Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

Chapter 369
Deepithelialized Flap From Arm to Chest
J. R. LEWIS JR.
EDITORIAL COMMENT
The turnover flap is most attractive to fill the subclavicular hollow. However, the vascularity is not totally
reliable.
Since there is a defect in the upper chest following resection of the pectoralis major muscle, it occurred to me a
number of years ago that corrections of chronic lymphedema of the arm and of the defect of the upper chest
might be combined by the use of a deepithelialized fat flap from the upper arm onto the chest. It was further felt
that this might give some chance of reestablishing lymphatics across the axilla onto the chest, further improving
the residual lymphedema. Whether or not this theoretic consideration is actually borne out by the results remains
to be proven.
INDICATIONS
The deepithelialized flap from the arm to the chest is used to fill out the infraclavicular hollow after
mastectomy. The flap is created during resection of some of the excess fibrofatty tissue of the
lymphedematous arm. This procedure has been used, along with breast reconstruction and as an isolated
procedure, in an attempt to reestablish lymphatic return and to improve lymphedema.
FIGURE 369.1 A: Arm flap outlined on the posteromedial aspect of the upper arm. This flap may extend
down into the forearm when the lymphedema is more marked, and the distal portion is usually discarded in
such cases. The residual flap is then turned over onto the chest across the axilla. B: Following shift of the
arm flap onto the upper chest and axilla. The purpose is to give further bulk to the upper chest in breast
reconstructions and to help improve the lymphedema of the arm by resecting some of the excess
lymphedematous fat. This is also done to improve the transfer of lymphatics across the scar tissue of the
anterior axilla.
ANATOMY
The circulation to the flap is derived from branches of the brachial artery, and the return circulation is by
accompanying small veins, including branches of the basilic vein. Lymphatics that accompany these vessels and
the normal lymphatics in the subcutaneous fat are included with the flap.

FLAP DESIGN AND DIMENSIONS
A length-to-width ratio of 2.5:1 is probably reasonable with a flap of this type. The flap is outlined by parallel
incisions along the posteromedial aspect of the upper arm, extending onto the forearm when the lymphedema is
more extensive (Fig. 369.1).
FIGURE 369.2 A,B: Preoperative appearance of the patient following radical mastectomy. Note that there is
lymphedema of the right arm and upper portion of the forearm. Also, there is a hollow in the upper chest. Most of
the pectoralis muscles have been resected along with the breast. C,D: Following reconstruction of the right
breast by an advancement flap from the abdomen, securing the flap onto the chest wall at the proposed
inframammary crease. The defect in the upper chest has been corrected by the arm flap turned onto the chest
from the right upper arm. This has reduced the bulk of the arm for correction of the lymphedema of the upper arm
and forearm and a transfer of tissue containing lymphatics across the axilla onto the chest. The distal part of this
flap more medially on the chest probably has taken as a free-fat graft rather than as a flap surviving on its own
circulation. The patient has been followed for 4 years.
OPERATIVE TECHNIQUE
The incision is carried through the fat and to the fascia, being very careful to avoid injury to the deeper
structures, including major arteries, veins, and nerves. The flap is essentially a subcutaneous tissue flap,
including at first the skin which is deepithelialized. Ideally, the dermis is left in place on the flap.
The flap is then turned upward, based in the upper arm opposite the axilla. Obviously, the whole length of the
flap will not survive on its own circulation, and the flap is resected at the desired point. The residual flap is turned
onto the chest into a subcutaneous pocket, which is dissected through a short incision in the axilla or by the
planned resection of a chest scar.
It is important that the base of the flap not be angled or flexed sharply, so as to ensure circulation into the tissue.
Leaving the dermis intact probably salvages some of the more superficial vessels, but the dermis is thin in this
area.

The base of the flap at the axilla is generally denuded in order to close the skin. If there is some uncertainty
about the circulation, the skin may be left intact at the base, to be corrected later when the flap has healed
satisfactorily. This is a variation from the usual technique and is a combination of skin-fat pedicle and
deepithelialized fat flap.
Fixation sutures are pulled through at the farthest point medially and at other points along the flap course, and a
light tie-on bandage is applied. A small drain is left if desired, and the arm is wrapped snugly, but not tightly, with
an elastic bandage from the fingers upward.
CLINICAL RESULTS
The results of this procedure in a small series seem to have been worth the effort (Fig. 369.2). If the flap is
left long, the distal portion of the flap probably “takes” more as a free-fat graft, and there is usually a certain
amount of fat necrosis and/or fibrosis, while the proximal portion of the flap apparently survives as a flap.
The firmness in the distal portion of the flap in the more medial upper chest gradually resolves, leaving
increased fullness in the area of the deficiency of the pectoralis major muscle.
In my series, there have been no complications, except for the obvious “take” in the distal portion of the
pedicle as a free graft rather than as a well-vascularized flap. Generally, the results are good. There have
been no complications in the arm itself, because of great care to avoid damage to important structures deep
to the resected fat and careful postoperative care with dependent drainage of the arm.
SUMMARY
While resecting excess lymphedematous tissue in the postmastectomy arm, a deepithelialized flap can be
created. The flap can be used to help fill out the infraclavicular hollow resulting from loss of the pectoralis
muscle. It is also hoped that the flap will help to improve the transfer of lymphatics across the scar tissue of
the anterior axilla in an attempt to reduce the lymphedema.
Reference
1. Lewis JR Jr. Reconstruction of the breasts. In: Lewis JR, Jr., ed. The art of aesthetic plastic surgery.
Boston: Little, Brown, 1989;941.

Chapter 370
Tubed Abdominal Skin Flap
J. C. KELLEHER
R. V. JANEVICIUS
EDITORIAL COMMENT
The versatility and artistry of plastic surgeons who were well versed in the manipulation of tubed flaps are
demonstrated in these clinical cases of breast reconstruction. The introduction of the transverse rectus
abdominus myocutaneous (TRAM) flap on its own pedicle or used with microvascular techniques has
supplanted most of these multistage procedures.
Although many procedures have been described for rebuilding a breast mound following mastectomy, the
concept of breast reconstruction has been popularized only relatively recently. Prior to the recent advances in
musculocutaneous flaps and the development of acceptable breast prostheses, many ingenious methods of
breast reconstruction with local and distant flaps were designed (1, 2, 3, 4, 5, 6).
Our experience with tubed abdominal skin flaps for breast reconstruction occurred in the early 1970s and forms
the basis for our description.
INDICATIONS
With the tubed abdominal skin flap used to recreate a breast mound (5, 6), new tissue is transferred to an
area of tissue deficiency. The skin and subcutaneous fat transferred are of similar consistency to the normal
breast, and the amount transferred can be varied to simulate the size of the contralateral breast. Moreover,
implants can be placed as necessary. The umbilicus can be everted and incorporated into the transfer to
simulate an areola (5, 6).
Although newer methods of breast reconstruction have, to a large extent, supplanted the use of the tubed
abdominal skin flap, it did provide a means of breast mound creation at a time when few methods were
available, and it should be considered when other breast reconstruction procedures are not possible.
FLAP DESIGN AND DIMENSIONS
A 15 × 8 cm flap of skin and subcutaneous fat extending from the right chest obliquely toward the umbilicus is
elevated and tubed. Two subsequent delays, 3 and 4 weeks later, incorporate the umbilicus into the medial
paddle. All donor sites are undermined and closed primarily.
OPERATIVE TECHNIQUE
The medial end of the tube is transferred into the inferior margin of the mastectomy scar. Following two delays of
the lateral end of the pedicle, it is transferred into the superior aspect of the mastectomy scar along the anterior
axillary fold. The tube is subsequently opened and fashioned into a breast mound, and the umbilicus is everted
to simulate an areola (Fig. 370.1).
Modification

We have used a modification of this flap in which redundant lower abdominal skin and fat, otherwise discarded
after a dermatolipectomy, are tubed and then transferred to create a left breast mound. The redundant lower
abdominal skin and fat are fashioned into a tube 20 cm long and 14 cm wide at the bases, maintaining a 5-cm
central bridge inferiorly.
The abdominoplasty incision is closed in the usual fashion. The central bridge is subsequently severed to
complete tubing of the pedicle. Two delays are performed prior to transferring the right side to a left upper
abdominal carrier site. Following two delays, the left side is inset into the breast site. The remaining tissue is
finally transferred, the tube is opened, and a breast mound is constructed (Fig. 370.2).
CLINICAL RESULTS
The reconstructive procedure necessitates multiple stages, requiring several months to complete. Donor
sites can be closed primarily, but scars at the donor sites, as well as on the breast mound itself, are
unavoidable.
SUMMARY
When some of the newer methods of breast reconstruction are not available, the tubed abdominal skin flap
should be considered.

FIGURE 370.1 A: An oblique abdominal pedicle, including the umbilicus medially, has been tubed. B: The
medial end of the tubed pedicle is transferred. C: The lateral end of the tubed pedicle is transferred. D:
Postoperative appearance after left subcutaneous mastectomy with submuscular implant and right
reconstruction with tubed abdominal skin flap and submuscular implant. E,F: Follow-up photographs 14
years after initial reconstruction. In the meantime, a recurrence on the right side was successfully excised
and treated with chemotherapy. A ruptured gel implant that presented as a cystic swelling was also
removed and eventually replaced.
FIGURE 370.2 A: The redundant lower abdominal skin and fat are fashioned into a tubed pedicle. B:
Postoperative appearance after insertion of a 350-ml prosthesis on the left, reconstruction of the areola with
labia minora, and a ptosis procedure on the right. Note the U-shaped scar in the upper abdomen, the site of
the pedicle carrier. C,D: Result at follow-up many years later.
References
1. Thorek M, ed. Plastic surgery of the breast and abdominal wall. Springfield, Ill.: Charles C Thomas,
1942;383.
2. Yannilos HG. The use of composite tubed pedicle in reconstruction of breast defect with subsequent
cosmetic repair of the donor breast. Plast Reconstr Surg 1950;6:396.
3. Holdsworth WG. A method of reconstructing the breast. Br J Plast Surg 1956;9:161.

4. Converse JM. Repair of large radiation ulcers situated over the heart and brain. Ann Surg 1951;133:95.
5. Gillies H. Surgical replacement of the breast. Proc R Soc Med 1959; 52:597.
6. de Cholnoky T. Breast reconstruction after radical mastectomy: formation of missing nipple by everted
navel. Plast Reconstr Surg 1966;38:577.

