The Thoracodorsal Artery Perforator

Flap: Anatomic Basis and Clinical

Application
Christoph Heitmann, MD*
Aldo Guerra, MD†
Stephan W. Metzinger, MD†
L. Scott Levin, MD*
Robert J. Allen, MD†

Based on the dissection of 20 fresh cadavers, the authors have of skin or subcutaneous fat that receives its blood
detailed further the vascular anatomy of the thoracodorsal artery supply from isolated perforator vessels of a
and its cutaneous perforator vessels. The thoracodorsal artery
showed a constant bifurcation into a horizontal branch and a
known source artery.2– 4 If the perforating vessel
lateral branch, located on the deep surface of the latissimus dorsi traverses through muscle to supply the overlying
muscle 4 cm (range, 3– 6 cm) distal to the inferior scapular skin, the flap is classified as a muscle perforator
border and 2.5 cm (range, 1– 4 cm) medial to the lateral free flap, such as the deep inferior epigastric perfora-
margin of the muscle. In 20 specimens there was a total of 64
tor flap, the superior gluteal artery perforator flap,
musculocutaneous perforators larger than 0.5 mm. Thirty-six
perforators (56%) originated from the lateral branch and 28 and the thoracodorsal artery perforator (TDAP)
perforators (44%) originated from the horizontal branch. All flap.5– 8 If the perforator vessel traverses through
perforators originated within a distance of 8 cm from the neuro- septum only to supply the overlying skin, the flap
vascular hilus and ran in proximity with the horizontal or lateral
is named a septal perforator flap, such as the
branches. In 11 dissections (55%) there was also a direct
cutaneous branch originating from the extramuscular course of radial artery perforator flap, the posterior tibial
the thoracodorsal artery before the neurovascular hilus. This artery perforator flap, and the lateral circumflex
cutaneous branch did not pierce the latissimus muscle but femoral artery perforator (anterolateral thigh)
rounded the lateral muscle edge and supplied the overlying flap.9 –11 After these pioneering years the senior
subcutaneous tissue and skin. It is hoped that the constant
anatomy will encourage surgeons in the future to use the thora-
author has experienced interest in and the diffi-
codorsal artery perforator flap more often. culties with one particular muscle perforator
flap—the TDAP flap. Therefore we performed an
Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodor-
sal artery perforator flap: anatomic basis and clinical application. Ann Plast anatomic study to clarify the distribution of the
Surg. 2003;51:23–29
cutaneous perforator vessels of the thoracodorsal
From the *Division of Plastic, Reconstructive, Maxillofacial and Oral
artery as it refers to the design of the TDAP flap.
Surgery, Duke University Medical Center, Durham, NC; and the †Section of
Plastic Surgery, Louisiana State University Health Sciences Center, New
Orleans, LA.
Material and Methods
Received Sep 13, 2002 and in revised form Nov 7, 2002. Accepted for
publication Nov 7, 2002.
Address correspondence and reprint requests to Dr Heitmann, Department
Twenty dissections were carried out on 16 fresh
of Plastic, Reconstructive and Hand Surgery, BG Trauma Center Ludwig- cadavers. In each, the subscapular artery was
shafen, University of Heidelberg, Ludwig Guttman Str. 13, 67071 Lud-
wigshafen, Germany.
cannulated with a 16-Fr Foley catheter, the cir-
cumflex scapular artery was ligated, and the
remaining arterial system was irrigated with nor-
mal saline solution until the venous return was
clear. Twenty milliliters of full-strength Ward’s
Since the clinical success of the deep inferior Colored Latex (Ward’s, Rochester, NY) were then
epigastric artery flap, the whole body was quickly injected under firm manual pressure. The cadav-
screened for other perforator flaps.1 More and ers were then refrigerated at 4°C for 48 hours to
more articles on the use of perforator flaps have allow the latex to consolidate.
been published and, after some confusion result- The cadavers were then positioned with the
ing from the lack of proper terminology, a perfo- ipsilateral arm abducted 90 deg at the shoulder
rator flap was finally defined as a flap consisting and with the elbow in 90 deg of flexion. The tip of

