Reliability of anatomical landmarks for skin perforators of the thoracodorsal artery perforator flap

Background: The thoracodorsal artery perforator flap was first introduced in 1995. Many authors focused on using anatomical landmarks to identify skin perforators and on thinning procedures for a skin paddle. In this study, we used the superthin free thoracodorsal artery perforator flap for resurfacing shallow defects of the extremities in 10 patients. Methods: Two anatomical landmarks previously presented by other authors were used for the guidance of flap elevation. The first landmark represented the site of the proximal skin perforator originating from the descending branch of the thoracodorsal artery, and the second landmark marked the site of the thoracodorsal neurovascular hilum. Ten flaps were performed, and all skin perforators originated from the descending branch of the thoracodorsal artery. The skin paddle carried only skin and the superficial adipose layer, and the largest skin paddle was 23 x 9 cm. Results: All defects were resurfaced with smooth contour, except for one flap in which the authors encountered flap tip superficial necrosis. The operative findings did not coincide with the first anatomical landmark in five patients. Likewise, these findings were not consistent with the second landmark in eight patients. In four patients, the thoracodorsal neurovascular hilum was located at the same level of the scapular tip or even above it. These unwanted anatomical variations increased the difficulty of exploration for skin perforators. Conclusions: The thoracodorsal artery perforator flap is a feasible choice for shallow defects in superthin form. Using a color Doppler device to identify the skin perforators preoperatively is highly suggested to prevent unexpected anatomical variations.