Chapter 371
Omental Flap
R. T. ROUTLEDGE
S. K. DAS
EDITORIAL COMMENT
The omentum obviously can be used for breast reconstruction if so desired, since the anatomic length of
the omentum will easily reach to the breast area. The editors are perplexed at the use of omentum over a
breast implant, since there are no known advantages to the resurfacing of an implant with omental fat.
After years of intense activity, interest in methods of breast reconstruction following ablative surgery continues to
grow, and certainly the last word on the subject has not yet been written. Merely covering the defect of a
mastectomy wound with omentum is discussed in Chapter 406. The use of omentum for reconstruction after
mastectomy is described here (1, 2, 3, 4, 5).
INDICATIONS
The omentum is ideally suited for breast reconstruction because of its shape and unique blood supply.
Since it is highly vascular, omentum will protect the overlying skin flap following subcutaneous mastectomy,
a flap that is often riddled with the multiple scars of previous biopsies and thereby jeopardized. The
omentum also will protect the underlying prosthesis that is most commonly used to replace volume loss
following mastectomy and thus reduce the incidence of extrusion. In a high percentage of patients, the
volume of breast tissue removed is so large that no implant made could properly fill the skin envelope. To
place too small an implant and hope that the skin envelope will shrink to accommodate it is a certain recipe
for aesthetic disaster.
Another use of omentum in breast reconstruction is to replace volume, exploiting the special property of
omentum to accept split-thickness skin grafts; the omentum is brought out to the chest, shaped like a
breast, and a skin graft is applied.
Indications for the use of the procedure include (1) immediate one-stage breast reconstruction following
subcutaneous mastectomy, either unilateral or bilateral, with or without a silicone implant, depending on the
size of the breast, and (2) late or delayed breast reconstruction (1) following simple or radical mastectomy
when there are no other suitable alternatives, e.g., in patients in whom extensive burns have destroyed
local skin or there has been extensive radionecrosis and/or radiodermatitis.
ANATOMY
The arrangement of the two main vessels of the omentum, right and left gastroepiploic vessels, allows the
division of the omentum in half on each of these pedicles for bilateral targets (Fig. 371.1). As far as volume is
concerned, however, total omentum may be adequate for reconstruction of only one breast. Since the silicone
gel prosthesis is so easily available, the volume problem can be obviated by its use. Omentum, then, will function
primarily as a vascular protective apron, but in some cases it will replace volume as well.

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FIGURE 371.1 Construction of two omental flaps, each based on one of the gastroepiploic pedicles. (From
Barron, Saad, ref. 7, with permission.)
FLAP DESIGN AND DIMENSIONS
The average size of the omentum in a female is 33 cm in length and 32.5 cm in width. This allows a sheet of
omentum at least 16 × 16 cm for each breast cover. Even when a minimum amount of omentum is available, it is
still at least 19 × 20.4 cm, thus allowing enough to cover both breasts (6, 7, 8).
It is possible to predict the length and width of the omentum from the woman's height and weight before
laparotomy (4); the only practical difficulty is if the patient has undergone previous laparotomy and has acquired
adhesions of the omentum. Even so, with careful dissection, all the adhesions can be freed.
OPERATIVE TECHNIQUE
The subcutaneous mastectomy is performed through an inferolateral approach (Fig. 371.2), separating a thin
layer of skin and fat from the surface of the breast up to the level of the clavicle and paying particular attention to
the axillary extension laterally and the thinned inner breast quadrants medially. The gland is then elevated from
the pectoral fascia and removed, and hemostasis is secured.
Through a midline upper abdominal incision, the omentum is brought out, and its area and vascular pattern are
noted (Fig. 371.2). Previous abdominal disease may have produced multiple adhesions, which have to be
painstakingly divided before delivery of sufficient bulk can be effected. The omentum is then freed from the
transverse colon along the avascular plane, so that the middle colic vessels will not be damaged (8).

FIGURE 371.2 A: Omentum being inspected after delivery through laparotomy wound, following
omentocololysis, and before planning the two breast flaps. B: Creation of two omental flaps following division
through the middle of the omentum for bilateral breast reconstruction. Each flap is tunneled subcutaneously to
the chest and inspected for viability before placing it over the implants. Lower incision is for laparotomy, and
upper incisions are for subcutaneous mastectomy. Margins of the omentum are secured peripherally under the
skin flap with bolster sutures for permanent fixation. C: Elastoplast® dressing to hold omentum and implant in
place.
Then the omentum is freed from the greater curvature of the stomach, basing the pedicle on the right
gastroepiploic vessels if the omentum is being used for reconstructing only one breast. If both breasts are to be
reconstructed, the omentogastrolysis is started in the middle of the greater curvature of the stomach and
progresses on either side of the midline, thereby maintaining both right and left gastroepiploic pedicles (8). The
plane of dissection runs close to the greater curve of the stomach, making sure that the gastroepiploic arch is
preserved with the omentum.
There should now be sufficient length for the omentum to reach easily from the abdominal incision into the breast
pocket by means of a subcutaneous tunnel. Within the breast pocket, the omentum is spread out into a fan to
line the skin envelope. The pedicle must be checked to ensure that no torsion exists.
The omental fan can be tacked peripherally by catgut sutures to the deep surface of the skin or secured by
peripherally placed sutures brought up through the skin and lightly tied over bolsters. A suitably sized silicone gel
prosthesis is inserted deep to the omental layer, and the breast wound is closed in layers, picking up the lower
omental edge with subcutaneous sutures. Suction drainage is instituted (Fig. 371.2C).
The abdominal wound is closed in layers, leaving a small dehiscence superiorly where the omental pedicle runs
through. A light dressing is secured with Elastoplast® (Fig. 371.2C). A bra dressing must be avoided, for fear of
compression of the omental pedicle as it runs up over the costal margin.
In big-breasted females, the subcutaneous mastectomy is performed through incisions based on a standard
Strombeck pattern for breast reduction (Fig. 371.3). At first, we kept the nipple-areola complex intact on the
dermal pedicles, but

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although viability appeared secure on the table, subsequent nipple necrosis was the rule. This is hardly
surprising when one considers that the nipple-areola complex depends for its vascular supply on two long,
attenuated, excessively thin dermal pedicles which themselves are attached to skin flaps of considerably
diminished viability. In later cases, we removed the nipple- areola complex, thinned it, and applied it as a free
graft to a prepared disk on the reconstructed breast.
FIGURE 371.3 Breasts 6 years following breast reconstruction with omentum. In this patient, the size of the skin
flaps was reduced following the pattern of a Strombeck reduction mammaplasty.
CLINICAL RESULTS
There have been very few criticisms about the use of omentum for breast reconstruction. In all, we have
treated 26 patients in this manner, 22 unilateral and 4 bilateral, with maximum follow-up of 9 years.
Complications have been encouragingly few.
Of the abdominal complications, only one patient developed an abdominal hernia and one patient had a
prolonged ileus. Five patients, however, complained of prolonged abdominal discomfort. Of the breast
complications, 12 had a minimal skin loss that healed spontaneously. There were 5 implant displacements
and 1 extrusion. Four patients developed a hematoma, and 1 patient developed an infection.
There has been only one serious and irreversible set of complications in the series, and this involved one
patient treated by bilateral subcutaneous mastectomy and immediate repair. She was anticoagulated
postoperatively for a pulmonary embolus and subsequently developed repeated hematomas. These
eventually became infected, despite aspiration, necessitating removal of the implant.
Significant displacement of the prosthesis postoperatively occurred most often in early patients in the
series, in whom we erred in reconstructing with implants much too small for the overcapacious breast
pocket. Despite carefully applied support, there was significant lateral displacement of the implants. Today
we would not hesitate to reduce the size of the skin envelope before implanting.
We are aware of potential dangers and would now advise our patients to undergo, after 3 months, a minor
secondary procedure in which the omental pedicle is divided and returned to the abdomen with full closure
of the abdominal wall. There have been no long-term disasters resulting from the loss of the “abdominal
policeman,” even in those few patients in whom, for lack of material, most of the omentum has been
transferred out of the abdomen.

SUMMARY
Omentum has proven ideal for breast reconstruction, providing a protective cover both for the skin flaps and
for the implant, as well as actually providing some volume.
References
1. Arnold PG, Hartrampf CR, Jurkiewicz MJ. One-stage reconstruction of the breast using the transposed
greater omentum. Plast Reconstr Surg 1976; 57:520.
2. Woods JE, Irons GB, Mason JK. Use of muscle, musculocutaneous and omental flaps to reconstruct
difficult defects. Plast Reconstr Surg 1977; 59:191.
3. McColl I. Reconstruction of the breast with omentum after subcutaneous mastectomy. Lancet 1(Jan-Jun):
134, 1979.
4. Fissete J. Le lambeau épipldïque darts la reconstruction mammaire. Acta Chir Belg 1980;2:115.
5. Depoorter M. Reconstructive procedures after breast cancer surgery. Acta Chir Belg 1980;2:119.
6. Das SK. The size of the human omentum and methods of lengthening it for transplantation. Br J Plast Surg
1976;29:170.
7. Das SK. In: Barron JN, Saad MN, eds. Operative plastic and reconstructive surgery. Edinburgh: Churchill-
Livingstone, 1980. Chap. 5;137-147.
8. Das SK. Assessment of the size of the human omentum. Acta Anat 1981; 110:108.

Chapter 372
Fat Grafting for Breast Reconstruction Revision
FRANK P. ALBINO
MAURICE Y. NAHABEDIAN
EDITORIAL COMMENT
A relatively safe addition to the multiple procedures of breast reconstruction. Most useful for correction of
breast contour defects.
INDICATIONS
The number of breast reconstructions using either autologous tissue or alloplastic devices has increased
over the past decade. Efforts to improve reconstructive outcomes over this period placed increasing focus
on maximizing aesthetic outcomes. Patient and surgeon expectations continue to rise. Autologous fat
grafting to the reconstructed breast remains one of the most valuable tools to enhance outcomes by
improving shape and contour in the setting of either implant-based or autologous breast reconstruction.
Applications for fat grafting aim to correct flap contour, improve breast symmetry, disguise implant borders,
recover irradiated tissue, and reduce postmastectomy pain (1). Regardless of how successful the breast
reconstruction is, whether by flap or alloplastic device, most patients will have some degree of contour
irregularity. These irregularities are common occurrences and are frequently improved by fat injections.
In the absence of contour irregularities, fat grafting still proves beneficial. Superomedial deficiency of the
reconstructed breast can be augmented with lipoinfiltration (2). Additionally, adjuvant radiation induces
many deleterious skin changes, including significant distortion of flap or implant construct, which are
particularly difficult to address secondary to compromised blood supply. The desire to balance additional
revisions for improvements to breast shape must be tempered against the potential for delayed healing,
infection, and ultimately losing a reconstruction. Protective lipofilling may be offered in the setting of
immediate prosthetic breast reconstruction when postoperative radiotherapy is needed. One or two fat
grafting sessions between radiation therapy and the expander-implant exchange may reduce complications
and improve results (3).
FIGURE 372.1 Preoperative markings identifying contour irregularities to be addressed and the planned
graft harvest site in Patient A (A) and Patient B (B).

