The lateral intercostal neurovascular free flap. Plast Reconstr Surg 1984;73(1):17e26. 14. Prasad V, Morris SF. Propeller DICAP flap for a large defect on the back-case report and review of the literature. Microsurg 2012;32(8):617e21. 15. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel P, Monstrey S. The versatility of the inter-costal artery perforator
16. 17.
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(ICAP) flaps. J Plast Reconstr Aesthetic Surg 2006;59(6): 644e52. Kerrigan CL, Daniel RK. The intercostal flap: an anatomical and hemodynamic approach. Ann Plast Surg 1979;2(5):411e21. Lee K, Mun G. A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg 2014;134(2):303e14. Gigliofiorito P, Iacob S, Pendolino AL, Piombino L, Segreto F, Persichetti P. True and “choke” anastomoses between perforator angiosomes: part I. Anatomical location. Plast Reconstr Surg 2014;133(6):890ee1e. Roche NA, Van Landuyt K, Blondeel PN, Matton G, Monstrey SJ. The use of pedicled perforator flaps for reconstruction of lumbosacral defects. Ann Plast Surg 2000;45(1):7e14. Iida T, Narushima M, Yoshimatsu H, et al. Versatility of lateral cutaneous branches of intercostal vessels and nerves: anatomical study and clinical application. J Plast Reconstr Aesthetic Surg 2013;66(11):1564e8. Hallock GG. The island anterior intercostal artery perforator flap as another option for the difficult epigastric abdominal wound. Ann Plas Surg 2009;63(4):414e7. Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction. J Hand Surg Am 2011;36(5):853e63. Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011;127(2):716e22. Wong CH, Cui F, Tan BK, et al. Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps. Ann Plast Surg 2007;59(6):672e8. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009;124(6 Suppl):e419e26. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114(4):910e6. Bravo FG, Schwarze HP. Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesthet Surg 2009;62(5):602e8.
Intercostal artery perforator propeller flap for reconstruction of trunk defects following sarcoma resection Mengqing Zang a, Shengji Yu b, Libin Xu b, Zhenguo Zhao b, Shan Zhu a, Qiang Ding a, Yuanbo Liu a,* a Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China b Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
Received 16 December 2014; accepted 3 February 2015
KEYWORDS Intercostal artery perforator flap; Propeller flap; Trunk reconstruction; Sarcoma
Abstract Trunk defects following soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities and some trunk regions lack reliable recipient vessels. The intercostal arteries give off multiple perforators, which distribute widely over the trunk and can supply various pedicle flaps. Our purpose is to use various intercostal artery perforator propeller flaps for trunk oncologic reconstruction. Between November 2013 and July 2014, nine intercostal artery perforator propeller flaps were performed in seven patients to reconstruct the defects following sarcoma resection in different regions of the trunk, including the back, lumbar, chest, and abdomen. Two perforators from intercostal arteries were identified for each flap using Doppler ultrasound probe adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel. An elliptical flap was raised and rotated in a propeller fashion to repair the defects. There were one dorsal intercostal artery perforator flap, four dorsolateral intercostal artery perforator flaps, three lateral intercostal artery perforator flaps, and one anterior intercostal artery perforator flap. The mean skin paddle dimension was 9.38 cm in width (range 6e14 cm) and 21.22 cm in length (range 13e28 cm). All intercostal artery perforator flaps survived completely, except for marginal necrosis in one flap harvested close to the previous flap donor site. The intercostal artery perforator propeller flap provides various and valuable options in our reconstructive armamentarium for trunk oncologic reconstruction. To our knowledge, this is the first case series of using intercostal artery perforator propeller
* Corresponding author. Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, No. 33 Badachu Road, Shijingshan District, Beijing 100144, China. Tel.: þ86 1088771985; fax: þ86 1088964137. E-mail address: [email protected] (Y. Liu). http://dx.doi.org/10.1016/j.bjps.2015.02.009 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Intercostal artery perforator propeller flap for oncological reconstruction of trunk