Copyright © 2003 by Lippincott Williams & Wilkins, Inc. 23

Annals of Plastic Surgery Volume 51 / Number 1 / July 2003

Fig 1. (A) Anatomic specimen showing the posterior surface of the latissimus dorsi muscle with the vascular
branching of the thoracodorsal artery that has been injected with blue latex. The thoracodorsal artery starts at the
bottom left, gives off the serratus branch, and then bifurcates into the lateral branch running in line with the
thoracodorsal artery and the horizontal branch running upward. (B) Anatomic specimen after Spalteholz clearing
demonstrating the intramuscular branching of the thoracodorsal artery. The branching pattern follows that of view A.

the scapular as well as the free lateral margin of (range, 2–5 cm) from the edge, and the lateral
the latissimus dorsi muscle were marked and an branch runs parallel to the lateral free border of
incision was made down to the fascia starting at the muscle 2 cm (range, 1– 4 cm) from the lateral
the tendinous insertion toward the iliac crest so margin. Both branches remain basically on the
that the skin overlying the triangular shape of the deep surface of the latissimus dorsi muscle
latissimus was divided in half. From this incision throughout its course (Fig 1). The horizontal
the skin and subcutaneous tissues were elevated branch had an external vessel diameter of 1.1 mm
above the fascia toward the free lateral and upper (range, 0.8 –1.5 mm), and the lateral branch had
margins of the latissimus muscle. All cutaneous an external vessel diameter of 1.0 mm (range,
perforators larger than 0.5 mm were mapped if they 0.8 –1.5 mm). When searching the area overlying
could be followed to the thoracodorsal artery. the latissimus dorsi muscle in 20 specimens there
When measurements of cutaneous perforators were was a total of 64 musculocutaneous perforators
made, the outside diameter at the origin from the larger than 0.5 mm. Thirty-six perforators (56%)
thoracodorsal artery was recorded. Of further inter- originated from the lateral branch and 28 perfo-
est was the branching pattern of the thoracodorsal rators (44%) originated from the horizontal
artery within the latissimus dorsi muscle. There- branch. There was an average of 1.8 perforators
fore one specimen underwent tissue clearing after
(range, 1– 4 perforators) of the lateral branch and
Spalteholz to illustrate the intramuscular branch-
a mean of 1.4 perforators (range, 1–3 perforators)
ing of the thoracodorsal artery.12
of the horizontal branch (Fig 2). Musculocutane-
ous perforators of that size were found only in
Results proximity of the horizontal and lateral branches
within a distance of 8 cm distal to the neurovas-
The thoracodorsal artery entered the deep surface cular hilus. In addition, in 11 dissections (55%)
of the latissimus muscle at a clearly defined there was a direct cutaneous perforator originat-
vascular hilus 2.5 cm (range, 1– 4 cm) medial to ing directly from the thoracodorsal artery proxi-
the lateral edge of the latissimus dorsi muscle mal to the neurovascular hilus. This perforator
and approximately 4 cm (range, 3– 6 cm) distal to made its way around the free lateral border of the
the inferior scapular border. At that point the latissimus dorsi muscle to reach subcutaneous fat
thoracodorsal artery bifurcates. The horizontal and skin (Fig 3). A synopsis of the complete data
branch runs parallel to the superior border 3.5 cm of the 20 dissections is given in the Table.

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 Heitmann et al: The Thoracodorsal Artery Perforator Flap

Fig 2. Anatomic specimen showing two musculocutaneous

perforators of the lateral branch. The main vascular
pedicle and the axilla would be to the right side. Fig 3. Anatomic specimen with the axilla to the right.
The vascular pedicle of the latissimus dorsi muscle is
injected with red latex (artery) and blue latex (veins).
The photograph demonstrates the lateral branch of the
Patient Reports thoracodorsal artery at the lateral free border of the
latissimus dorsi muscle that gives off two
Patient 1 musculocutaneous perforators and one direct cutaneous
A 33-year-old patient sustained a shotgun injury branch that runs in the opposite direction. The direct
branch originates from the extramuscular course of the
to the lower leg that resulted in skin necrosis and
thoracodorsal artery before the bifurcation at the
osteitis of the fibula (Figs 4A, B). After repeated neurovascular hilus.
debridement the area was resurfaced with a free
TDAP flap. The flap was harvested from the
lateral branch of the thoracodorsal artery and had tibial artery (end to side) and on the vena comi-
three musculocutaneous perforator vessels. tans (end to end). Figures 4C, D show the result
Anastomoses were performed on the posterior 18 months after this one-stage reconstruction.