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ANATOMY
With the patient standing, areas of contour irregularity around the autologous or prosthetic reconstruction are
identified and marked to plan for fat transfer (Fig. 372.1A and B). The lower abdomen, upper abdomen, thighs,
flanks, knees, and
trochanters are commonly selected donor sites. The location selected for graft harvest should be chosen based
upon patient preference balanced against areas of sufficient adipose deposition. There is no clear consensus of
a relationship between graft survival and donor site with limited evidence supporting greater adipose-derived
stem cells in the lower abdomen compared to other harvest sites (4).
FIGURE 372.2 Intraoperative injection of processed adipose tissue in an extracapsular plane to marked areas of
deficiency.
Intraoperatively, the fat may be injected into a number of difference planes depending upon the severity of the
defect being addressed, quality of the mastectomy skin flaps, type of reconstruction, and whether radiation was
delivered or planned. Fat should be deposited extracapsular in the setting of alloplastic reconstruction in the
dermis, subcutaneous tissue, and muscle (Fig. 372.2). In the setting of a flap, however, it is advisable to extend
fat grafting into the deeper autologous tissue when needed to address larger contour irregularities.
OPERATIVE TECHNIQUE
Graft harvest and processing continues to be debated in an effort to maximize fat viability and graft take. Direct
excision, syringe aspiration, and liposuction have all been compared both in vivo and in vitro in order to
determine the most successful method of harvest. Ultimately, low-pressure aspiration has been found to improve
adipocyte survival; however, there is no one approach that consistently proves superior. The Coleman technique
using a 10-mL Luer-Lok syringe and blunt cannula directed through 3-mm skin incisions remains the most
common approach for graft harvest.
Fat processing prior to injection is also variable. Centrifugation, filtering, cottonoid absorption, and sieves have
all been used without reproducible, objective evidence demonstrating differences in graft survival at 1 year. More
importantly, however, is the approach to graft injection in order to minimize sheer forces applied to individual fat
cells. A 1- or 2-mL syringe with 17-gauge blunt cannula allows for smaller graft volumes to be delivered in
multiple passes in order to minimize pressure to the graft and maximize graft survival. Using smaller volumes in

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multiple passes creates a lattice of fat deposition that optimizes the graft-to-recipient bed interface, thereby
improving adipose survival (4).
CLINICAL RESULTS
Successful fat grafting can be used to thicken mastectomy skin flaps and improve contour irregularities in
the setting of any reconstructive technique. A 44-year-old female 8 months following a left skin-sparing
mastectomy and immediate tissue expander reconstruction with acellular dermal matrix presents 4 months
following an exchange to implant and right circumvertical mastopexy with the desire to develop a more
gradual slope to the reconstruction, as shown in Figure 372.3A. The contour irregularity and the planned
lower abdominal donor site are marked with the patient standing preoperatively. Ultimately, 80 mL of fat is
transferred to the area of relative deficiency and a stable, moderate improvement is noted at 6 months (Fig.
372.3B).
Similarly, a 52-year-old female 4 months following bilateral deep inferior epigastric perforator flap breast
reconstruction immediately prior to fat grafting presented with a desire for more upper pole fullness
bilaterally (Fig. 372.4A). Eight months following 110 mL of bilateral fat grafting and nipple reconstruction
(Fig. 372.4B), the overall contour is also moderately improved. Despite initial concern for its oncologic
safety, autologous fat grafting is a safe procedure to correct defects following breast reconstruction with a
low complication profile (5). There remains no consistent evidence to suggest an interference with disease
surveillance or changes to local recurrence and survivorship in the setting of fat grafting for breast
reconstruction defects (5, 6).
SUMMARY
Fat grafting to the reconstructed breast provides a safe solution to improve contour irregularities and
moderate deformities developing following either alloplastic or autologous breast reconstruction.
FIGURE 372.3 A 44-year-old female (A) preoperatively marked for left superior fat grafting and (B) 6
months postoperatively following 80 mL of fat injection and nipple reconstruction.

FIGURE 372.4 A 52-year-old female (A) preoperatively marked for bilateral superior and lateral fat grafting
and (B) 8 months postoperatively following 110 mL of fat injection bilaterally.
References
1. Kling RE, Mehrara BJ, Pusic AL, et al. Trends in autologous fat grafting to the breast: a national survey of
the American society of plastic surgeons. Plast Reconstr Surg 2013;132(1):35-46.
2. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed
breast. Plast Reconstr Surg 2005;116(5):1300-1305.
3. Ribuffo D, Atzeni M, Guerra M, et al. Treatment of irradiated expanders: protective lipofilling allows
immediate prosthetic breast reconstruction in the setting of postoperative radiotherapy. Aesthetic Plast Surg
2013;37:1146-1152.
4. Ross RJ, Shayan R, Mutimer KL, et al. Autologous fat grafting. Ann Plast Surg 2014;73(3):352-357.
5. Brenelli F, Rietjens M, De Lorenzi F, et al. Oncological safety of autologous fat grafting after breast
conservative treatment: a prospective evaluation Breast J 2014;20(2):159-165.
6. Claro F, Fiqueiredo JC, Zampar AG, et al. Applicability and safety of autologous fat for reconstruction of
the breast. Br J Surg 2012;99(6):768-780.

Chapter 373
Latissimus Dorsi Musculocutaneous Flap
J. M. GRIFFIN
EDITORIAL COMMENT
It was the latissimus dorsi myocutaneous flap that opened up the whole field of breast reconstruction. As
initially introduced, it required the use of a prosthesis. Further modifications, such as described in the
following chapters, may make it possible to reconstruct the breast without a prosthesis. This flap remains a
most reliable one; it can be used with the muscle alone, or with an overlying skin island.
The latissimus dorsi musculocutaneous flap is a remarkably versatile, large, robust flap of many uses. The
concept and development of this flap have revolutionized the approach to breast reconstruction (1, 2, 3, 4, 5, 6,
7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20). Although the rectus abdominis flap has reduced its popularity,
the latissimus flap can still be quite useful for breast and chest-wall reconstruction.
INDICATIONS
There are several problems to consider when reconstructing a breast after mastectomy: (1) resurfacing of
the chest wall with healthy tissue, (2) reconstruction of the breast mound itself, (3) restoration of the
infraclavicular defect in the event of ablation or denervation of the pectoralis muscle, (4) reconstruction of
the axillary tail of the breast, and (5) reconstruction of the nipple. All these reconstructive steps are
performed with the purpose of restoration of normal breast symmetry. The latissimus dorsi flap can be used
with considerable success in approaching all the preceeding problems except for restoration of the
infraclavicular defect.
ANATOMY
The latissimus dorsi muscle, as the name implies, “broadest of the back,” has six origins: (1) the lower six
thoracic spines and supraspinous ligaments, (2) the posterior layer of lumbar fascia, (3) the tendinous
attachments to the iliac crest, (4) strips of muscle interdigitating with the external oblique muscle, (5) muscular
slips from the lower four ribs, and (6) muscular slips from the scapula. The anterior and upper borders of the
muscle are essentially free. The muscle is deep to the trapezius. The upper edge of the latissimus dorsi forms a
“vest pocket” for the inferior angle of the scapula by running horizontally across the angle, from which it receives
additional fibers. The insertion of the latissimus dorsi is in a broad ribbon-like tendon about 10 cm long, which
inserts into the floor of the bicipital groove of the humerus behind the tendon of the long head of the biceps. The
latissimus tendon curves around the lower border of the teres major muscle and forms, therefore, the posterior
fold of the axilla, along with the subscapularis muscle.
The blood supply of the latissimus dorsi comes from a terminal branch of the subscapular artery, itself a branch
of the third portion of the axillary artery (Fig. 373.1). The subscapular artery runs about 5 cm before dividing into
the scapular circumflex and thoracodorsal arteries (21, 22, 23). The thoracodorsal artery is about 2 to 4 mm in
diameter, and it courses along the posterior portion of the axilla for about 8 to 14 cm before it actually enters the
latissimus dorsi itself. The thoracodorsal artery gives off one or two branches to the serratus anterior muscle and

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one branch to the skin. The thoracodorsal artery is accompanied by the thoracodorsal nerve and one or two
thoracodorsal veins. The neurovascular supply to the latissimus dorsi muscle can be identified at the midpoint
between the scapula and the abducted humerus about 0.5 inch from the free border of the muscle. Once the
branches of the thoracodorsal artery penetrate the muscle, they divide and run parallel to the muscle fibers and,
through perforating vessels, supply the entire skin overlying these vessels. The tendon of insertion of the
latissimus dorsi can be divided close to the humerus without injury to the bundle. The combined lengths of the
subscapular and thoracodorsal arteries, once their branches are divided, provide a very long, resilient pedicle.
A vigorous blood supply to the muscle is also available at its origin (24, 25). Perforating vessels from the
intercostal and lumbar arteries supply the muscle and overlying skin. These perforators enter the origin of the
muscle just lateral to the thoracolumbar fascia, about 8 cm from the midline, at the level of the seventh, ninth,
and eleventh vertebral spines. These perforating vessels, usually 1 to 1.5 mm in diameter, supply the so-called
reversed latissimus flap.
FIGURE 373.1 The anatomy of the latissimus dorsi muscle and thoracodorsal pedicle.
The flap anatomy also allows the flap to be split and divided into two separate paddles if necessary (26).
FLAP DESIGN AND DIMENSIONS
Generally, when the flap is based at its insertion, the thoracodorsal vessels are not specifically identified and the
pivot point is at the level of the midposterior axillary wall (27). When used as an island flap based on the
subscapular and thoracodorsal vessels, the pivot point is 1.5 to 2 cm inferior to the pectoral humeral junction.
Provided these vessels to the island flap are not rotated 360 degrees, the resulting flap is extremely mobile and
can cover from the top of the head to the elbow region. The pivot point of the reversed flap is at the level of T7,
T9, or T11, about 4 to 8 cm from the midline, on one or more of the posterior perforating vessels.
A difference in bulk between the latissimus on the operated side and that on the unoperated side may be an
indication that the muscle has been denervated.
A skin paddle as large as 12 × 20 cm can be taken along with the muscle with the possibility of direct closure of
the donor site. Of course, a skin paddle as large as the muscle itself and extending as far as 5 cm anteriorly and
inferiorly to the muscle can be harvested without delay. If a larger skin portion is needed, appropriate surgical
delays will be necessary.