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flaps for trunk oncologic reconstruction and clinical application of dorsolateral intercostal artery perforator flaps. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction As soft tissue sarcomas often occur (10%) in the trunk,1 plastic surgeons are frequently asked to deal with problem wounds following soft tissue sarcoma resection in the back, lumbar, chest, and abdomen. Extensive removal of tissue is required in most of the cases, and primary closure is not usually possible. In addition, as more patients present with sarcoma recurrences, the re-resections further deplete the nearby tissues of redundancy and the transferring of healthy tissue from areas of excess is necessary. The complexity of the wounds following soft tissue sarcoma resection has increased, as more patients now receive preoperative radiotherapy. Radiation decreases the chance for a successful skin graft, and it also renders the wound edges ischemic. Therefore, well-vascularized tissues are required for reconstruction.2,3 Regional myocutaneous flaps, such as latissimus dorsi flaps, can usually repair the wounds resulting from sarcoma resection of the trunk.4 However, the muscles have to be sacrificed, which results in great donor-site morbidities. Distal free flaps can provide well-vascularized tissues for wound restoration. However, finding a reliable recipient vessel to support the microvascular transfer can be a real challenge in the torso region. Moreover, some regions, such as the lumbosacral region, are beyond the comfortable reach of most local flaps and also lack reliable recipient vessels.2 Since Koshima and Soeda in 1989 first introduced the perforator flap,5 the use of perforator flaps has increased with advantages of sparing of the underlying muscle with resultant decreased donor-site morbidity and its versatility. With a substantial number of perforators in the body, the pedicled perforator flap provides the surgeons more reconstructive options and can be a simpler alternative to free flaps.6 Hallock further improved the technique of the pedicled perforator flap with the introduction of a perforator-based propeller flap design.7 Some difficult clinical scenarios, previously relying on free flap and regional musculocutaneous flap, now can be easily managed using this technique. The intercostal vessels form the largest angiosome in the torso by means of their extensively distributed perforators to the skin.8,9 Various pedicled perforator flaps can be raised on these perforators to cover defects on the trunk, including dorsal intercostal artery perforator flap (DICAP), dorsolateral intercostal artery perforator (DLICAP) flap, lateral intercostal artery perforator (LICAP), and anterior intercostal artery perforator (AICAP) flap.10 These flaps provide versatile options for challenging defects on the trunk without sacrifice of the underlying muscle as well as concerns of the unavailability of reliable recipient vessels for free flap transfer.
Our objective was to demonstrate the versatility of propeller flaps based on the intercostal artery perforator (ICAP), which can become an alternative for reconstruction following soft tissue sarcoma resection in the different regions of the trunk.
Patients and methods Between November 2013 and July 2014, nine ICAP propeller flaps were performed in seven patients for reconstruction of trunk defects secondary to excision of malignant tumors. Patient demographics, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions, and operative records were reviewed. Outcome variables included complications and flap survival.
Operative technique Preoperative flap design (Figure 1A) Before the surgery, the extent of the soft tissue wounds following the tumor ablations was estimated. Doppler ultrasound probe was used to identify at least two large perforators adjacent to the defects at different intercostal spaces. The perforator can be the perforator of dorsal, dorsolateral, or lateral branches of the posterior intercostal artery or those of anterior intercostal artery, depending on the location of the defects. Then the one with the most prominent Doppler signals was selected as the preferred supply for the flap. The location of the selected perforator denoted the pivot point of the flap. An elliptical skin island was then designed so that the distance between the perforator and the distal portion of the flap was slightly longer than the distance between the perforator and the furthest part of the defect. Flap width allowing for primary closure of the donor site was determined by a pinch test. DICAP flap DICAPs are found about 5 cm lateral to the midline posteriorly from the third through 11th thoracic vertebrae.9 DLICAP flap DLICAPs are present within 2 cm of the midscapular line in intercostal spaces 8 through 11.11 LICAP flap LICAPs are found at the junction of the midaxillary line and the lower border of the corresponding rib in intercostal spaces 3 through 11.12
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Figure 1 Case 3. A. The design of an LICAP for abdominal defect reconstruction. At least two perforators were identified adjacent to the potential defect. B. A reliable LICAP was identified intraoperatively and employed as the pedicle vessels. C. The perforator was skeletonized and ICAP flap was rotated 150 to cover the abdominal defect. D. The flap was inset and donor site was closed directly.