Data of the Thoracodorsal Artery Branching and Cutaneous Perforators in 20 Dissections

Location of Distance to External
the Hilus Muscle Edge Diameter Number of
Direct
(cm) (cm) (mm) Perforators
Cutaneous
No. A B HB LB HB LB HB LB Perforator
1 1 4 4.0 2.0 1,0 1.2 2 1 ⫺
2 3 4 3.0 3.0 0.9 0.9 1 1 ⫹
3 4 6 2.5 1.5 1.2 1.0 2 3 ⫺
4 3 5 4.0 2.5 0.8 0.8 1 1 ⫹
5 3 4 2.0 4.0 1.2 1.5 4 2 ⫹
6 2 4 5.0 2.0 1.5 1.0 2 1 ⫹
7 1 3 3.5 1.5 1.1 0.9 1 1 ⫺
8 4 5 3.0 2.0 0.9 1.2 2 1 ⫺
9 3 4 4.0 1.0 1.2 1.0 2 2 ⫹
10 2 4 3.5 1.5 0.9 0.9 2 2 ⫺
11 2 3 2.5 2.0 1.4 1.0 1 1 ⫹
12 1 3 3.0 3.0 1.0 1.0 3 1 ⫹
13 3 4 4.0 1.0 1.2 1.0 1 1 ⫺
14 3 4 3.5 1.0 1.0 1.0 2 2 ⫺
15 4 5 4.5 2.0 1.2 0.9 2 1 ⫹
16 2 3 4.0 2.5 0.9 1.2 1 1 ⫹
17 2 4 3.0 2.0 1.2 1.0 2 2 ⫹
18 3 4 3.0 1.5 1.0 0.8 2 1 ⫹
19 3 3 3.0 3.0 0.9 1.2 1 1 ⫺
20 2 4 4.0 2.0 1.0 1.0 2 2 ⫺
Averages: 2.5 4 3.5 2 1.1 1.0 1.8 1.4

Abbreviations: A, distance from lateral muscle edge; B, distance from horizontal muscle edge; HB, horizontal branch; LB, lateral branch.

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Annals of Plastic Surgery Volume 51 / Number 1 / July 2003

Fig 4. (A, B) Clinical aspect and

radiograph of the right lower leg 3
months after shotgun injury. (C, D)
Result 18 months after free
thoracodorsal artery perforator flap
transfer.

Patient 2 Discussion
A 28-year-old patient had a chronic elbow wound
after an open fracture caused by a motor vehicle The latissimus dorsi muscle is one of the largest
accident (Fig 5A). There were no local options for muscles in the human body. It is one of the most
wound coverage, and simple skin grafting had versatile and widely used tissue transfers in re-
failed. After radical debridement a TDAP flap constructive surgery. Previous anatomic studies
from the lateral branch of the thoracodorsal artery have elucidated clearly the gross anatomy of the
with two perforator vessels was harvested (Fig latissimus dorsi muscle.13,14 Therefore it is a
5B). Vascular anastomoses were performed to the known fact that the main vascular supply comes
common interosseous artery and a vena comi- from the thoracodorsal vessels, whereas the
tans. The free TDAP flap transfer resulted in lower and medial parts of the latissimus dorsi
stable wound conditions (Fig 5C). muscle are supplied by intercostals and paraspi-

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 Heitmann et al: The Thoracodorsal Artery Perforator Flap

Fig 5. (A) Chronic elbow wound after open fracture.