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When drawing out the skin paddle, one must remember that the further the paddle is from the axillary pivot point,
the more difficult the dissection of the entire muscle will be, since considerable subcutaneous tunneling and
retraction will be necessary.
With the patient standing or sitting, draw the outline of the latissimus dorsi on the patient using a cloth pattern.
Using the pattern or measuring tape, determine the extent of the flap area needed and the mobility required.
Determine the inframammary crease on the operated side and shade 3 to 4 cm in area below this crease for
dissection and insetting of the muscle portion of the flap. The resulting breast reconstruction would prove to be
too high if dissection were terminated at the inframammary crease itself.
Unless surgical considerations necessitate excision of the opposite breast, try to match the reconstruction with
the existing breast. Avoid, if possible, the necessity for changing the contour of the existing breast. To this end, it
is necessary to provide a reconstructed ptotic, normal-appearing breast. This goal requires that the skin portion
of the latissimus flap be placed low and transversely on the reconstructed breast, preferably at the level of the
inframammary crease. The shape of the skin paddle should not necessarily be elliptical, but rather should be in
the shape of an L or J. This shape will provide a generous amount of tissue inferiorly and can extend up toward
the axilla to simulate an axillary tail. One should take care that the skin portion of the flap be inserted low. This
will avoid exposure of the flap skin, which is of a different color and texture than breast skin, when the patient is
wearing low-cut clothes. If tissue is needed higher on the reconstructed breast to fill out the infraclavicular defect,
one should deepithelialize the skin portion of the flap and insert it beneath the existing chest skin.
If possible, the design of the skin paddle on the latissimus dorsi flap should be such that the resulting scar on the
back is generally in a transverse or oblique position and can be covered by a brassiere (Fig. 373.2). To achieve
this end, it is helpful to make preliminary drawings of the flap with the patient wearing her brassiere. The position
of the resulting donor-site scar can be localized in relationship to this garment.
OPERATIVE TECHNIQUE
The easiest position on the operating table for raising the flap is the lateral position with the appropriate shoulder
abducted and flexed to 90 degrees. The position may have to be changed after dissection of the flap to facilitate
transfer of the flap, breast reconstruction, and possible surgery on the opposite breast. The position provides,
however, the best exposure for dissection of the flap.
The incision should be straight down to the underlying muscle and should not undermine the skin flap. The skin
inferior and superior to the skin paddle over the muscle must be freed by sharp or cautery dissection. Blunt
dissection is extremely difficult in this plane. The muscle can then be defined and dissected sharply from either
its anterior or superior free borders. Deep to the muscle anteriorly and perpendicular to the fibers of the
latissimus dorsi are the fibers of the serratus anterior insertion. These fibers can be elevated easily with the
latissimus dorsi and should be separated under direct vision using sharp dissection. If one starts dissection from
the superior free border, blunt dissection usually is effective in elevating only the latissimus and not the
surrounding muscles. If the serratus is inadvertently raised with the latissimus, it should be dissected from the
latissimus sharply and returned to its proper place on the chest wall. Occasionally, particularly if the dissection is
started inferiorly, posteriorly, or anteriorly, the overlying trapezius muscle can be raised with the flap and hinder
anterior transposition of the flap.
If, while separating the latissimus muscle posteriorly, perforating vessels are encountered, the perforators should
be divided and tied on both the flap and donor sides. One should realize that there are two sets of perforating
vessels along the paravertebral area; these produce a considerable amount of bleeding if they are disturbed. For
purposes of reconstruction, one needs muscle much more than fascia, and therefore, one

should try to move only a small amount of fascia beyond the end of muscle from the paravertebral area. If one
dissects only a short way into the paravertebral area and does not dissect as low as the iliac crest, one will avoid
many large bleeders. Bleeding also may occur where the rib origin of latissimus dorsi interdigitates with the
external oblique muscle. This dissection must be sharp, and appropriate hemostasis is necessary.
FIGURE 373.2 Various design options diagrammatically outlined over the latissimus muscle.
Once the edges of the latissimus dorsi are dissected free and the muscle and skin are elevated toward the
insertion, the muscle becomes much more mobile. There is no need for direct visual exposure of the
thoracodorsal vessels if the flap is elevated only to about midaxillary level. If the flap is elevated beyond this point
or used as an island flap, the neurovascular bundle should be visualized. It can be seen entering the muscle
about 10 cm from its insertion, or at about the midpoint of the axilla with the arm abducted 90 degrees. The
thoracodorsal artery can be further freed just proximal to its entrance to the latissimus dorsi by dividing the
branch of the thoracodorsal artery to serratus anterior and by dividing the occasional cutaneous branch of the
thoracodorsal artery to the lateral chest wall. The proximal pedicle of the vessel is easily seen and dissected
from the areolar tissue adjacent to the muscle itself. Once the vascular pedicle is visualized and protected, the
insertion of the muscle can be encircled with the finger. With direct visualization of the vascular pedicle, the
insertion can then be divided and transposed and the muscle can be used as an island flap. This greatly
increases the flap's range and mobility.
The anterior pocket is dissected with the patient in the same position. Care is taken to dissect 3 to 4 cm inferior
to the inframammary crease. Exposure is carried to the sternum medially and well up under the pectoralis
remnant superiorly if the muscle is still intact. Dissection should not be carried too far laterally, since the breast
reconstruction may be asymmetrical and the donor-site pocket may inadvertently be entered (28).

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Once the anterior pocket is prepared, a tunnel is created from the posterior dissection high in the axilla and the
flap is passed to the anterior wound. One should take care to avoid twisting the flap, particularly if it is an island
flap. Kinking of the island pedicle by the branch of the thoracodorsal artery to the serratus anterior muscle should
be avoided by division and ligation of this branch. The tunnel should be large enough to avoid compression of
the flap but small enough to avoid lateral and posterior displacement of the prosthesis.
Once the flap is raised and transferred to the recipient site, the donor site can then be closed. The donor site
can be closed primarily in the great majority of musculocutaneous flap reconstructions. If the skin paddle is very
large, a skin graft may be necessary. Suction drainage should be used in the donor site and should be left in
several days.
At this stage, the patient may be turned to the supine position for the breast reconstruction and for surgery on the
opposite breast if needed.
Anteriorly, several sutures may be necessary to snug up the exit from the flap tunnel in the axilla. The muscle is
then sutured to the sternum medially, to the pectoralis muscle remnants superiorly, and to the chest wall 3 to 4
cm inferior to the inframammary crease. If not enough muscle is available to stretch inferiorly, then the muscle
should be sutured to the skin above the crease. Restricting the size of the pocket inferiorly should be avoided.
The implant is then inserted under the pectoralis and latissimus muscles. No attempt is made to place the implant
beneath the serratus anterior muscle.
At this point, one can attempt to reconstruct the infraclavicular defect. This is a problem that has not been solved
satisfactorily. The latissimus dorsi muscle can be attached to the clavicle, but it is relatively thin and would have
to be detached from its insertion. Even when the insertion of muscle is attached and folded over twice, it does
not provide enough bulk for satisfactory correction of this defect.
Custom silicone implants have been tried to reconstruct the infraclavicular defect, but the implants often form
capsular contractures with the edges of the implant palpable and visible.
A dermal graft from excess skin from the island over the latissimus dorsi muscle can be used. The graft can be
folded upon itself like a sandwich, to receive blood supply from two directions. The lower abdomen has not been
a satisfactory donor site for this sort of graft because of the relatively thin dermis and thick subdermal fat layer.
The axillary tail of the breast can be reconstructed by deepithelializing a portion of the skin paddle and extending
it into the axilla or the latissimus muscle can be divided from its insertion (Fig. 373.3). One must take care to
avoid the neurovascular bundle to the latissimus dorsi. The tendon of insertion can be attached to the pectoralis
muscle and provide a satisfactory reconstruction.
Nipple reconstruction is usually deferred until maturation of the reconstruction; this subsequent surgery can be
performed on an outpatient basis.

FIGURE 373.3 The latissimus dorsi musculocutaneous unit can be designed and inset in various ways
depending on the extent and nature of the recipient defect.
CLINICAL RESULTS
Seromas or hematomas can form either at the donor or recipient site. If these occur once the drains have
been removed, incisions can be made in the most dependent portions of the wounds. Multiple needle
aspirations can be performed, but these may be less effective.
Because of the strong, vigorous blood supply to the flap, flap necrosis is rare, even with ablation of the
thoracodorsal artery in previous surgery. Necrosis has been reported when there has been undue tension
or torsion on the flap pedicle.
Transient brachial palsy, particularly posterior cord or radial nerve palsy, can be encountered with improper
positioning. Vigorous dissection near the takeoff of the subscapular artery from the axillary artery also can
produce transient palsy, since this dissection is adjacent to the brachial plexus itself. Unless direct surgical
damage has been inflicted on the brachial plexus, the palsy is reversible within several weeks.
Inadvertent elevation of the serratus or trapezius muscles along with the latissimus muscle will produce
limited flap mobility and may restrict shoulder motion.
Vigorously active patients may experience some weakness of the shoulder in lifting themselves from a chair
or on parallel bars or may experience weakness in competitive swimming. Crutch walking is not usually
affected. The latissimus dorsi may be required by patients with polio who need the muscle to elevate the
ipsilateral pelvis in walking.
Results from breast reconstruction using the latissimus dorsi flap have been quite satisfactory. The use of a
J-shaped flap, rather than the elliptical flap, and the low placement of this flap on the reconstructed breast
have made a significant improvement in the quality of breast reconstructions. Flap viability has been quite
predictable, although there have been some flap losses reported, associated with a combination of

excessive flap tension and a previously ablated thoracodorsal vessel.
SUMMARY
The latissimus dorsi musculocutaneous flap, combined with an implant, can provide the excess skin and
bulk needed for breast reconstruction after mastectomy.
References
1. Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J
Plast Surg 1977;30:277.
2. Bostwick J, Vasconez LO, Jurkiewicz MJ. Breast reconstruction after a radical mastectomy. Plast Reconstr
Surg 1978;61:682.
3. Bailey BN. Latissimus dorsi flap—a practical approach. Ann Acad Med 1979;8:445.
4. Bostwick J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg
1979;63:31.
5. Horton CE, Rosato FA, McCraw JB, Dowden RV. Immediate reconstruction following mastectomy for
cancer. Clin Plast Surg 1979;6:37.
6. McCraw JB, Bostwick J, Horton CE. Methods of soft tissue coverage for the mastectomy defect. Clin Plast
Surg 1979;6:57.
7. Olivari N. The latissimus dorsi flap, experience with 51 operations. Acta Chir Belg 1980;2:111.
8. Depoorter M. Reconstructive procedures after breast cancer surgery. Acta Chir Belg 1980;2:119.
9. Bostwick J. Reconstruction of the breast. Acta Chir Belg 1980;2:125.
10. McCraw JB, Maxwell GP, Horton CE. Reconstruction of the breast following mastectomy. Acta Chir Belg
1980;2:131.
11. Lejour M, Eder H, De Mey A, Mattheiem W. Breast reconstruction at the Tumor Center of the University
of Brussels. Acta Chir Belg 1980;2:135.
12. Mendelson BC. The latissimus dorsi flap for breast reconstruction. Aust NZ J Surg 1980;50:200.
13. Bostwick J, Jurkiewicz MJ. Recent advances in breast reconstruction: transposition of the latissimus dorsi
muscle singly or with the overlying skin. Am Surg 1980;46:537.
14. Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr

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Surg 1980;65:686.
15. Bostwick J, Scheflan M, Nahai F, Jurkiewicz MJ. The “reverse” latissimus dorsi muscle and
musculocutaneous flap: anatomic and clinical considerations. Plast Reconstr Surg 1980;65:395.
16. Bishop JB, Fisher J, Bostwick J. The burned female breast. Ann Plast Surg 1980;4:25.
17. Fodor PB, Khoury F. Latissimus dorsi muscle flap in reconstruction of congenitally absent breast and
pectoralis muscle. Ann Plast Surg 1980; 4:422.
18. Pendergrast WJ, Bostwick J, Jurkiewicz MJ. The subcutaneous mastectomy cripple: surgical
rehabilitation with the latissimus dorsi flap. Plast Reconstr Surg 1980;66:554.
19. Bostwick J, Scheflan M. The latissimus dorsi musculocutaneous flap: a onestage breast reconstruction.
Clin Plast Surg 1980;7:71.
20. Vasconez LO, Johnson-Giebink R, Hall EJ. Breast reconstruction. Clin Plast Surg 1980;7:79.
21. McCraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories. Plast
Reconstr Surg 1977;60:212.
22. Rubinstein ZJ, Shafir R, Tsur H. The value of angiography prior to use of the latissimus dorsi
myocutaneous flap. Plast Reconstr Surg 1979;63:374.
23. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631.
24. Levine RA, DeFelice CA. Possible explanation of successful latissimus dorsi flap without the
thoracodorsal artery. Plast Reconstr Surg 1980;65:532.
25. Maxwell GP, McGibbon BM, Hoopes JE. Vascular considerations in the use of a latissimus dorsi
myocutaneous flap after a mastectomy with an axillary dissection. Plast Reconstr Surg 1979;64:771.
26. Tobin GR, Schustennan M, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.
27. Dinner MI, Peters CR. The arc of the latissimus dorsi myocutaneous flap. Ann Plast Surg 1979;3:425.
28. Vasconez LO. Colloquium: total breast reconstruction. Ann Plast Surg 1981;7:62.

