Trunk reconstruction with free style pedicled perforator flaps: clinical experience and decisional algorithm
Before the introduction of perforator flaps, superficial or complex defects of the trunk were usually approached with muscular or myo-cutaneous flaps or, in alternative, with less complex techniques such as random flaps or skin grafts. Both options were associated with sub-optimal morphological and functional results.
The introduction in the clinical practice of local perforator flaps and free style flaps allowed to overcome the limits of previous reconstructive techniques, obtaining a "like with like" reconstruction by using nearby tissues, optimizing the vascular supply and minimizing the donor site morbidity.
The authors reviewed their experience with free style pedicled perforator flaps of the trunk and hereby present a decisional algorithm to simplify the choice of the most suitable flap according to the region to be reconstructed.
Materials and methods
From June 2014 to April 2018, 70 defects involving different regions of the trunk (thoraco-clavicular region, anterior thorax and breast, axillary region, posterior thorax, lumbar region), resulting from oncological resection or chronic wounds were reconstructed with free style pedicled perforator flaps. All flaps were harvested in a perforator-based fashion, using the free style Doppler-guided philosophy, with preservation of the underlying source vessels. We evaluated the vascularization patterns, the type of movement and complications associated with each flap and elaborated a decisional algorithm in order to optimize the success of the reconstructive procedure.
We performed 28 DICAP (Dorsal Intercostal Artery Perforator) flaps, 7 LICAP (Lateral Intercostal Artery Perforator) flaps, 4 AICAP (Anterior Intercostal Artery Perforator) flaps, 10 TDAP (Thoracodorsal Artery Perforator) flaps, 4 CSAP (Circumflex Scapular Artery Perforator) flaps, 4 LAP (Lumbar Artery Perforator) flaps, 8 IMAP (Internal Mammary Artery Perforator) flaps, 2 DSAP (Dorsal Scapular Artery Perforator) flaps, 2 TAP (Thoracoacromial Artery Perforator) flaps and 1 DIEP (Deep Inferior Epigastric Perforator) flap. Flaps were mobilized on one or more perforators in a propeller and V-Y fashion in 45 and 25 cases respectively. The mean surgical time was 150 minutes. 7 patients (10%) presented vascular complications (partial necrosis of the flap).
The clinical reliability of local perforator flaps in trunk reconstruction has been widely demonstrated by many authors. Our clinical experience confirmed the advantages deriving from their usage (reliability in complex reconstructions, minimal donor site morbidity, shorter surgical time, wide arc of rotation, shorter time of recovery). Besides atypical indications, DICAP flaps confirmed to be the best option for reconstructing the back, while LICAP and TDAP flaps better addressed the reconstruction of the axillary region and lateral quadrants of the breast.
With the advent of perforator flap surgery, trunk reconstruction is increasingly approached with more sophisticated and minimally invasive techniques. Muscular and myo-cutaneous flaps still maintain their indications, specifically for the treatment of complex cases associated with significant infection and hardware exposure. Nevertheless, our experience confirms the versatility and safety of free style pedicled perforator flaps to obtain optimal aesthetic and functional results, minimizing donor site morbidity, reducing the operatory time and shortening the time of recovery.