AICAP flap AICAPs are usually located 1e3 cm from the lateral sternal border in intercostal spaces 1 through 9.12
Flap elevation and rotation An opening incision facilitating all perforators’ exploration was made down to the deep fascia. Dissection proceeded subfascially from caudal to cranial and distal to proximal until the previously marked perforators were visualized. The perforator with visible pulsation was finally selected as the pedicle perforator (Figure 1B). The flap design might have to be modified based on the location of the selected perforator. The flap was incised like an island, and all other perforators were ligated. The pedicle was skeletonized to obtain sufficient rotation. The rotation direction (clockwise Table 1
or counterclockwise) resulting in less twisting or kinking of the pedicle was chosen. The flap could be rotated with the versatile swing arc up to 180 (Figure 1C). Circulation was verified with capillary reaction after rotation. If it appeared obviously hyperemic with slow capillary refill, the pedicle was skeletonized or retrograde-dissected intramuscularly longer to reduce the effect of twisting on vascular patency. Then, the flap was inset and the donor sites were directly closed (Figure 1D).
Results Demographics (Table 1) Wide excision was performed in all patients. The mean age of patients was 34.85 years (range 19e52 years). Five
Summary of the patients.
Case No
Sex/Age (yr)
Cause of wound
Location of defect
Size of defect (cm)
1 2 3 4 5 6 7
f/52 m/41 m/36 m/24 f/42 f/19 m/30
Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Fibromatosis Malignant fibrous histiocytoma Malignant peripheral nerve sheath tumor Dermatofibrosarcoma protuberans
Back Chest Abdomen Lumbar Back Lumbar Chest
6 15 15 26 20 26 30
6 13 10 13 12 13 20
Intercostal artery perforator propeller flap for oncological reconstruction of trunk patients underwent tumor resection before and suffered tumor recurrence. Three patients underwent radiation therapy before the surgery. Two patients underwent radiation therapy intraoperatively. The defects were located at the back (two patients), lumbar (two patients), chest (two patients), and abdomen (one patient). The size of the defects ranged from 6 6 cm to 30 20 cm.
Outcome (Table 2) There were one DICAP flap, four DLICAP flaps, three LICAP flaps, and one AICAP flap. All flaps were based on one perforator except one. The mean skin paddle dimensions were 9.38 cm in width (range 6e14 cm) and 21.22 cm in length (range 13e28 cm). In three patients, the ICAP flap was combined with another flap, which consisted of a deep inferior epigastric artery perforator (DIEAP) flap in one patient, a superior epigastric artery perforator (SEAP) flap in one patient, and a superficial circumflex iliac artery perforator (SCIAP) flap in another patient. In two patients, the defects were reconstructed using two ICAP flaps.
Complications (Table 2) There were no flap losses. One ICAP flap exhibited marginal necrosis. The distal 2 cm of the flap required debridement and was repaired with advancement of the combined DIEAP flap. The remaining ICAP flaps healed without complications. In two patients, the combined flaps, including an SCIAP flap and an SEAP flap, had partial necrosis. The secondary defects following debridement were repaired with a superior gluteal artery perforator propeller flap and an AICAP propeller flaps, respectively. No functional loss related to flap harvesting was recognized.
Case reports Case 1 A 42-year-old woman underwent wide resection of the recurrent malignant fibrous histiocytoma at her central back (Figure 2A). A part of the trapezius and latissimus
Table 2
Perforator
Orientation Size (cm) Type
6 7
dorsi muscle was ablated with tumor. The defect measured approximately 20 12 cm (Figure 2B). Two ICAP flaps were designed to reconstruct the huge defect together. Perforators from dorsolateral branch and dorsal branch of the posterior intercostal artery were identified adjacent to the defect in the ninth intercostal space. A 20 14-cm elliptical DLICAP flap was harvested on the right back extending to the anterior axillary line and rotated to the defect. A small flap, measuring 13 6.5 cm, based on the DICAP was harvested on the left back and rotated to aid repairing the large defect (Figure 2C). The donor sites were closed primarily (Figure 2D). The flaps survived without any complications.