Chapter 374
Extended Composite Latissimus Dorsi Musculocutaneous Flap
D. R. MARSHALL
The early results of breast reconstruction with a latissimus dorsi musculocutaneous flap combined with a
prosthesis are good (1), but there is a significant complication rate in the long term, capsule formation is
common, and outright rejection happens not infrequently (2).
The extended composite latissimus dorsi musculocutaneous flap is most suitable in a woman with a breast of
average size. It relies on use of the whole latissimus dorsi muscle to carry a skin paddle for reconstruction of the
mastectomy loss and also to carry a deepithelialized portion of skin and dermis to provide the volume usually
provided by a prosthesis.
INDICATIONS
The skin and fat of the lower abdomen are excellent donors for a soft-tissue reconstruction (3), but there
are many problems in the transfer of this tissue to the breast. The direct flap transfer (4) is too cumbersome,
and the external oblique musculocutaneous flap (see Chapter 378) is useful in the patient who is not
particularly overweight, but the blood supply is somewhat unpredictable and a delay procedure may be
required for the safe transfer of the soft tissue.
The rectus abdominis flap is not without donor-site problems (3), and the risk of thromboembolic
complications is significant. It is much simpler to use the highly vascular latissimus dorsi flap to provide the
normal muscle and skin required in a postmastectomy reconstruction, and it is possible to carry enough soft
tissue with it to provide for the required augmentation.
ANATOMY
See Chapter 373.
FLAP DESIGN AND DIMENSIONS
Various methods have been described for locating the skin incision and for taking the underlying muscle when
performing a latissimus dorsi flap (5). Whether a small or large portion of the muscle remains is unimportant,
since it is completely denervated and, subsequent to the operation, gradually atrophies. There is thus no reason
why one should not transfer the whole of the latissimus dorsi muscle and in doing so carry with it into the breast
a much larger volume of skin and subcutaneous tissue than was previously possible. The muscle extends from
the angle of the scapula to the iliac crest, and there is considerably more subcutaneous tissue situated over the
lower than the upper part of the muscle.
The whole of the latissimus dorsi muscle and adherent subcutaneous tissue from the loin, equal to the volume of
the prosthesis usually employed in breast reconstruction, may be safely raised on the subscapular vascular
pedicle and used to achieve a one-stage breast reconstruction without need for a prosthesis.
A large sickle of skin and fat is outlined on the back, lower down than usual. The sickle is planned to be let into
the submammary groove and is outlined to lie basically in the skin fold below the scapula, since more tissue can
be taken in this plane and the wound can be closed without tension (Fig. 374.1C).
The large dart of skin marked out beneath the sickle extends down over the lower portion of the latissimus dorsi

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muscle as far as the iliac crest to provide a T-shaped flap of skin and subcutaneous tissue.
OPERATIVE TECHNIQUE
The operation is carried out in a patient with a breast of moderate size (Fig. 374.1) and with the patient on her
side. The epithelium is removed from the vertical portion of the T of skin and fat (Fig. 374.2), and then the flap is
elevated in the usual way. The muscle is dissected off the underlying serratus anterior and from the overlying
skin and fat up to the axilla, but it is not necessary to dissect beyond the branches of the subcapsular vessels to
the serratus anterior muscle.
The lower portion of the muscle is dissected off the thoracic and lumbar spines and from the posterior portion of
the iliac crest and out laterally to its free border. The muscle is dissected upward off the rib cage where it
interdigitates with the external oblique muscle, and the large flap of subcutaneous tissue is left attached to the
muscle throughout (Fig. 374.2B). There is no problem with viability, and at the completion of the dissection, the
flap is seen bleeding freely.
It is fortunate that the subcutaneous tissue situated in the loin corresponds in most women to the size of the
breast. In a
relatively thin woman, there is a small but adequate amount of soft tissue in the loin for breast reconstruction,
while in a woman with a larger breast, there is a large amount of subcutaneous tissue in this region both
overlying the latissimus dorsi muscle and lying beneath it in the groove adjacent to the erector spinae muscles.
FIGURE 374.1 A: This patient had a Patey mastectomy for carcinoma of the breast 2 years prior to
reconstruction. She has a normal right breast of average size. B: The planned incision is shown, since placing
the flap in the submammary groove generally produces a better breast contour. C: The limits of the latissimus
dorsi muscle are shown, and the large sickle of skin and fat to replace the skin defect is shown running in the
crease line, well below the angle of the scapula. The large dart of skin to be deepithelialized runs inferiorly to
this, down to and over the iliac crest.
Direct closure of the defect is achieved by mobilizing the skin across the midline and dissecting it off the spines
of the lumbar vertebrae. The flap is transferred around anteriorly and is let into the incision in the submammary
groove. The skin and subcutaneous tissue are lifted off the chest wall to accommodate the new breast. Any
remnant of pectoral muscle is left attached to the skin flap, since problems of viability are more likely to be
encountered here than with the composite latissimus dorsi flap.
The sickle-shaped flap of skin is inserted into the defect created in the submammary groove and deepithelialized
skin and subcutaneous tissue, and the lower portion of muscle is turned beneath the skin flap and is sutured to
the muscle higher up to provide adequate bulk in the upper portion of the reconstructed breast. Only a few
sutures are necessary, and the breast tissue is allowed to fall into the somewhat dependent shape of the normal
breast. The wounds are closed with drainage.

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FIGURE 374.2 A: The sickle-shaped flap and its dermis/subcutaneous extension all overlying the latissimus
dorsi muscle and the area that is deepithelialized are shown. B: The whole of the latissimus dorsi muscle is
elevated and extends to the limits of the deepithelialized flap.
CLINICAL RESULTS
Complications are extremely rare. Postoperative hematoma and wound infection can be prevented by
meticulous technique. The vascularity of the flap is excellent both for skin replacement and for dermis-fat
volume replacement. The usual problems of a deepithelialized dermis as a volume replacement occasionally
occur, viz., epithelial cyst formation, but this is very uncommon.
The procedure is well tolerated by the patient, and postoperative recovery is much faster than for a rectus
abdominis or external oblique musculocutaneous flap reconstruction. An occasional seroma may develop
beneath the skin flaps of the back, but this responds quickly to aspiration. The donor scar, while obvious, is
in an area where it is out of sight and it is quite well accepted (Fig. 374.3).
SUMMARY
A modification of the standard latissimus dorsi musculocutaneous flap makes it a far more acceptable
procedure for breast reconstruction. A large paddle of deepithelialized skin and subcutaneous tissue is
added so that a prosthesis is not necessary.
FIGURE 374.3 A, B: The result 3 months later, with the breast of similar volume to the normal side. A nipple
reconstruction has been carried out using a composite graft, and symmetrical breasts of normal consistency
are the result. No prosthesis has been used. C: Note that the donor-site incisions have been closed
primarily. The donor scar can be seen, and although extensive, it is in a position where it is not normally
seen by the patient. It is well accepted.

References
1. Bostwick J, Vasconez LO, Jurkiewicz, MJ. Breast reconstruction after radical mastectomy. Plast Reconstr
Surg 1978;61:682.
2. Marshall DR, Mutimer KA. Complications of breast reconstruction. Presented at the 56th General Surgery
Meeting of the Royal Academy, Hong Kong, 1983.
3. Dinner MI, Labandter HP, Dowden RV. The role of the rectus abdominis myocutaneous flap in breast
reconstruction. Plast Reconstr Surg 1982; 69:209.
4. Marshall DR, Anstee EJ, Stapleton MJ. Postmastectomy breast reconstruction using a direct flap from an
abdominal lipectomy. Br J Plast Surg 1981;34:280.
5. Wolf LE, Biggs TM. Aesthetic refinements in the use of the latissimus dorsi flap in breast reconstruction.
Plast Reconstr Surg 1982;69:788.

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Chapter 375
Pedicled Descending Branch Muscle-Sparing Latissimus Dorsi
Flap for Breast Reconstruction
CHELSEA JOHNSON
ANITA T. MOHAN
LIN ZHU
MICHEL SAINT-CYR
EDITORIAL COMMENT
This flap is most useful for coverage of lateral and inferior defects of the breast. We agree that taking a strip
of muscle alongside the descending branch of the thoracodorsal vessel facilitates flap elevation.
INDICATIONS
The pedicled descending branch muscle-sparing latissimus dorsi (LD) flap can be used for breast
reconstruction following mastectomy in combination with a tissue expander, providing coverage to the lower
two-thirds of the implant, for correction of breast contour deformities following lumpectomy and fat necrosis
and for managing implant-related complications. This flap can also be used for trunk and upper extremity
soft tissue coverage and harvested as a free flap. A
full muscle-width LD flap is preferred, however, in the presence of previous radiotherapy.
FIGURE 375.1 Illustration demonstrating the anatomy of the thoracodorsal artery, its transverse and
descending branches, and their relationship to the thoracodorsal nerve.
ANATOMY
The LD muscle is a flat, triangular-shaped muscle of the posterior trunk. Its origin arises from the posterior iliac