(B) Intraoperative view showing two
musculocutaneous perforators of the lateral
thoracodorsal artery perforator flap. (C) Result 12
months postoperatively showing stable coverage.

nal vessels. In addition, Tobin and colleagues15 the thoracodorsal vessels, creating an adipocuta-
described a constant branching of the thoracodor- neous flap without sacrifice of the muscle. Angri-
sal vessels in a horizontal and a lateral branch, giani and colleagues,19 among others,20 –23 used
which run on the deep surface of the muscle. the Doppler probe to localize the perforators and
These anatomic findings led to the clinical refine- to determine flap design.
ment of the split latissimus dorsi flap.16 Some We revisited the latissimus dorsi muscle to
authors even proposed to fillet the muscle in a provide a comprehensive synopsis of its anat-
horizontal plane with transfer of just the deep omy. The focus was on cutaneous perforator
segment to reduce bulkiness.17 vessels of the thoracodorsal artery and the goal
A fresh and different approach to address bulk- was to describe a pattern of how they might be
iness of flaps was initiated with the advent of distributed. We found the neurovascular hilus on
perforator flaps. In anatomic studies Taylor and the deep surface of the latissimus dorsi muscle
Palmer18 found 374 cutaneous perforators larger approximately 4 cm distal to the inferior scapular
than 0.5 mm throughout the body, and the sche- border and 2.5 cm medial to the lateral free
matic diagrams revealed five to nine of these border of the latissimus muscle. At that point
perforators in the area of the latissimus dorsi there was a constant bifurcation into a horizontal
muscle. However there were no further details branch and a lateral branch. This is in line with
given regarding the specific location and origin of the findings of Barlett and associates13 and
the perforators. Angrigiani and colleagues19 were Friedrich and coworkers.14 The dissections were
the first who applied the principle of the perfo- then focused on cutaneous perforator vessels
rator flaps to the latissimus dorsi muscle. The overlying the latissimus muscle that could be
perforators were followed through the muscle to traced to the thoracodorsal artery and had a

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Annals of Plastic Surgery Volume 51 / Number 1 / July 2003