Case 2 A 30-year-old man with a recurrent dermatofibrosarcoma protuberans underwent wide resection of the tumor on his anterior chest wall. The resultant defect measured 30 20 cm (Figure 3A). A 28 10-cm elliptical flap based on the eighth lateral intercostal artery was harvested on the left side of the defect and rotated 180 to repair the upper portion of the defect (Figure 3B). The lower portion was reconstructed with an SEAP propeller flap. The distal one-fourth of the SEAP flap was lost (Figure 3C) and subsequently repaired with a 20 10-cm flap based on two fourth AICAPs, which were harvested on the right chest (Figure 3D). Both the ICAP flaps healed uneventfully (Figure 3E).
Discussion Perforator flaps based on any of the cutaneous branches of the posterior or anterior intercostal arteries are generally called ICAP flaps.12 In 1984, Badran et al. described the free flap based on the cutaneous branch of the posterior intercostal artery without any muscle, creating the first true ICAP flap.13 Since then, the ICAP flaps have been described by several authors, more often as a pedicle flap, which are most often based on the dorsal and lateral branches of the posterior intercostal artery (PICA).14,15
Summary of the results.
Case No Flap
1 2 3 4 5
825
Horizontal Horizontal Horizontal Oblique Horizontal Horizontal Vertical Horizontal Horizontal
16 26 17 28 20 13 23 28 20
6 10 10 8 14 6.5 10 10 10
DLICAP LICAP LICAP DLICAP DLICAP DICAP DLICAP LICAP AICAP
Flap rotation degree Combined flap Complications
Location (ICS) 11th 7th 8th 9th 9th 9th 9th 8th 4th
180 180 150 150 150 150 180 180 180
None None None DIEAP flap ICAP flap
None None None Marginal necrosis of ICAP flap None
SCIAP flap SEAP flap
Partial necrosis of SCIAP flap Partial necrosis of SEAP flap
Abbreviation ICS: Intercostal space; DLICAP: Dorsolateral intercostal artery perforator; LICAP: lateral intercostal artery perforator; DICAP: Dorsal intercostal artery perforator; AICAP: Anterior intercostal artery perforator; DIEAP: deep inferior epigastric artery perforator; SCIAP: superficial circumflex iliac artery; SEAP: superior epigastric artery perforator.
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Figure 2 Case 5. A. The flap design of double LICAP flaps for repairing a large defect in the central back. B. The wide resection of the sarcoma resulted in a huge soft tissue defect. C. A large flap based on a DLICAP from the ninth intercostal space was raised and rotated 150 to cover the majority of the back defect and a small flap based on a DICAP from the ninth intercostal space was harvested to repair the rest of the defect. D. The dual flaps were inset and the donor sites were closed primarily.
The anatomy and course of intercostal vessels have been studied by Kerrigan and Daniel.16 The intercostal vessels form an arcade between the aorta and the internal mammary vessels, which gives numerous perforators during their long courses along the intercostal space. The course of the intercostal vessels can be divided into four segments: vertebral, costal groove, intermuscular, and rectus.16 Each segment gives off cutaneous branches to supply the overlying skin, for example, known as DICAP from the vertebral segment, or DLICAP and LICAP from the costal segment.10 These perforators distribute widely over the trunk, making the pedicled perforator flaps of the intercostal arteries a capable reconstructive tool for the defects in different regions of the torso. In 2006, Hamdi et al. presented a study of the versatile clinical use of the ICAP flaps for defects over the trunk.15 They demonstrated the ICAP flaps could be harvested to cover defects that extend on the trunk from the lower neck to lower abdomen and lumbosacral area. Soft tissue sarcoma can appear in any region of the trunk. In the back region, wound closure following the tumor resection can benefit from the use of a pedicled latissimus dorsi myocutaneous flap or the reverse latissimus dorsi myocutaneous flap.4 However, functional impairment of the shoulder could develop after latissimus dorsi muscle flap transfer.17 Nevertheless, the muscle-sparing latissimus dorsi showed low functional morbidity.17 In terms of donorsite morbidities, the ICAP flap has an advantage over the muscle flap. Furthermore, the pivot points and donor sites of the regional myocutaneous flaps are relatively fixed, lacking flexibility in flap design. By contrast, the ICAPs distribute widely over the back, along the midline