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crest, thoracolumbar fascia, and spinous processes of vertebrae T7 to L5. At the level of the scapula, the fibers
merge, forming the posterior wall of the axilla, and the muscle inserts onto the humerus, anterior to teres major.
The thoracodorsal artery provides the dominant blood supply, in addition to segmental perforating branches from
the intercostal and lumbar arteries (Mathes and Nahai type V circulatory pattern). The thoracodorsal artery
pierces the LD muscle 10 to 11 cm distal to the origin of its insertion (1) and bifurcates into the transverse and
descending branches, with significant overlap of vascular territories via cross-linking vessels (2, 3). The average
distance from the axillary artery, the subscapular artery, and posterior axillary fold to the bifurcation is
approximately 8, 4, and 5 cm, respectively (2). The descending branch runs from the bifurcation, which lies
approximately 2 cm medial to the muscle edge (range 1 to 4 cm), parallel to the lateral border of the muscle, and
courses slightly more posteriorly distally (Fig. 375.1). The mean length of the descending branch is around 15
cm (4). The descending branch musculocutaneous perfusion territory represents approximately 87% of the total
thoracodorsal artery perfusion (2). The majority of perforators arise from the descending branch, and the most
proximal perforator generally has the largest diameter (2, 5). The area of greatest perforator density can be
found between 9 and 15 cm from the posterior axillary fold and within 4 cm from the lateral edge of the latissimus
muscle (5).
FIGURE 375.2 A: Patient A, preoperative anatomical landmarks and flap design for bilateral muscle-sparing
latissimus dorsi reconstruction. B: Patient B, intraoperative photograph in lateral decubitus position showing
anatomical landmarks and flap design.
The muscle is innervated by the thoracodorsal nerve, which divides 2 to 3 cm superior to the thoracodorsal
artery bifurcation (2), and runs alongside the thoracodorsal artery and its respective branches.
FLAP DESIGN AND DIMENSIONS
Preoperative markings include the anterior border of the LD muscle, scapular tip, iliac crest, midline of the back,
and the maximal lower back adipose tissue roll during lateral flexion (Fig. 375.2A). Unlike the thoracodorsal
artery perforator flap, the descending branch muscle-sparing LD flap is not dependent on a specific perforator.
The skin paddle location is designed irrespective of perforator location and can be positioned at any level along
the axis of the descending branch of the thoracodorsal artery (Fig. 375.3). The skin paddle, if required, is
oriented transversely or slightly oblique along one of the natural adipose tissue rolls of the lower back to
maximize flap dimension, placing the donor scar along a natural skin crease and minimizing closing tension, as
seen in Figure 375.4 (4, 6). Skin paddle perfusion can be optimized by centering it over an LD muscle cuff
harvested along the descending branch and consideration of perforator density in the area described above
(2, 5). The most lateral edge of the skin paddle should be 1 to 2 cm anterior to the muscle border to optimize
perforators captured and, therefore, flap perfusion (Fig. 375.2B) (7). A handheld Doppler probe is used to map
the course of the descending branch from its bifurcation from the transverse branch of the thoracodorsal artery to
where it enters the flap (˜9 cm from the bifurcation). Adjustments in the skin paddle design are made at this point.

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The superior skin flap is draped over the proposed lower skin paddle incision to confirm primary closure. The
maximum size of the skin paddle is dependent on available skin laxity, but can range up to 25 × 12 cm, while still
permitting primary closure (Fig. 375.5). Positioning the skin paddle lower on the back will provide a longer
pedicle with a greater amount of freedom in the arc of rotation. If no skin paddle is required, a 15- to 20-cm
incision is created 5 cm posterior to the anterior border of the LD muscle, starting 5 cm inferior to the scapular
tip, parallel to the muscle fibers towards the iliac crest.
FIGURE 375.3 Illustration of the vascular anatomy, the transverse skin flap design, and the area of latissimus
muscle to be harvested.
OPERATIVE TECHNIQUE
With the patient positioned in the lateral decubitus position (Fig. 375.2B), the superior skin flap is elevated first
for only a few centimeters above the skin paddle and over the area corresponding to the descending branch of
the thoracodorsal artery towards the axilla (Fig. 375.6A). The anterior border of the LD can be visualized, and
limited undermining over the muscle and in the axilla helps to minimize dead space and seroma formation. The
superior skin flap can be advanced towards the inferior wound edge to ensure that closure of the donor site is
possible without undue tension. The inferior skin
flap is then elevated with minimal medial undermining and progressing only over the corresponding area of the
anterior LD muscle that is to be raised within the flap. The anterior border of the muscle is released and
dissected on the undersurface towards the midline for 4 cm (Fig. 375.6B). The descending branch of the
thoracodorsal artery can then be identified coursing along the undersurface. Its course is marked with a line on
its superficial surface using handheld Doppler ultrasound (Fig. 375.6C) superior to the skin paddle; this line is
then continued inferiorly and drawn parallel to the anterior border of the muscle (Fig. 375.6D). This line is
approximately 3 to 4 cm from the anterior border and represents the pedicle width of the muscle harvested. The
skin paddle is raised off the muscle, beginning with the medial edge near the posterior midline (Fig. 375.6E) and
dissecting laterally until the edge of the planned muscle pedicle is reached (4 cm from the anterior muscle
border). The inferior portion of the LD flap is released and raised using a vertical muscle splitting technique
along its natural muscle fiber orientation , 1 cm medial to the path of the descending branch of the thoracodorsal
artery (Fig. 375.6F and G). This dissection is continued proximally and stopped well proximal to the bifurcation
point of the thoracodorsal artery, which can be found on average 5 cm from the posterior axillary fold (range, 2.1
to 7.5 cm), or at the level of the lateral mammary fold in women (7). It is important to preserve the transverse

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nerve branch to provide innervation to the remaining muscle. Then, a subcutaneous tunnel is created above the
lateral mammary fold, and the flap is transferred without tension into the recipient site. The skin paddle can be
de-epithelized as required, leaving a smaller paddle for postoperative monitoring, which can be later excised
(Fig. 375.6H). If additional pedicle length is required, further intramuscular dissection can be performed that may
yield in excess of 15 cm in length (2). If additional peripheral adipose
tissue is needed, it can be harvested with the skin paddle as an extended version of the descending branch
muscle-sparing LD flap to maximize autologous tissue reconstruction (8). Alternatively, the muscle-sparing LD
can be harvested with simultaneous fat grafting for breast reconstruction as a reliable and efficient technique,
which may be particularly useful in bilateral reconstruction (9).
FIGURE 375.4 Illustration demonstrating the potential orientation of skin paddle designs for harvest of pedicled
muscle-sparing latissimus dorsi flap for breast reconstruction.
FIGURE 375.5 Intraoperative illustrative example of a free musclesparing latissimus dorsi flap planned with a 23-

× 8-cm skin paddle.
FIGURE 375.6 Intraoperative photographs demonstrating surgical technique. A: Superior skin flap elevated with
limited dissection over the muscle and centered over the path of thoracodorsal artery to avoid the creation of
additional dead space. B: Inferior skin flap raised and release of anterior border of the latissimus muscle up to 4
cm. C: Handheld Doppler ultrasound used to delineate the descending branch of the thoracodorsal artery course
within the anterior border of the latissimus muscle. D: A line is drawn to mark the course of the descending
branch superior to the skin paddle, and this is continued inferiorly and drawn parallel to the anterior edge of the
muscle. This line is approximately 4 cm from the anterior border of the muscle. E: The skin paddle is then raised
from the posterior midline working laterally towards the portion of the muscle flap to be harvested and the line of
the descending branch of the thoracodorsal artery. F: The inferior portion of the flap is then released and raised
via a muscle splitting technique and following a line 1 cm medial to the marked course of the descending
branch of the thoracodorsal artery. Continued

FIGURE 375.6 (Continued) G: Skin paddle and anterior latissimus muscle fully raised and ready for transfer
anteriorly through a subcutaneous tunnel, created to eliminate any tension or compression of the pedicle. H:
Flap inset and skin paddle de-epithelized as required while maintaining a small external skin paddle for
monitoring postoperatively. I, J: Final postoperative result following muscle-sparing latissimus dorsi and resultant
donor site.
CLINICAL RESULTS
The pedicled descending branch muscle-sparing LD flap with a transversely oriented skin paddle presents
distinct advantages in breast reconstruction. Compared with full-width LD flap harvest, it has several
advantages. These include an aesthetically pleasing donor site because of harvest of the skin paddle from
a natural skin fold produced on lateral flexion (4, 6), no disruption of the axillary silhouette (4, 10), reduced
risk of seroma (4, 7, 10, 11, 12, 13), no detectable difference in strength or range of motion between
operated and nonoperated sides (4, 10), and more favorable aesthetic outcomes by minimizing contour
defects of the back (4, 14). It also has advantages over its thoracodorsal perforator-based counterpart that
include simple technical dissection, versatility in flap design irrespective of an adequately sized perforator
location, and better neurovascular pedicle protection due to the small muscle cuff retained (4, 15, 16). A
large arc of rotation is made possible by two flap pivot points that are located at the flap-muscle juncture
and at the proximal bifurcation point. This enables reconstruction of a variety of defects reaching to the
midline of the chest, upper extremity, shoulder, and axilla (7).
SUMMARY
The pedicled descending branch muscle-sparing LD flap with a transversely orientated skin paddle results
in minimal functional deficit of the donor site, reduced risk of seroma, large freedom of orientation of the skin

paddle, low rate of flap complications, and a cosmetically acceptable scar.
References
1. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67(5):631-636.
2. Colohan S, Wong C, Lakhiani C, et al. The free descending branch muscle- sparing latissimus dorsi flap:
vascular anatomy and clinical applications. Plast Reconstr Surg 2012;130(6):776e-777e.
3. Tobin GR, Schusterman M, Peterson G, et al. The intramuscular neurovascular anatomy of the Latissimus
dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637-641.
4. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled descending branch muscle-sparing latissimus
dorsi flap for breast reconstruction. Plast Reconstr Surg 2009;123(1):13-24.
5. Schaverien M, Wong C, Bailey S, et al. Thoracodorsal artery perforator flap and Latissimus dorsi
myocutaneous flap—anatomical study of the constant skin paddle perforator locations. J Plast Reconstr
Aesthet Surg 2010;63:2123-2127.
6. Bailey S, Saint-Cyr M, Zhang K, et al. Breast reconstruction with the latissimus dorsi flap: women's
preference for scar location. Plast Reconstr Surg 2010;126(2):358-365.
7. Wong C, Saint-Cyr M. The pedicled descending branch muscle-sparing latissimus dorsi flap for trunk and
upper extremity reconstruction. J Plast Reconstr Aesthet Surg 2010;63(4):623-632.
8. Brackley PT, Mishra A, Sigaroudina M, et al. Modified muscle sparing latissimus dorsi with implant for total
breast reconstruction—extending the boundaries. J Plast Reconstr Aesthet Surg 2010;63(9):1495-1502.
9. Veber M, Guerin AN, Faure C, et al. Breast reconstruction using muscle sparing latissimus dorsi and fat
grafting. Ann Chir Plast Esthet 2012;57:366-372.
10. Bonomi S, Settembrini F, Salval A, et al. Current indications for and comparative analysis of three
different types of latissimus dorsi flaps. Aesthet Surg J 2012;32(3):294-302.
11. Randolph LC, Barone J, Angelats J, et al. Prediction of postoperative seroma after latissimus dorsi breast
reconstruction. Plast Reconstr Surg 2005;116(5):1287-1290.
12. Tomita K, Yano K, Masuoka T, et al. Postoperative seroma formation in breast reconstruction with
latissimus dorsi flaps: a retrospective study of 174 consecutive cases. Ann Plast Surg 2007;59(2):149-151.
13. Buntic RF, Horton KM, Brooks D, et al. The free partial superior latissimus muscle flap: preservation of
donor-site form and function. Plast Reconstr Surg 2008;121(5):1659-1663.

14. Schwabegger AH, Harpf C, Rainer C. Muscle-sparing latissimus dorsi myocutaneous flap with
maintenance of muscle innervation, function, and aesthetic appearance of the donor site. Plast Reconstr
Surg 2003;111(4):1407-1411.
15. Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator flaps in breast reconstruction: a new
concept. Br J Plast Surg 2004;57(6):531-539.
16. Nassab R, Shaaban H, Alvi R, et al. A comparative study of postoperative patient-controlled analgesia
use in latissimus dorsi and muscle-sparing latissimus dorsi flaps in breast reconstruction. Plast Reconstr
Surg 2014;134(1):175e-176e.

