Regional flaps for axillary reconstruction: Indications and algorithm

Regional flaps for axillary reconstruction: Indications and algorithm

Karim Khalil El-Lamie, MD

Department of Plastic  Surgery, Ain Shams University, Cairo, Egypt. Correspondence:

Assistant  professor in plastic surgery department, Ain Shams University.

Address: 3 Beyrouni  street, Heliopolis, Cairo, Egypt. Phone number: 202 4183038

E.mail:  dr_ karimlamie@}wtmail.com

Abstract

For the past three decades, works concerning axillary reconstruction were merely dedicated to axillary hidradenitis  suppurativa. Other causes were neglected and many techniques were introduced to treat just the affected zone. Axillary reconstruction after major burn contracture can be complex necessitating the transfer of large area of skin to adequately resurface the whole axilla. In this article, 13 patients were operated upon for either major axillary contracture or for hidradenitis suppurativa. Three regional flaps were used on the 13 patients: the thoracodorsal artery perforator (TAP) flap, the scapular flap and the latissimus dorsi myocutaneous flap. The number of flaps performed was 15 in the 13 patients. The choice of the flap was dictated by the degree of scarring of the axilla and the adjacent skin. All flaps survived and an algorithm is suggested for the reconstruction of the axilla  based on the extent of axillary damage  and affection of adjacent tissues.

Key  words: Axillary  reconstruction,  hidradenitis  suppurativa,  thoracodorsal  artery perforator (TAP) flap, scapular flap, latissimus dorsi myocutaneous flap, axillary contractures, regional flaps for axillary reconstruction.

Introduction:

Axillary  reconstruction  has  been overlooked in literature for the past three decades. Several factors contributed to the paucity of works about such a subject.  First of all, the axilla itself is a groove bounded by two folds formed mainly by pectoralis major anteriorly and latissimus dorsi posteriorly.! These two muscles  as  well as the  humerus laterally offer good protection to the axillary contents which makes any accidental trauma to the axillary soft tissue a rare casualty. By the same talking, major bums of the chest involving the axillary skin are usually treated by   simple   procedures   like  skin   grafting, Z-plasties  or  small  local  flaps.2   Moreover,

axillary  hidradenitis  suppurativa,  despite being  a  common  pathology  the  disease  is rarely cited in literature. Adequate surgical excision  of the whole  affected  area  is necessary to avoid recurrence.3 Some forms of V-Y advancement  flaps either random or based on unnamed perforators were described to reconstruct the resulting defect.4-6 Those works   offer   solutions   to   minor   form   of axillary reconstruction  yet in cases of major affection of the axillary skin larger flaps are needed  for resurfacing  the  whole  armpit in order to ensure full mobility of the shoulder joint.

In this article, three flaps: the thoracodorsal artery perforator flap, the scapular flap and the

latissimus dorsi myocutaneous flap, are used to  reconstruct  major  axillary  defects.7-9 All three flaps are based on well known reliable vascular  pedicles  so that  a large amount of skin can be safely transferred.

Patients and methods:

A   total    of   fifteen   flaps    in   thirteen cases (8 females and 5 males) of axillary reconstruction  were performed by the author between   November   2010   and  July   2012. The age  ranged from  5 to  28 years  with a mean of 15. Eleven patients suffered from severe   unilateral   axillary   contracture   due to  extensive  long  standing  bums  affecting both the anterior and posterior axillary folds. Shoulder   abduction   less  than  90  degrees, which was an essential inclusion criterion in the study, necessitated total release of axillary skin   and   both  folds.   Two  male   patients suffered from chronic bilateral axillary hidradenitis suppurativa which failed all medical treatment.   The thoracodorsal  artery perforator (TAP) flap was used in four burned patients. The scapular flap was used in five burned patients and the latissimus dorsi myocutaneous flap was performed in two patients. The two patients with hidradenitis suppurativa had bilateral affection of both axillae and received 4 scapular flaps. Awritten consent  was taken from each  patient before the operation  according to the regulations of Ain Shams Medical School research ethics committee. The patients were evaluated early postoperatively before discharge and 6 months postoperatively. Subjective evaluation was concerned with the flap thickness, the axillary contour and donor site scar and extent of arm abduction. Documentation was done by pre­ and postoperative digital photography.