posteriorly and midscapular line, rendering versatile flap design.10 One can choose a DICAP or a DLICAP as the pedicle to harvest abundant skin close to a back wound. Because of their versatility, the ICAP flap can be used to deal with the challenging back wounds. In case 5, a large defect at the midline posteriorly was repaired by combining two ICAP flaps, that is, a DLICAP and a DICAP flap. The use of DICAP flaps to reconstruct posterior trunk defects has been widely reported.14 The DICAPs can be found about 5 cm lateral to the midline posteriorly from the third through 11th thoracic vertebrae.9 Minabe and Harii demonstrated that the dorsal perforators in intercostal spaces 4e6 and 10e11 were more dominant compared with the perforators in intercostal spaces 7e9. The upper DICAP flap can be designed extending from the midline to the midaxillary line, and the lower DICAP flap is extendible to the iliac crest.9 The largest reported DICAP flap measured 40 15 cm14 The DLICAP flap was rarely reported and we found no clinical application of the DLICAP in the literature. In 2012, Vani Prasad et al. described the vascular anatomy of the DLICAP.11 The anatomical study showed that DLICAPs were present within 2 cm of the midscapular line in intercostal spaces 8 through 11. Perforators were oriented perpendicular to the direction of the muscle fibers of the latissimus dorsi and present one or two intercostal spaces below their origin from the PICA. Moreover, because anastomoses were present between the dorsolateral, dorsal, and lateral branches, they suggested that the DLICAP flap could be extended transversely to include the territories of dorsal and lateral branches and used to reconstruct defects on the back.11 Four DLICAP flaps were performed in this series. To
Intercostal artery perforator propeller flap for oncological reconstruction of trunk
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Figure 3 Case 7. A. The design of the LICAP flap and SEAP flap for the large chest defect reconstruction. B. The LICAP flap was used to repair part of the chest defect. C. The distal one-fourth of the SEAP flap was lost and a flap based on the perforator of IMA from the fifth intercostal space was planned to repair the resultant wound after debridement. D. The IMA perforator was not found intraoperatively. Fortunately, two AICAPs from the fourth intercostal spaces were identified and used to supply the propeller flap for the sternal defect reconstruction. Because both the perforators had small caliber, they were all included in the flap. E. Both the ICAP flaps survived completely. The symmetry of the bilateral nippleeareola complex was largely preserved.
our knowledge, it is the first clinical report of the DLICAP flap. We found that the flap could be designed not only in a horizontal orientation but also in an oblique and vertical direction. In case 6, the vertically designed flap based on a DLICAP of the ninth intercostal artery extended from the ninth to third intercostal space. According to the angiosome theory, this DLICAP perfused its own angiosome as well as more than two adjacent perforasomes of ICAP, which is beyond the limit of one and a half angiosomes proposed by Taylor.18 We thought this phenomenon could be explained by the fact that each angiosome of the branches of the posterior intercostal arteries was linked to its neighbor by the true anastomoses without change in caliber.18 The lumbosacral region can pose especially difficult reconstructive challenges, because this region is beyond comfortable reach of most local flaps, and free tissue transfer in this area is often hampered by the lack of reliable recipient vessels.3 The perforator flaps provide
versatile reconstructive options for lumbosacral defects.19 The DICAP flap and the LICAP flap have been used for lumbosacral reconstruction.10,19 In our cases, two large lumbar defects following sarcoma resection were repaired with DLICAP flaps combined with other flaps. Traditionally, large torso defects were reconstructed by a multiple random pattern or local pedicled myocutaneous flaps.3 Currently, ICAP flaps provide flexible options to be combined with other perforator flaps for such clinical scenario. Four complicated torso wounds after tumor ablation were successfully managed in such a way in this series. One advantage of using the ICAP flap for oncologic reconstruction is that it saves the muscle for the subsequent reconstruction in recurrent cases. On the contrary, it also provides a valuable reconstructive option if the muscles have been damaged in the previous surgery. In case 4, the reverse latissimus dorsi muscle flap had been harvested for the lumbar lesion reconstruction. A DLICAP was