Chapter 376
Autogenous Latissimus Flap for Breast Reconstruction
J. B. MCGRAW
C. A. RHEE
B. STRAUCH
EDITORIAL COMMENT
This is an excellent technique for breast reconstruction in which a prosthesis is not used. It does not replace
the TRAM or the free TRAM; however, in female patients with very large, thick septocutaneous layers, the
latissimus with expanded subcutaneous tissue can be utilized for breast reconstruction without a prosthesis.
Howerer, the concavity that is created at the donor site is noticeable, and the opposite side may have to be
suctioned for equalization.
The autogenous latissimus flap for breast reconstruction differs from the original design, in that it incorporates
full-thickness fat overlying the entire latissimus dorsi muscle, in addition to the myocutaneous paddle of skin, full-
thickness fat, and muscle.
INDICATIONS
The standard latissimus flap for breast reconstruction necessitates the additional use of an implant to
provide volume and shape. A high incidence of capsular contracture has been described with the use of this
technique. The autogenous latissimus flap can be used in partial reconstruction of the breast for contour
deformities following partial mastectomy and quadrantectomy. It has also been useful for reconstruction of
Poland's chest deformity and post-radiation-induced skin damage.
The method is a reasonable alternative when TRAM reconstruction cannot be performed, due to previous
abdominal lipectomy or procedures in which the blood supply to the rectus abdominis muscle or the muscle
itself have been disrupted. In addition, the autogenous latissimus flap can be used as a backup following
TRAM reconstruction, to restore contour deficiencies following partial flap failure.
The advantages of this flap include the use of autogenous tissue replacement of breast volume, thus
offering excellent restoration of the anterior axillary fold and infraclavicular breast, providing all the tissue
required for shaping the breast without the use of an implant (in most cases), as well as a good donor-site
scar. In all but very thin patients, a breast implant is not needed to restore volume. The procedure is a
reasonable alternative to the pedicled TRAM flap in patients who have more than 2 cm of back fat by pinch
test (1, 2, 3).
The procedure cannot be performed in patients who have had a previous thoracotomy in which the
latissimus muscle or blood supply has been disrupted. Prolonged postoperative seroma formation at the
donor site can be a problem.
ANATOMY
The latissimus dorsi muscle is a large, flat, triangular muscle, which extends over the lumbar region and the
lower part of the thorax. The muscle is supplied by the thoracodorsal artery and intercostal perforators, and it

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originates from the posterior aspect of the iliac crest, lumbar fascia, spines of the lower six thoracic vertebrae,
and from the lower three ribs. Its tendinous portion inserts onto the bicipital groove of the humerus. Its actions
are to extend, adduct, and medially rotate the arm.
FLAP DESIGN AND DIMENSIONS
Previously, a three-cornered skin paddle fleur-de-lis skin design (4) was initially used, but has since been
abandoned due to its unfavorable donor-site scar (Fig. 376.1). A crescent-shaped skin paddle is now used. The
skin paddle is oriented horizontally over the fat roll of the back (Fig. 376.2). This places the closure parallel to the
lines of skin tension and allows for a favorable scar when closed primarily. The bulk of the flap is provided by the
fat carried on the entire surface of the latissimus muscle, including the two adjacent areas: scapular fat overlying
the trapezius, and the fat above the iliac crest. The length of the flap varies with the girth of the patient, and the
width of the flap is designed in relation to what can be easily closed.
OPERATIVE TECHNIQUE
The skin paddle is incised full thickness through the fat of the back down to the latissimus muscle. The entire
muscle is
elevated with the overlying full-thickness layer of fat, including the scapular fat overlying the trapezius and the fat
above the iliac crest (Fig. 376.3).
FIGURE 376.1 Fleur-de-lis design. Initially used, but since abandoned because of unfavorable donor-site scar.
The thoracodorsal vessels are dissected completely free in the axilla, to avoid kinking of the pedicle. The
muscle, when transposed, reaches beyond the margin of the rib cage anteriorly and has the necessary mobility
for folding the muscle on itself (Fig. 376.4).

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FIGURE 376.2 Crescent-shaped skin paddle oriented horizontally over fat roll of back.
FIGURE 376.3 Latissimus myocutaneous flap elevated with muscle and full-thickness fat from the scapular
region and iliac crest.
Insetting begins by attaching the extensive fat surrounding the latissimus tendon to the tendon of the pectoralis
major muscle, to recreate the anterior axillary fold. The insetting is continued by attaching the anterior border of
the latissimus
muscle to the infraclavicular portion of the pectoralis muscle near the clavicle. Medially, the edge of the muscle
forms the cleavage through an inset near the midline on the sternum. The distal margin of the muscle is folded
beneath the skin paddle to provide projection, and tacked to the chest wall to recreate the inframammary fold
(Fig. 376.5).

FIGURE 376.4 Flap transposed anteriorly onto chest wall.
FIGURE 376.5 Lower portion of muscle folded inward to provide breast projection. Inframammary fold to be
created by tacking inferior border of fold to chest wall.
The skin paddle is shaped into a U, deepithelialized, and buried, if there is adequate skin cover (Fig. 376.6). If
there is deficient breast skin, the skin paddle is used to replace the lower breast skin that normally lies between
the nipple and inframammary fold.

FIGURE 376.6 Final result. Flap inset and lateral limbs deepithelialized and buried.
Prior to closure, the skin of the back is evaluated with 1000 mg fluorescein. Any areas of inadequate vascularity
are discarded. Suction drains are placed, and removed when the output is less than 30 cc per day. The back is
supported with elastic tape dressing, to provide compression and to allow the skin flap to adhere to the chest
wall.
SUMMARY
The autogenous latissimus flap is an improvement of the standard latissimus flap. This technique allows for
complete reconstruction of breast volume and, in most cases, obviates the need for implant placement. It
offers a feasible alternative to TRAM reconstruction, with acceptable results and minimal donor-site
morbidity.
References
1. McCraw JB, Papp C, Edwards A, McMellin A. The autogenous latissimus breast reconstruction. Clin Plast
Surg 1994;21:279.
2. Papp C, Zanon E, McCraw J. Breast volume replacement using the deepithelialized latissimus dorsi
myocutaneous flap. Eur J Plast Surg 1988; 11:120.
3. Schneider W, Hill L, Brown R. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast
Surg 1977;30:2277.
4. McCraw JB, Papp C. The fleur-de-lis autogenous latissimuss dorsi myocutaneous flap breast
reconstruction. Presented at the Annual Meeting of the American Association of Plastic Surgeons,
Scottsdale, AZ, May 1989.

Chapter 377
Intercostal Artery Perforator (Icap) Flap for Breast Reconstruction
in Post-Bariatric Weight Loss Patients
S. KWEI
L. J. BORUD
B. T. LEE
EDITORIAL COMMENT
This chapter shows how anatomical concepts can be applied to reconstructive efforts in treating an
increasing bariatric patient population.
Perforator flaps based on the intercostal vessels along the anterior axillary line were first described for free-
tissue transfer to resurface neck burn wounds. The intercostal artery perforator (ICAP) flap has also been
reported as a pedicled perforator flap for the reconstruction of partial mastectomy lateral defects. More recently,
the ICAP flap has been described for autologous breast augmentation after massive weight loss in bariatric
patients.
INDICATIONS
Patients with excessive lateral upper truncal tissue are candidates for the ICAP flap. The flap uses
redundant skin and subcutaneous tissue based on the intercostal artery perforators. This extra tissue may
be used as a free flap or redistributed regionally to augment the breast or to add volume to a lateral breast
defect. Common current applications for the pedicled ICAP flap include (a) reconstruction of lateral and
inferior oncologic breast defects (1, 2); (b) autologous breast augmentation in bariatric patients after
massive weight loss (1, 2, 3); (c) contralateral symmetry augmentation reconstruction in unilateral breast
cancer patients; and (d) autologous augmentation of a previously reconstructed breast.
ANATOMY
Intercostal flaps were first described in 1978 (1) for torso reconstruction and were designed based on branches
originating from the aorta between the T7 and T11 interspaces. These vessels were found to terminate
anteriorly, adjacent to branches from the superior and inferior epigastric vessels. The use of the latissimus dorsi
myocutaneous flap for breast reconstruction (1) characterized the potential of the thoracodorsal pedicle, and
perforator flaps from this system were later introduced in 1995 (1). The distinction between the thoracodorsal
artery perforator (TDAP) and intercostal artery perforator (ICAP) flaps was subsequently described for
reconstruction of breast defects (2). The intercostal flap described herein originates from the internal mammary
vessels, with perforators that penetrate the serratus anterior muscle at the level of the anterior axillary line. This
system is adjacent, yet distinct, from the thoracodorsal system.
The blood supply to the lateral chest wall is supplied by the thoracodorsal perforators, the lateral thoracic
vessels, and the intercostal artery perforators. The thoracodorsal perforators can be found at the anterior edge
of the latissimus muscle, and there can be one or two perforating vessels. The lateral thoracic vessels are
located anterior to the latissimus and are more superior on the chest. The intercostal artery perforators are

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located 2.5 to 5 cm anterior to the latissimus muscle. They emanate from the fifth interspace, and occasionally
the fourth interspace, at the anterior axillary line. These vessels penetrate the slips of the serratus and are
typically 1.5 mm in size but can be significantly larger in a patient with massive weight loss (4, 5, 6, 7, 8).
FLAP DESIGN AND DIMENSIONS
The ICAP flap is based on the fourth or fifth intercostal artery perforators (or both) that are located along the
anterior axillary line. With a Doppler probe, the intercostal cutaneous perforators are identified to plan the base
of the flap, measuring 6 to 8 cm, depending on the number of perforators incorporated into the flap. The length of
the flap extends posteriorly and follows the curvature of the ribs, up to 15 to 20 cm in length. The inferior border
of the flap is located just below the inframammary fold and the fifth interspace. Posteriorly, the flap can be angled
superiorly, according to the amount of excessive truncal tissue. When used in conjunction with a Wise-pattern
mastopexy, the flap is designed as a lateral extension of the inferior pedicle (Fig. 377.1). Once elevated, the flap
can then be rotated 90 degrees to fill the lateral aspect of the breast, or turned over to fill the inferior border.
OPERATIVE TECHNIQUE
Elevation of the ICAP flap begins at its distal apex from posterior to anterior. Patients with massive weight loss
may need to be placed in the prone position to gain access to the posterior
truncal tissue. Otherwise, some lateral rotation is required for access to the apex of the flap posteriorly.
Dissection is carried out through the skin and subcutaneous tissue, with inclusion of the muscle fascia in the flap.
FIGURE 377.1 Schematic illustration of the intercostal artery perforator (ICAP) flap.
If more volume is necessary, the periphery of the flap can be beveled outward. The muscle fascia is then raised
from posterior to anterior, and small perforating branches from the thoracodorsal axis are encountered first,
lateral to the major intercostal perforators. These thoracodorsal perforators are sacrificed lateral to the serratus
muscle. The lateral thoracic vessels can be seen at the superior aspect of the dissection and are divided, as
well. On identification of the serratus anterior muscle, great care is taken to identify the intercostal perforators
that traverse through the muscle slips. The largest perforator is usually at the fifth interspace, but another
perforator can be found at the fourth interspace. A Doppler probe may be used intraoperatively to ensure
incorporation of the intercostal perforators in the flap. It is not necessary to isolate the perforators through the
interspace.