Surgical technique:

The patient's axillary hair if present is shaved  the  night  before  the  operation  and a topical antibiotic cream is applied after shaving and on the morning ofthe operation. The patient is placed in a lateral decubitus position with the hand tied to the operating table behind the patient's head to ensure maximal   shoulder  abduction   position.   For

patients presenting with axillary contracture, the  bands  are  completely  released  and  the hand position is readjusted to ensure that the shoulder can reach full abduction. In case of hidradenitis   suppurativa,   the  axillary  skin and all the underlying subcutaneous tissues including the  affected swollen  lymph  nodes are  completely   removed   and  the  axillary vessels are visualized and their branches are preserved.  For the first  postoperative  week, all 13 patients were kept under observation with the arm abducted  90  degrees to  avoid any pressure on the vascular pedicle.

The thoracodorsal artery perforator (TAP)

flap:

The TAP flap  is used  when the scarring of the skin overlying the latissimus dorsi muscle just adjacent to the axilla is minimal and  superficial.   Such  scarring  should  not extend more than 2-3cm beyond the posterior axillary line. These criteria ensure that the subdermal plexus which is very important for the blood supply  of the flap is not affected. The  main   and  first   perforator   is  usually located at lOcm from axillary apex (just 1-2 em below the neurovascular hilum of the muscle).  A second  perforator  can  be found at 2-3cm  below  the first one. After release of the axillary contracture the thoracodorsal vessels  are followed  along  their  length  till the point of entry into the latissimus dorsi muscle. The thoracodorsal  nerve is dissected free from the vessels  at the hilum. The skin and subcutaneous tissue are raised anteriorly with  utmost  care  from  the  latissimus  dorsi until   the   perforator   is  located.   The  skin territory reaches Scm above this point and extends 15cm below with an axis parallel to the anterior border of the muscle. The width ofthe flap is lOcm beginning 2cm in front of the anterior border of the latissimus muscle. The flap is then incised superiorly, posteriorly and inferiorly and raised completely from the underlying muscle except from the area 2cm around the perforator. A small cuff of muscle about 2cm2 can be taken around the perforator after leaving the thoracodorsal nerve attached to the muscle.  The skin flap  is now rotated

180 degrees into the axillary defect with the

shoulder being fully abducted. Direct closure of donor site of more than 8cm is usually hard to  achieve  and  three  cases  required  a skin graft over part of the muscle Figure(l).

The scapular flap:

The scapular flap is the ideal flap for axillary reconstruction  especially  if the back skin  adjacent  to  the  posterior  axillary  fold is markedly affected. The length of the flap extends from the posterior axillary line to the midline of the back ranging between 26 and

28cm in adults. The width of the flap can reach

12cm and the resultant  defect can be closed primarily in all patients. The vascular pedicle is the  scapular  artery  which  is a branch  of the circumflex  scapular artery after entering the triangular space. This space is formed by the long head of triceps medially teres major inferiorly and teres minor superiorly. The triangular fossa can be located at distance D1 in centimeter using the equation D1= (D -1)/2, where D is the distance between the middle part ofthe spine and the tip of the scapula.

The triangular fossa can be located at distance D1 in centimeter using the equation Dl = (D -1)/2, where Dis the distance between the middle part of the spine and the tip of the scapula. Figuer(2).

The flap is designed as an ellipse oriented horizontally with the medial quarter of the ellipse  being  centered   over  the  triangular fossa. The upper and lower border of the marked ellipse are incised and the dissection proceeds from the midline of the back toward the pedicle in a subfascial plane until entering the space bounded by the teres major and minor. The artery is visualized and dissected within the space. The rest of the flap border overlying the long head of triceps and the latissimus  dorsi  is  continued  and  now  the flap is free to be rotated 120° into the axillary defect Figure(3).

