title: Inclusion of extra perforators--a single and efficient measure to prevent vascular insufficiency in unreliable thoracodorsal artery perforator flaps.
abstract: BACKGROUND
  The purpose of the study is to establish a clearly defined principle to prevent the vascular insufficiency of thoracodorsal artery perforator flaps, including the criteria to identify unreliable flaps and the measure to improve their viability.
  
  
  METHODS
  The whole project comprised the preliminary study and the major study. In the preliminary study of 42 patients, the intrinsic risk factors associated with the vascular insufficiency of flaps were identified. Using colour Doppler scanning, the linear correlation between colour signal width and external diameter of perforators was demonstrated. Based on the findings, the principle to prevent vascular insufficiency of flaps was established which involved two steps. First was introducing the inclusion criteria to identify the unreliable flaps. Second was including extra perforators as the single measure to improve the viability of unreliable flaps. The principle was applied in the major study of 50 patients to prove its efficacy.
  
  
  RESULTS
  In the major study, flap viability was not compromised in the 35 patients without any of the inclusion criteria. At least one of the inclusion criteria was met in the other 15 patients. Three of the 15 unreliable flaps sustained vascular insufficiency. In one patient, only single small-sized perforator was available to support the flap. The principle was disobeyed in the other two patients because of the intertwined relation, and their less dominant perforators were cut to spare the intertwined motor nerves. The rate of compromised flap viability was 2.1% in the 48 patients with complete execution of the principle in comparison with the 16.7% rate in the preliminary study.
  
  
  CONCLUSIONS
  The inclusion criteria are useful to identify unreliable thoracodorsal artery perforator flaps. Inclusion of extra perforators is a single and efficient measure to prevent vascular insufficiency of unreliable flaps.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Cheng-Ta
authors.initials: CT
authors.lastname: Lin
authors.forename: Lee-Wei
authors.initials: LW
authors.lastname: Chen
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000517:prevention & control*; D011379:Prognosis; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013348:Subclavian Artery / Q000601:surgery*; D013524:Surgical Flaps / Q000098:blood supply*; D018615:Ultrasonography, Doppler, Color; D014652:Vascular Diseases / Q000000981:diagnostic imaging / Q000517:prevention & control*; D055815:Young Adult