Sunday, October 10, 2004

Thoracodorsal Artery Perforator (T.a.P.) Type I V-Y Advancement Flap in Axillary Hidradenitis Suppurutiva



Surgical removal of all apocrine glands in the axilla is the treatment of choice in hidradenitis suppurutiva. The wound can be left to heal secondarily or closed primarily. Secondary healing is prolonged and cause contractures and stiffening of the shoulder. Primary healing includes direct closure, split-skin grafting and local flap application. Primary closure is associated with a high incidence of recurrence compared to skin grafting and flaps. Skin grafts have a lower recurrence rate but requires the use of splints to hold the shoulder in abduction for weeks. Local flap cover is therefore the ideal method of wound closure after excision of the glands. More recently, perforator-based flaps are being used since the length to width ratio is greater. Double-opposing perforator-based V-Y advancement flap ( type II ) and lateral thoracic fasciocutaneous flaps have been described. We have used a thoracodorsal artery perforator ( TAP ) V-Y advancement flap ( type I ) to achieve closure as a single-stage procedure. This technique was used successfully in all four cases. It is a safe, single stage procedure capable of closing large axillary defects while preserving the axillary contour.


Perforators along the anterior border of the latissimus dorsi were located using a hand-held Doppler device. A single V-Y advancement flap based on the marked out musculo-cutaneous perforators of the thoracodorsal vessels was planned. Its vascular territory encompasses a quadrilateral area bordered superiorly by the third rib, inferiorly by the seventh rib, posteriorly by the lateral scapular border and anteriorly by the mid-axillary line. The V-Y flap was dissected sub-fascially beginning anteriorly. Next, the superior border of the flap was elevated and finally its posterior border. Once islanded, sub-fascial dissection gradually released the flap until sufficiently lax to close the primary defect. No additional effort was taken to isolate the perforators as the flap advanced comfortably from below upwards. A single drain was inserted posteriorly.


In all five cases, there were no immediate post-operative complications like haematoma, infection or flap loss. Shoulder movements were initiated by two weeks. On six month follow-up there was a 20 % recurrence rate of the disease.


Schwabegger et al have used a similar V-Y advancement flap to us but based on random perforators. This flap is a perforator flap based on the musculocutaneous branches of the thoracodorsal vessels which supply the latissimus dorsi muscle and the skin over the muscle. In our case series, we found no need to dissect down to the thoracodorsal vessels as one would in a typical TAP flap though it is an option for larger defects. Baudet et al showed that this system of vessels was highly reliable being present in all cases, have large diameters and are easily located. Angrigiani et al first described in 1995, free perforator flaps based on the thoracodorsal artery whilst preserving the latissimus dorsi. The advantages of this flap are it is reliable and reproducibile with no need to immobilize the shoulder. Moreover, the scar is easily hidden along the posterior axillary fold, providing excellent colour and texture match to the axillary fossa. This has resulted in a simpler, safer and more user-friendly flap that is the ideal choice of achieving cover after excision of the hair-bearing skin of the axilla as exemplified by our high success rate. As such, we highly recommend its use in clinical practice both in the treatment of axillary hidradenitis suppurutiva and the closure of axillary defects in general.

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