The latissimus dorsi myocutaneous flap

The reach of the previous two cutaneous flaps is limited  by the  length of the  pedicle and such flaps  designed  as an ellipse  have the maximal width when rotated in the midaxillary  line. This flap  is mainly  useful for   defects   affecting  the  anterior   axillary

fold  and adjacent skin over the chest where the widest part of the ellipse can be centered mainly along the anterior axillary line. Although  the  vascular  pedicle  is the  same as that of the TAP flap the use of the muscle as vehicle to transfer  distant normal skin of the back  is the main  advantage  of this  flap over the perforator version. The ellipse is incised and the remaining skin of the back is elevated  from  the  latissimus  muscle  which is then separated from its origin along the lumbar fascia and vertebrae. After dissecting the thoracodorsal  vessels,  the  latissimus tendon is cut and the thoracodorsal  nerve is severed to decrease the bulk of the flap. The flap is rotated and inset with the muscle edges sutured along the undermined  borders of the defect Figure(4).

Results:

Three well vascularized regional flaps: the thoracodorsal  artery perforator (TAP) flap, scapular fasciocutaneous  flap and latissimus dorsi  myocutaneous  flap  were  used in  this study   to   reconstruct    axillary   defects   in

13 patients. Of these patients eleven had unilateral postbum contractures  and two had bilateral   chronic   hidradenitis   suppurativa. In all, the indication for surgery was either limitation of arm abduction to less than 90 degrees or severe acneiform suppurativa axillary nodules which failed medical treatment.  The  TAP flap  was  performed  in

4 patients. The scapular flap was used in 7 patients  with  2  receiving  bilateral  scapular flaps  for  hidradenitis  suppurativa.  Two patients were operated by the latissimus dorsi myocutaneous flap.

Recovery was uneventful in all cases. All patients  had full  range of arm abduction  at

6  months  postoperative  follow-up.  Despite the  relatively  bulky  reconstruction  with the

2 latissimus  dorsi  myocutaneous  flaps  and one case of scapular flap, all patients were satisfied with outcome and did not ask for additional procedures. All donor sites were closed primarily except in three cases of TAP flap which necessitated skin grafting.

Figure (1): A. A22 year-old female patient with post-burn contracted axilla. B. The TAP flap dissected and a small cuff of the latissimus muscle held by the forceps is harvested with the flap for safety. C.3 months- postoperative result showing complete release of the axilla. Part of the donor site was closed by split thickness skin graft.

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Figure (2): The measurement procedure: The triangular fossa is located at distance D1 in centimeter using the equation D J= (D -1)12, where Dis the distance between the middle part of the spine and the tip of the scapula. S, scapular branch; P, parascapular branch.

Figure (3): A. A 30- year old male patient with extensive axillary hidradenitis suppurativa. B. Complete excision of the left axillary skin and subcutaneous tissue including the affected swollen lymph nodes and reconstruction by scapular flap 25xllem. C. 8 months postoperative view after reconstruction of the two axillae by scapular flaps. The flap on the right axilla measured 28 xl2cm. D. Dorsal view after donor sites direct closure.

Figure (4): A.  A 24 year-oldfomale patient showing long standing post-burn contracted left axilla with main affection to the anterior axillary fold and deltopectoral region.  B. The drawing of the latissimus dorsi myocutaneous flap with the skin paddle (15 xl0 em) marked on the lower back. The (x) on the upper back delineates the site of entry of the vascular pedicle into the muscle. C. Intraoperative view of the left axilla after the release and the inset of the flap. D. 2 months postoperative  view

Axillary defect

Sk;n defect related ma;n

Axillary fol d and the deltopectoral region

Skin defecf'related  mainly to the central part of the axilla

Latissimus dorsi myocutaneous flap                                 Skin over the anterior border of the latissimus muscle

Not or minimally affected                 Heavily affected

Thoracodorsal artery perforator (TAP) flap                              Scapula r flap

Figure (5): Algorithm for reconstruction of axillary defects.

