Dorsal intercostal artery perforator flap: anatomical study and clinical applications.
BACKGROUND
The posterior intercostal arteries form the largest angiosome in the torso by means of their many perforators to the skin, the arteries of which are proposed to be the vascular pedicle of an island flap. Using these perforators, the authors developed a new flap, the dorsal intercostal artery perforator flap, harvested in the back.


METHODS
An anatomical study was conducted on five fresh human cadavers injected with a lead oxide-gelatin mixture as a radiopaque agent. The study consisted of the cadaver dissection and the angiographic studies to map the dorsal intercostal artery perforators in detail.


RESULTS
Each of the fourth to twelfth posterior intercostal arteries consistently supplied the dorsal perforators. Those derived from the fourth, fifth, sixth, tenth, and eleventh posterior intercostal arteries were the dominant direct cutaneous perforators. They were located within 5 cm of the spinous processes of the vertebrae and were clinically detectable by Doppler probe preoperatively. Eleven dorsal intercostal artery perforator flaps were applied in 10 cases. In nine cases, the muscles of the latissimus dorsi, the trapezius, or the scapular circumflex artery had been sacrificed in previous operations. The maximum flap dimension was 31 x 13 cm. All flaps showed stable postoperative blood circulation and survived completely, except for marginal necrosis in the largest flap. No functional loss attributable to flap harvest was recognized.


CONCLUSIONS
Flap extendibility and less invasiveness without sacrifice of the underlying muscles have proved that the dorsal intercostal artery perforator flap is a new reconstructive option in the back, where suitable flaps are often proposed.
Minabe
Toshiharu
T
Tokyo, Japan From the Department of Plastic and Reconstructive Surgery, Kyorin University.
Harii
Kiyonori
K
D000328:Adult; D000368:Aged; D001158:Arteries / Q000033:anatomy & histology*; D002102:Cadaver; D018223:Dermatofibrosarcoma / Q000601:surgery*; D005260:Female; D006801:Humans; D007890:Leiomyosarcoma / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D003668:Pressure Ulcer / Q000601:surgery*; D012878:Skin Neoplasms / Q000601:surgery*; D013524:Surgical Flaps / Q000098:blood supply*; D035441:Thoracic Wall / Q000098:blood supply*
Taylor, G. I., and Minabe, T. The angiosomes of the mammals and other vertebrates. Plast. Reconstr. Surg. 89: 181, 1992.
Rees, M. J. W., and Taylor, G. I. A simplified lead oxide cadaver injection technique. Plast. Reconstr. Surg. 77: 141, 1986.
Nakajima, H., Minabe, T., and Imanishi, N. Three-dimensional analysis and classification of arteries in the skin and subcutaneous adipofascial tissue by computer graphics imaging. Plast. Reconstr. Surg. 102: 748, 1998.
Nakajima, H., Fujino, T., and Adachi, S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann. Plast. Surg. 16: 1, 1986.
Taylor, G. I., and Palmer, J. H. The vascular territories (angiosomes) of the human body: Experimental study and clinical applications. Br. J. Plast. Surg. 40: 113, 1987.
Hallock, G. G. Direct and indirect perforator flaps: The history and the controversy. Plast. Reconstr. Surg. 111: 855, 2003.
Blondeel, P. N., Van Landuyt, K. H. I., Monstrey, S. J. M., et al. The “Gent” consensus on perforator flap terminology: Preliminary definitions. Plast. Reconstr. Surg. 112: 1378, 2003.
Daniel, R. K., and Taylor, G. I. Distant transfer of an island flap by microvascular anastomoses. Plast. Reconstr. Surg. 52: 111, 1973.
Harii, K., Omori, K., and Omori, S. Successful clinical transfer of ten free flaps by microvascular anastomoses. Plast. Reconstr. Surg. 53: 259, 1974.
Omori, K., and Harii, K. Free groin flaps: Their vascular basis. Plast. Reconstr. Surg. 28: 238, 1975.
Taylor, G. I., and Daniel, R. K. The anatomy of several free flap donor sites. Plast. Reconstr. Surg. 56: 243, 1975.
Mathes, S. J., and Nahai, F. Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis: Mosby, 1982.
Koshima, I., and Soeda, S. Inferior epigastric artery skin flap without rectus abdominis muscle. Br. J. Plast. Surg. 42: 645, 1989.
Daniel, R. K., Kerrigan, C. L., and Gard, D. A. The great potential of the intercostal flap for torso reconstruction. Plast. Reconstr. Surg. 58: 653, 1978.
Kerrigan, C. L., and Daniel, R. K. The intercostal flap: An anatomical and hemodynamic approach. Ann. Plast. Surg. 2: 411, 1979.
Cormack, C. G., and Lamberty, B. G. H. The Arterial Anatomy of Skin Flaps, 2nd Ed. London: Churchill Livingstone, 1994. Pp. 150–165.
Callgari, P. R., Taylor, G. I., Caddy, M. C., and Minabe, T. An anatomic review of the delay phenomenon: I. Experimental studies. Plast. Reconstr. Surg. 89: 397, 1992.
Taylor, G. I., Doyle, M., and McCarten, G. The Doppler probe for planning flaps: Anatomical study and clinical applications. Br. J. Plast. Surg. 43: 1, 1990.
Wei, F. C., and Mardini, S. Free-style free flaps. Plast. Reconstr. Surg. 114: 910, 2004.