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FIGURE 377.2 A,B: The intercostal artery perforator flap for autologous augmentation after massive weight loss.
C,D: Preoperative markings. Note that the inferior border of the flap extends below the inframammary fold
laterally. E,F: One-year postoperative result. Note the improvement in the lateral breast contour.
The flap-donor site is closed in a layered fashion. Depending on the size of the donor-site defect, a drain may be
placed. Once the donor site is closed, the patient is returned to the supine position for breast shaping. The flap
is then deepithelialized, and the distal perfusion of the flap can be assessed. In mastopexy and autologous
augmentation, such as in the patient with massive weight loss, the flap is designed in conjunction with a Wise-
pattern mastopexy inferior pedicle. The ICAP flap is rotated superiorly up to the breast and anchored to the chest
wall and inferior pedicle, to provide definition to the lateral border of the breast. It has also been described in
conjunction with a superior-pedicle mastopexy.
When used to reconstruct a partial mastectomy defect, the flap can be rotated 90 degrees to fill laterally, or
turned over to fill inferiorly. It can be designed for replacement of the skin envelope or augmentation of a contour
deformity. The flap can also be used for augmentation of a previously reconstructed breast. For this purpose,
dissection is carried out under the previous reconstruction, and the flap is tacked into this pocket.
CLINICAL RESULTS
Successful pedicled ICAP flap reconstruction has been achieved in patients for partial mastectomy defects,
for autologous augmentation in patients with massive weight loss (9) (Fig. 377.2), and for restoration of
breast symmetry in a previously reconstructed or contralateral breast. Early reports have noted seroma
occurrence, as well as fat necrosis, with a large flap and a long distal component. These early findings
have been minimized, as the perforator anatomy is better understood, ensuring more robust survival of the
ICAP flap.
SUMMARY
The use of lateral truncal tissue based on the intercostal artery perforators provides an appealing source for
extra volume. The ICAP flap can be useful for augmentation or reconstruction of lateral and inferior defects
of the breast. Careful identification of the perforating vessels ensures robust, long-term survival of the flap,

with minimal fat necrosis.
References
1. Badran HA, Youssef MK, Shaker AA. Management of facial contour deformities with deepithelialized lateral
intercostal free flap. Ann Plast Surg 1997;37:94.
2. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: a
new concept. Br J Plast Surg 2004;57:531.
3. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast reconstruction for partial mastectomy
defects. Plast Reconstr Surg 2005;116:762.
4. Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the intercostal artery perforator (ICAP). J
Plast Reconstruct Aesth Surg 2006;59:644.
5. Rubin P, Agha-Mohammadi S, O'Toole JP, et al. Breast reshaping after massive weight loss. In: Aly A, ed.
Body contouring after massive weight loss. St. Louis: Quality Medical Publishing, 2006.
6. Daniel R, Kerrigan CL, Gard DA. The great potential of the intercostal flap for torso reconstruction. Plast
Reconstr Surg 1978;61:652.
7. Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J
Plast Surg 1977;30:277.
8. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr
Surg 1995;96:1608.
9. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight loss: the
intercostal artery perforator (ICAP) flap. Ann Plast Surg 2006;57:361.

Chapter 378
External Oblique Musculocutaneous Abdominal Flap
D. R. MARSHALL
EDITORIAL COMMENT
This procedure has had limited use because of the uncertainty about the amount of infraumbilical skin that
can be safely carried on the external oblique muscle.
The external oblique musculocutaneous abdominal flap provides a satisfactory method of breast reconstruction
using soft tissue alone without a prosthesis. Its arc of rotation allows it to be transferred for use in the breast,
upper abdomen, or thigh. The main advantage of the procedure is that it spares the abdominal wall from any
major insult and places the donor scar well down in an acceptable position.
INDICATIONS
The skin and fat of the lower abdomen provide an excellent source of soft tissue for breast reconstruction,
and many methods of transfer have been described, ranging from a single- stage microvascular repair (1) to
a two-stage open-flap procedure (2).
While each of these methods of transferring tissue from the lower abdomen is occasionally indicated,
practical difficulties rule them out for routine use. Use of the rectus abdominis musculocutaneous flap has
provided a method of transferring the skin and fat of the lower abdomen to the breast, but many surgeons
are concerned about the long-term effects of the sacrifice of the rectus abdominis muscle (3). The
latissimus dorsi flap combined with a prosthesis produces excellent early results, but there are a sufficient
number of capsular contractures to make the late results of a soft-tissue repair alone superior (4). The skin
and fat of the lower abdomen, normally discarded in an abdominal lipectomy, are the ideal sources for
reconstruction. Many mastectomy patients have an abdominal roll, and furthermore, the fat of this region is
contained in large, discrete compartments and bears an excellent likeness to breast tissue.
To enable the abdominal skin and fat to be transferred to the breast, it is clear that the vascular pedicle
must come from above, and the superior epigastric leash is commonly used. However, the lower portion of
the rectus abdominis muscle lies directly beneath the required skin flap and cannot be sacrificed without
weakening the lower abdominal wall, since there is no posterior rectus sheath below the arcuate line.
The only other abdominal muscle that is a possible carrier for flap transfer is the external oblique, running
as it does from the rib cage laterally to the midline of the abdomen, anterior to the rectus abdominis, and
beneath the skin flap (Fig. 378.1).
ANATOMY
The segmental intercostal vessels pass forward into the abdomen and lie between the internal oblique and the
transversus muscles as far as the rectus sheath (Fig. 378.2A), but their lateral cutaneous branches pass through
the internal oblique in the midlateral line to pass forward deep to the external oblique and supply the skin and fat
of the abdominal wall (Fig. 378.2B).

FIGURE 378.1 Line drawing to show on the right side of the patient, the skin flap outlined with a solid black line
and the underlying muscle flap outlined with a dotted line, and on the left side of the patient, the
musculocutaneous flap with an island of skin and fat transferred superiorly into the region of the breast (skin
tunnel not shown). Note the deficiency in the external oblique muscle, with the underlying fibers of internal
oblique running as far as the lateral edge of the rectus sheath and the vertical rectus abdominis muscle medial to
this.
FIGURE 378.2 A: Drawing of a transverse section of the left side of the abdominal wall. Note the external
oblique, internal oblique, transversus abdominis, and the fascial arrangement of the rectus sheath. The
segmental nerves and vessels and their midlateral branches are shown as a broken line. The plane of elevation
of the musculocutaneous flap is shown as a dotted line and passes as far posteriorly as the lateral branches. B:
Drawing of a transverse section of the abdominal wall with the flap now elevated. Note that the rectus abdominis
muscle is undisturbed. The skin and fat overlying the external oblique muscle are raised as an island.
During a number of routine abdominal lipectomies, it is possible to demonstrate the circulatory competence of the
flap, in which the skin and fat are left as an island attached to the muscle flap that is temporarily developed up to
the rib cage. It is later replaced, the skin is excised, and the lipectomy is completed in the usual way. The defect
in the external oblique muscle seems unlikely to cause a problem, providing the underlying muscles are in no
way damaged.
FLAP DESIGN AND DIMENSIONS
It is technically feasible to carry the skin and subcutaneous tissue of the lower abdomen into the breast by
means of a subcutaneous tunnel over the ribs using such an external oblique musculocutaneous flap. The skin
flap is outlined on the side of the defect from umbilicus to pubis in the midline and extending as a triangle to the
anterior superior iliac spine.

OPERATIVE TECHNIQUE
The incision is deepened through the external oblique aponeurosis, and the anterior rectus sheath is elevated in
continuity. The skin and fat from pubis to umbilicus, usually discarded in an abdominal lipectomy, are left
attached to the external oblique muscle. A strip of external oblique 4 in wide is elevated from the underlying
internal oblique muscle back as far as the rib cage. The muscle is freed from the iliac crest, and the posterior
free border of the muscle is transected. The lateral perforating vessels are identified and preserved in two
spaces as the muscle is elevated from the lateral surface of the ribs. The abdominal skin above the island flap is
elevated from the abdominal wall as in a normal lipectomy.
The mastectomy scar is opened, and the skin flaps are raised from the chest wall. A subcutaneous tunnel is
established from the breast to the abdominal wound, and the musculocutaneous flap is then passed through this
into the breast. The flap is arranged to conform as accurately as possible to the normal breast, and no prosthesis
is required.
The abdominal lipectomy is then completed with a transposition of the umbilicus and excision of the skin and fat
on the opposite side (Fig. 378.3).
A second operation may be performed some months later to adjust the shape of the breast and to divide the
pedicle of the flap as low down as possible, allowing the subcutaneous tissue and muscle to be turned superiorly
to augment the breast volume further. A nipple reconstruction may be performed at this time (Fig. 378.4).
CLINICAL RESULTS
The complications of the procedure relate particularly to the blood supply, since the vascularity of the flap is
only just adequate and any tension or compression will lead to ischemic necrosis. It is wise to leave the flap
for a short period of time after elevation to confirm that the blood supply is adequate. If there is any doubt,
then the flap should not be transferred but should be left as a delay and the reconstruction carried out as a
staged procedure.
Problems of necrosis of the flap may occur as a result of compression in the subcutaneous tunnel. This has
occurred in obese elderly patients. In this situation, an incision through the overlying skin of the tunnel may
be required to prevent any vascular compression. The operation is contraindicated in the obese and the
elderly.
SUMMARY
The external oblique musculocutaneous flap can be used for breast reconstruction in certain circumstances.

FIGURE 378.3 A: A patient who had an external oblique myocutaneous flap reconstruction of the left breast
4 weeks previously. The patient had had a left Patey mastectomy 2 years prior to the reconstruction. Note
the postlipectomy appearance of the abdomen and the flap in situ in the left breast. B: The same patient.
Note the bulge over the left rib cage where the pedicle of the flap lies beneath the skin.
FIGURE 378.4 A: The same patient as in Fig. 3 after detachment of the pedicle of the flap that has been
turned into the left breast to augment the volume further. The right breast has been reduced and the nipple
uplifted, along with a nipple reconstruction on the left side. B: The same patient showing satisfactory
symmetry. Note that the fullness over the left rib cage is no longer evident.
References
1. Holmstrom H. The free abdominoplasty flap and its use in breast reconstruction: an experimental study
and a clinical case report. Scand J Plast Reconstr Surg 1979;13:423.
2. Marshall DR, Anstee EL Stapleton MJ. Postmastectomy breast reconstruction using a direct flap from an
abdominal lipectomy. Br J Plast Surg 1981;34:280.
3. Dinner MI, Labandter HP, Dowden RV. The role of the rectus abdominis myocutaneous flap in breast
reconstruction. Plast Reconstr Surg 1982; 69:209.
4. Maxwell GP, Rasto FE, Horton CE. Postmastectomy breast reconstruction. Curr Prob Surg 1972;17:11.