828 identified beside the previous incision and supplied an oblique flap for repairing the defect after the recurrent tumor resection. However, there is a risk to raise a perforator flap near the previous donor site, because the flap circulation might be injured in the previous surgery. We believe that this factor might contribute to the marginal necrosis of this ICAP flap. Because of the availability of large muscle units in the front torso, muscle or myocutaneous flaps are generally selected for complex defect reconstruction of the chest and abdomen.3 The ICAP flaps can provide coverage without sacrifice of the muscles. Badran et al. found that LICAPs were located at the level of the midaxillary line and flaps as large as 25 20 cm could be safely raised.13,16 However, these results were based on the anatomical investigation of only the last three intercostal arteries. The anatomical study of LICAP in upper intercostal spaces showed that the dominant perforators were located in the fourth to eighth intercostal spaces with a higher concentration in the sixth and seventh intercostal spaces, and located an average of 3.5 cm from the anterior border of the latissimus dorsi muscle.12 The recent study of lower ICAP exhibited that the lowest LICAP was located 2e5 cm cranially from a point 7e11 cm posterior to the anterior superior iliac spine along the iliac crest and the upper perforators were identified every 3 cm cranially with each being located 0.5 cm anterior to their immediate caudal counterparts.20 The largest application of LICAP flaps is in breast surgery,12 and the reports on employing LICAP flaps for trunk reconstruction are quite limited. The LICAP flaps have been used to cover defects in the chest, flank, groin, and back regions.20 We found that a flap based on the LICAP from the eighth intercostal space could be transferred in a propeller fashion to repair the defect in upper abdomen (case 3), which made an addition to the current literature on the possibility of torso reconstruction with pedicled LICAP flaps. The anterior intercostal artery derives from the internal mammary artery (IMA, first to sixth space) and from its musculophrenic branch (seventh to ninth space). It communicates with the PICA at about the anteromedial third of the ribs. The AICAPs can pierce anywhere between the IMA and PICA, usually within 1e3 cm lateral to the sternal border, but only through the upper fifth to sixth intercostal space.10 The caliber of the anterior intercostal arteries is small (about 1.0 mm in diameter) with their musculocutaneous perforators even smaller.10 In addition, there are no injection studies suggesting the safe dimensions of AICAP flaps. For these reasons, reports of AICAP flap application are rare and it is usually considered as a secondary option for local reconstruction.21 The AICAP flaps can be used for repairing the sternal, breast, thoracic, and epigastric abdominal wounds.15,21 We employed the AICAP flap to cover a sternal defect secondary to the partial distal necrosis of an SEAP flap (case 7). We planned to use the perforator of IMA as the pedicle, but the perforator could not be found intraoperatively. Fortunately, two AICAPs were identified in the fourth intercostal space instead. We included both the perforators in the flap to guarantee the flap vascularity, owing to their small caliber. The flap healed uneventfully. Despite the clinical importance of ICAP flaps in breast surgery, their use has not become popular, possibly because
M. Zang et al. the ICAPs are relatively shorter than those of other regions of the body and dissection of the main pedicle for more length is difficult, with the potential for pneumothorax.21 The unique design of the propeller flap can resolve this problem. The large blade of the propeller flap is designed slightly longer than the distance between the pivot point of the flap and the furthest part of the defect.22 The adequate flap length can avoid the aggressive retrograde dissection of the perforator. In addition, the design of propeller flap uses a bridge segment of flap to cover the widest portion of the donor site, making the closure much easier.23 In our series, dissection for more pedicle length within the costal groove was not needed. However, pedicle skeletonization was necessary to avoid any twisting or kinking. Generally speaking, a 3-cm pedicle length is desirable for a 180 propeller rotation, and will not compromise the flap vascularity.24 Although the anatomy of the ICAP has been studied by many authors, the detailed description of the perforator distribution of the entire ICA system is still not available. In addition, there is variation of perforator location in the different intercostal spaces.10 Therefore, we complied with freestyle flap concept25e27 when we designed the ICAP flaps. We think it is important that at least two perforators should be located adjacent to the defect preoperatively and the flap should not be completely raised until a reliable perforator is identified. Further, surgeons should have a backup flap in mind. The exact dynamic territory perfused by a single ICAP perforator is still unknown. Because there are true anastomoses between the neighbor ICAP angiosomes,18 we think the ICAP flaps can be designed exceeding two angiosomes. However, further vascular anatomical studies are needed to investigate the maximum dimension of an ICAP flap.