Table (1): The clinical daJa and donor site closure.

Discussion:

Works dedicated to axillary reconstruction are usually centered on some local random flaps  or free  style  perforator  flaps.4,5,6,10,ll The  main  causes  of axillary  reconstruction are post bum  contracture,  axillary skin affection by tumor metastasis and hidradenitis suppurativa. The latter is a chronic acneiform infection ofthe cutaneous apocrine glands that also can involve adjacent subcutaneous tissue and fascia.9   The  condition  is  characterized by swollen, painful, inflamed lesions in the axilla, groin and other parts of the body that contain  apocrine  glands.  Surgical  removal of the involved area is the most effective treatment particularly among chronically affected  patients.  The  type  of  surgical excisions is important since inadequate excision  is the major cause of recurrence.l3

The affected part is better treated like a tumor with removal of the all abnormal skin, the underlying  subcutaneous  tissues  as  well  as the swollen lymph nodes. Post bum axillary contracture may involve one or both axillary folds, the entire axilla or may extend into adjacent  areas. Local  flaps  like Z-plasty  or V-Y plasty  may  be  used for  reconstruction of  minor  defects  but  scarring  of  the  base may  jeopardize  circulation  resulting  in flap

necrosis. 14 Different  techniques   have  been

described  for  reconstruction  of  axillary defects.  The  three  flaps  used  in this  study are  all  reliable  and  versatile.  However  the use  of each  is  determined  by the  cause  of the   reconstruction   and   condition   of   the axilla and its surrounding tissues. Therefore an algorithm is suggested to tailor the reconstruction according to each situation Figure(5).

The scapular flap has been first described by Sajio and further refined by dos Santos.l5,8

Since   then   it  was   described   as  tool  for axillary   reconstruction.    The   introduction of   thoracodorsal   artery   perforator   (TAP) flap  added  another  tool  of  reconstruction.7

Despite the fact that the territory  of the flap is  quite  similar  to  that  of  the  parascapular flap,    immediate    flap    thinning    was    a main advantage of this method over the conventional       fasciocutaneous       vers10n.

However it was found  difficult to close the flap  donor site defects exceeding  more than

8cm in width due to tightness of tissues along the lateral thoracic region. Inability to locate a  sizable  perforator  was  also  reported  by some  authors.l6  Recently  other flaps  based on unnamed perforators have been described and were used to reconstruct axillary defects either in rotation or V-Y fashion.l 7,18 However, an intact  subdermal  plexus  is  essential  for complete flap survival of any perforator flap. This may not  be always  a constant  finding in extensive  bums. If the back skin adjacent to  the   posterior   axillary   line  is   severely affected it would be wise to choose another reconstructive  modality.  Moreover  in  some situations of extensive bum contractures, the maximum tissue deficiency is mainly located along the anterior axillary line and the adjacent shoulder and chest skin. Both of these flaps are inefficient in resurfacing such defects. The scapular flap pedicle location limits its reach to the anterior axillary line with a maximum width of the flap in this region ranging from

5-6cm. The TAP flap despite its reach to this region cannot provide adequate tissue to the deltopectoral  region without compromise  to the rest of axillary skin during flap inset being itself a part of the posterior axillary fold. The use of latissimus dorsi muscle as a vehicle to transfer more distal and normal back skin is advantageous in such situations. The muscle is tunneled  underneath the  normal posterior axillary skin while the skin island comes to fit through the more anteriorly located defect. The flap is an indispensible  armamentarium in  axillary  reconstruction   despite  the  bulk of tissues transferred.  The thickness of the composite flap can be reduced by cutting the thoracodorsal nerve and thereby inducing atrophy ofthe muscle.

In this study, the author evaluated the use of  three  different  regional  flaps  for  major axillary   reconstruction.   The  thoracodorsal artery  perforator  (TAP) flap  being thin  and just adjacent to the axilla was promoted  by other surgeons as the best solution. Although considered  a modification  of the  latissimus dorsi myocutaneous  flap, the TAP flap could not  replace the  latter  in its reach  when  the