Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e140ee141
CASE REPORT
Inadvertent free intercostal artery perforator flaps
James Henderson*, Jonathon J. Clibbon, Richard M. Haywood
Department of Plastic Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
Received 13 June 2008; accepted 17 June 2008
KEYWORDSIntercostal arteryperforator flap;Lateral intercostalartery perforator flap;Free intercostal arteryperforator flap
* Corresponding author. Tel. þ44 1288378.
E-mail address: jh@jameshenderso
1748-6815/$-seefrontmatterª2008Bridoi:10.1016/j.bjps.2008.06.087
Summary Two cases of free lateral intercostal artery perforator flaps are presented in thisarticle. Both flaps were raised instead of thoracodorsal artery perforator flaps, which had beenthe initial operative plan. The free intercostal artery perforator flap can be technically diffi-cult, the pedicle is relatively short and the vessel diameters can be small. The pedicle mayneed to be dissected along the intercostal groove to obtain sufficient vessel length and diam-eter. Despite all these issues, we describe a relatively straightforward salvage operation ifa perforator flap raised on a presumed thoracodorsal artery axis is found to be an intercostalartery perforator flap.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.
Wehaveperformed free-tissue transferofa lateral intercostalartery perforator (LICAP) flap as classified by Hamdi et al.1 ontwo occasions: to prefabricate soft tissue over a knee jointprior to joint-replacement surgery and for reconstruction ofa defect over the clavicle after wide excision of dermatofi-brosarcoma protruberans (DFSP). Although the pedicledlateral intercostal artery perforator flap has been previouslydescribed,2 we believe this is the first report of free-tissuetransfer based on an intercostal artery perforator.
The first patient, a 61-year-old non-smoker, wasreferred to us for consideration of prefabrication of softtissue over the lateral aspect of her right knee. At the ageof 18, she had undergone biopsy and subsequent removal ofan osteoclastoma from the lateral femoral condyle, leavingtwo scars. These were parallel in part, and crossed distally,
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leaving an area of tight skin and soft-tissue paucity over theanterolateral aspect of the knee. Severe valgus deformityhad subsequently developed.
In order to create suitable soft-tissue cover prior to totalknee replacement, a thoracodorsal artery perforator (TDAPor TAP) flap was planned.3 This flap would provide a tissueof a similar consistency to the peri-articular integumentand have a good pedicle length.
The flap was planned as an oblique ellipse 17� 8 cmwith the superomedial end being 2 cm from the posteriormidline at the level of the tip of the scapula and theinferolateral end 4 cm anterior to the anterior border oflatissimus dorsi on the left back (Figure 1a). Three perfo-rators were identified within the planned flap by pre-operative unidirectional Doppler examination.
Intra-operatively, four perforating arteriovenous pedi-cles were identified, but these were all found to originatefrom intercostal vessels instead of the thoracodorsal axis.The flap was raised on the largest perforating artery, which
tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.
Figure 1 A.The LICAP flap donor site is similar to that for a TDAP flap. B. LICAP flap inset into the anterolateral aspect of theknee. Arthroplasty surgery was subsequently successfully performed by elevating the flap from the lateral side.
Inadvertent free intercostal artery perforator flaps e141
originated from the costal portion of the intercostal artery,designated as a LICAP.1
The perforating vessels gave a pedicle length ofapproximately 3 cm and a small calibre artery. Therefore,the intercostal artery and vein were dissected posteriorlyfrom the subcostal groove for a further 3 cm, preserving theintercostal nerve and giving a total pedicle length of 6 cm,and more importantly, increasing the diameter of thevessels to 2 mm for the vein and 1 mm for the artery.
Anastomosis was performed to the long saphenous veinwith a 2-mm coupler device (Unilink, 3 M�) and side to endto the reflected posterior tibial artery at the anteromedialaspect of the leg at the level of the tibial tuberosity. Theinset flap is shown in Figure 1B. Six months after tissueprefabrication with the free LICAP flap, arthroplasty wassuccessfully performed by elevating the flap laterally toprotect the medially based pedicle.
The second patient, a 56-year-old non-smoker, wasreferred for removal of DFSP from her right clavicular area.It was thought that a skin graft would be unsightly anduncomfortable, and the patient elected for flap recon-struction. In addition to providing a suitably thin flap, we
Figure 2 LICAP flap inset over the clavicle and anastomosedto the acromial artery and vein.
hoped to be able to perform a pedicled TDAP flap bydissecting the vessels into the axilla.
A 12� 12-cm flap was planned around a presumedthoracodorsal artery perforator identified pre-operativelywith the Doppler probe. Since the acromial artery and veinhad been identified in the defect as good recipient vessels,the flap pedicle only required dissection as far as the costalportion of the intercostal artery. The pedicle length of thisflap was approximately 6 cm without the need to dissectalong the costal groove. A 1.5-mm coupler was used toanastomose the vein, and the artery also had a diameter ofapproximately 1.5 mm. The inset flap is shown in Figure 2.
We believe that this is the first report of free-tissuetransfer based on intercostal artery perforators, andfurther to the paper of Hamdi et al.,1 we can be certainthat the perforator is from the intercostal vessels ratherthan potentially being based on the thoracodorsal orinternal mammary vessels, which could be the case withpedicled dorsal (DICAP) and lateral (LICAP) or anterior(AICAP) intercostal artery perforator flaps, respectively.
The free ICAP pedicle length is short, the vessels aresmall and the dissection is difficult if it needs to be carriedon into the subcostal groove. We would not recommend thisas a free flap of choice, but it can be successfully used inthe event of an ICAP flap being inadvertently raised or ifthere is no suitable thoracodorsal perforator.
References
1. Hamdi M, Van Landuyt Y, de Frene B, et al. The versatility of theinter-costal artery perforator flaps. J Plast Reconstruct AesthetSurg 2006;59:644e52.
2. Hamdi M, Van Landuyt K, Blondeel P, et al. Autologous breastaugmentation with the lateral intercostal artery perforator flapin massive weight loss patients. J Plast Reconstruct AesthetSurg; 2007 Nov 26 [Epub ahead of print].
3. Guerra AB, Metzinger SE, Lund KM, et al. The thoracodorsalartery perforator Flap: clinical experience and anatomic studywith emphasis on harvest techniques. Plast Reconstr Surg 2004;114:32e41.