Conclusions Because of their reduced morbidities and versatility, the ICAP propeller flap provides a valuable option in our reconstructive armamentarium for reconstruction of trunk defects following sarcoma resection.
Conflict of interest statement The authors have no conflict of interest or any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work.
Funding None.
References 1. Fletcher CMD. WHO classification of tumours of soft tissue and bone. 4th ed. Lyon: International Agency for Research on Cancer; 2013. p. 14. 2. Langstein HN, Robb GL. Reconstructive approaches in soft tissue sarcoma. Semin Surg Oncol 1999;17(1):52e65.
Intercostal artery perforator propeller flap for oncological reconstruction of trunk 3. Chang DW, Robb GL. Recent advances in reconstructive surgery for soft-tissue sarcomas. Curr Oncol Rep 2000;2(6):495e501. 4. Muramatsu K, Ihara K, Taguchi T. Selection of myocutaneous flaps for reconstruction following oncologic resection of sarcoma. Ann Plas Surg 2010;64(3):307e10. 5. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42(6):645e8. 6. Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg 2010;126(5):1589e603. 7. Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006;56(5):540e2. 8. Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Reconstr Surg 1992;89(2):181e215. 9. Minabe T, Harii K. Dorsal intercostal artery perforator flap: anatomical study and clinical applications. Plast Reconstr Surg 2007;120(3):681e9. 10. Hamdi MVLK. Intercostal and lumbar artery perforator flaps. In: Blondeel PH N, editor. Perforator flaps: anatomy, technique, & clinical applications. St. Louis: Quality Medical Publishing; 2006. p. 513e22. 11. Prasad V, Almutairi K, Kimble FW, Stewart F, Morris SF. Dorsolateral musculocutaneous perforators of posterior intercostal artery: an anatomical study. J Plast Reconstr Aesthetic Surg 2012;65(11):1518e24. 12. Hamdi M, Spano A, Landuyt KV, D’Herde K, Blondeel P, Monstrey S. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg 2008;121(2):389e96. 13. Badran HA, El-Helaly MS, Safe I. The lateral intercostal neurovascular free flap. Plast Reconstr Surg 1984;73(1):17e26. 14. Prasad V, Morris SF. Propeller DICAP flap for a large defect on the back-case report and review of the literature. Microsurg 2012;32(8):617e21. 15. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel P, Monstrey S. The versatility of the inter-costal artery perforator
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(ICAP) flaps. J Plast Reconstr Aesthetic Surg 2006;59(6): 644e52. Kerrigan CL, Daniel RK. The intercostal flap: an anatomical and hemodynamic approach. Ann Plast Surg 1979;2(5):411e21. Lee K, Mun G. A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg 2014;134(2):303e14. Gigliofiorito P, Iacob S, Pendolino AL, Piombino L, Segreto F, Persichetti P. True and “choke” anastomoses between perforator angiosomes: part I. Anatomical location. Plast Reconstr Surg 2014;133(6):890ee1e. Roche NA, Van Landuyt K, Blondeel PN, Matton G, Monstrey SJ. The use of pedicled perforator flaps for reconstruction of lumbosacral defects. Ann Plast Surg 2000;45(1):7e14. Iida T, Narushima M, Yoshimatsu H, et al. Versatility of lateral cutaneous branches of intercostal vessels and nerves: anatomical study and clinical application. J Plast Reconstr Aesthetic Surg 2013;66(11):1564e8. Hallock GG. The island anterior intercostal artery perforator flap as another option for the difficult epigastric abdominal wound. Ann Plas Surg 2009;63(4):414e7. Ono S, Sebastin SJ, Yazaki N, Hyakusoku H, Chung KC. Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction. J Hand Surg Am 2011;36(5):853e63. Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011;127(2):716e22. Wong CH, Cui F, Tan BK, et al. Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps. Ann Plast Surg 2007;59(6):672e8. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009;124(6 Suppl):e419e26. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114(4):910e6. Bravo FG, Schwarze HP. Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesthet Surg 2009;62(5):602e8.