References

1 Allen RJ, Heitmann C. The history of perforator flaps.

Handchir Mikrochir Plast Chir. 2003;34:216 –218.
2 Blondeel PN. Debate: the consensus on perforator flap termi-
nology: preliminary definitions. Presented at the Interna-
tional Course on Perforator Flaps. Gent, Belgium. 2001.
3 Giunta R, Geiswald A. Defining perforator flaps: what is
really perforated? Plast Reconstr Surg. 2002;109:1460 –
1461.
4 Wei FC, Jain V, Suominen S, Chen HC. Confusion among
perforator flaps: what is a true perforator flap? Plast
Reconstr Surg. 2001;107:874 – 876.
5 Allen RJ, Treece P. Deep inferior epigastric perforator flap
for breast reconstruction. Ann Plast Surg. 1994;32:32–38.
6 Allen RJ, Tucker C. Superior gluteal artery perforator free
flap for breast reconstruction. Plast Reconstr Surg. 1995;
95:1207–1212.
Fig 6. Drawing illustrating the flap design of the 7 Angrigianni C, Grilli D, Siebert J. Latissimus dorsi muscu-
thoracodorsal artery perforator flap. locutaneous flap without muscle. Plast Reconstr Surg.
1995;96:1608 –1614.
8 Khoobehi K, Allen RJ, Montegut WJ. Thoracodorsal artery
caliber greater than 0.5 mm. We found these perforator flap for reconstruction. South Med J. 1996;89:
S110.
perforators always in proximity to the horizontal 9 Safak T, Akyurek M. Free transfer of the radial forearm
or lateral branch. There were two or more such flap with preservation of the radial artery. Ann Plast Surg.
perforators per latissimus, with a slightly higher 2000;45:97–99.
10 Koshima I, Soeda S. Free posterior tibial perforator-based
percentage originating from the lateral branch. flaps. Ann Plast Surg. 1991;26:284 –288.
All thoracodorsal cutaneous perforators origi- 11 Wei FC, Jain V, Celic N, et al. Have we found an ideal soft
nated within a distance of 8 cm distal to the tissue flap? An experience with 672 anterolateral thigh
flaps. Plast Reconstr Surg. 2002;109:2219 –2230.
neurovascular hilus. In addition there was a 12 Steinke H, Wolff W. A modified Spalteholz technique with
direct cutaneous branch originating from the tho- preservation of the histology. Ann Anat. 2001;183:91–95.
racodorsal artery before the neurovascular hilus 13 Barlett SP, May JW, Yaremchuk MJ. The latissimus dorsi
muscle: a fresh cadaver study of the primary neurovascu-
in 55% of the specimens. This branch was also lar pedicle. Plast Reconstr Surg. 1981;67:631– 636.
described by Cabanie and colleagues24 in 75% of 14 Friedrich W, Herberhold C, Lierse W. Vascularization of
30 cadaveric dissections but remains somewhat the myocutaneous latissimus dorsi flap. Acta Anat. 1988;
131:97–102.
variable in origin. Rowsell and associates25 ob- 15 Tobin GR, Schusterman M, Peterson GH, et al. The intra-
served this direct cutaneous branch in 81% of muscular neurovascular anatomy of the latissimus dorsi
100 cadaveric dissections, but found that it arose muscle: the basis for splitting the flap. Plast Reconstr Surg.
1981;67:637– 641.
from the thoracodorsal artery in only 47%. In the 16 Tobin GR, Moberg AW, DuBou RH, et al. The split latis-
remainder of the specimens it arose from the simus dorsi myocutaneous flap. Ann Plast Surg. 1981;7:
subscapular (27%) and axillary (7%) arteries. 272–280.
17 Rowsell AR, Eisenberg N, Davies DM, Taylor GI. The
This branch does not pierce the latissimus mus- anatomy of the thoracodorsal artery within the latissimus
cle but rounds the lateral edge of the muscle to dorsi muscle. Br J Plast Surg. 1986;39:206 –209.
contribute to the blood supply of the lateral 18 Taylor GI, Palmer JH. The vascular territories (angio-
somes) of the body: experimental study and clinical ap-
thoracic skin and subcutaneous tissue. plications. Br J Plast Surg. 1987;40:113–141.
The results of this anatomic study have a direct 19 Angrigiani C, Grilli D, Siebert J. Latissimus dorsi muscu-
impact on our flap design. We center the skin locutaneous flap without muscle. Plast Reconstr Surg.
1995;96:1608 –1614.
island of the TDAP flap above the free upper or 20 Cavadas PC, Teran–Saavedra PP. Combined latissimus
preferably lateral border of the latissimus dorsi dorsi–thoracodorsal artery perforator free flap: the “razor
muscle (Fig 6). It is crucial to place the skin flap.” J Reconstr Microsurg. 2002;18:29 –31.
21 Kim JT, Koo BS, Kim SK. The thin latissimus dorsi
island rather high to be in the area of the thora- perforator based free flap for resurfacing. Plast Reconstr
codorsal perforators and not the paraspinal and Surg. 2001;107:374 –382.
intercostal perforators. It is hoped that this ana- 22 Koshima I, Saisho H, Kawada S, et al. Flow-through thin
latissimus dorsi perforator flap for repair of soft tissue
tomic study will expand the flexibility and the defects in the legs. Plast Reconstr Surg. 1999;103:1483–
use of the TDAP flap in the future. 1490.

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 Heitmann et al: The Thoracodorsal Artery Perforator Flap

23 Spinelli HM, Fink JA, Muzaffar AR. The latissimus dorsi by means of microvascular surgery. Anat Clin. 1980;2:65–
perforator based fasciocutaneous flap. Ann Plast Surg. 73.
1996;37:500 –506. 25 Rowsell AR, Eisenberg DN, Taylor GI. The anatomy of the
24 Cabanie H, Garbe JF, Guimberteau JC. Anatomical bases of subscapular–thoracodorsal arterial system: study of 100
the thoracodorsal axillary flap with respect to its transfer cadaver dissections. Br J Plast Surg. 1984;37:574 –576.

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