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LETTERS

The Sensate Medial Dorsal Intercostal Artery Perforator Flap as an Option for Treatment of Dorsal Cervicothoracic Midline Defects

Weum, Sven M.D.; de Weerd, Louis M.D.

Author Information
Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 1122-1124
doi: 10.1097/PRS.0b013e3181e3b76d
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Sir:

We read with interest the CME article on chest wall reconstruction by Netscher et al.1 We agree with the authors that regional reconstruction of the posterior trunk can be challenging because of relative inaccessibility for pedicled flaps, exposure of bone or orthopedic hardware, infection, and loss of function.

Traditionally, muscle or musculocutaneous flaps have been used to treat posterior midline defects in the cervicothoracic area. These flaps provide well-vascularized tissue for the treatment of infection, to fill dead space, and cover bone and orthopedic hardware. Although perforator flaps have become increasingly popular, the authors mention only the distant musculocutaneous perforator flaps for the treatment of defects in the midline. According to the authors, these flaps require a distinct dissection that even can take a transpleural course.

Recently, we reported on the use of a sensate fasciocutaneous perforator flap based on the medial dorsal intercostal artery perforator for the closure of complex dorsal midline defects.2 Our anatomical study revealed that there appeared to be a medial perforator at each intercostal level, although the perforators varied in caliber. We have used flaps based on this perforator to close complex defects in the cervicothoracic midline. This axial flap provided well-vascularized tissue to the area to allow tension-free closure of the defect. The flap was used to cover exposed bone and orthopedic hardware and provided enough volume to fill dead space. By including the cutaneous nerve accompanying the perforator, protective sensibility was obtained as well. The flap sizes ranged from 13 × 4 cm to 16 × 7 cm. The use of this flap is illustrated with a drawing in Figure 1 and a clinical case in Figure 2.

Fig. 1.
Fig. 1.:
The axial perforator flap based on the medial dorsal intercostal artery has its pivot point close to the midline and rotates easily into midline defects.
Fig. 2.
Fig. 2.:
(Left) A 57-year-old man presented with a postoperative wound infection after spinal surgery. After débridement, exposed bone and orthopedic hardware were covered by using a sensate medial dorsal intercostal artery perforator flap (right). The Semmes-Weinstein monofilament test at 6 weeks showed a threshold value of 3.61, indicating that protective sensibility had been obtained.

An experimental study by Guerra et al. showed that there was no statistically significant difference in the results of treatment of deep and superficial infections with a musculocutaneous latissimus dorsi flap and its perforator counterpart.3 The regional perfusion index for both flap types was greater than 0.6, indicating a similar capacity to heal wounds.

We agree with the authors that muscle function preservation at the donor site is important in any reconstruction. One of the main advantages of perforator flaps is their minimal donor-site morbidity, as no muscle is included. With the use of the sensate medial dorsal intercostal artery perforator flap, muscle preservation is obtained. The dissection of this sensate flap with its base at the midline is relatively easy. We would like to draw attention to the possible use of this flap for dorsal midline defects in the cervicothoracic area. In case of failure or recurrence, the more traditional muscle flaps can still be used.

DISCLOSURE

No financial support or benefits have been received by the authors, by any member of their immediate families, or by any individual or entity with whom or with which they have a relationship from any commercial source that is related directly or indirectly to the scientific work reported on in the communication.

Sven Weum, M.D.

Institute of Clinical Medicine

University of Tromsø, and

Department of Radiology

University Hospital North Norway

Louis de Weerd, M.D.

Department of Plastic Surgery and Hand Surgery

University Hospital North Norway

Tromsø, Norway

REFERENCES

1.Netscher DT, Baumholtz MA, Bullocks J. Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk). Plast Reconstr Surg. 2009;124:427e–435e.
2.de Weerd L, Weum S. The sensate medial dorsal intercostal artery perforator flap for closure of cervicothoracic midline defects after spinal surgery: An anatomic study and case reports. Ann Plast Surg. 2009;63:418–421.
3.Guerra AB, Gill PS, Trahan CG, et al. Comparison of bacterial inoculation and transcutaneous oxygen tension in the rabbit S1 perforator and latissimus dorsi musculocutaneous flaps. J Reconstr Microsurg. 2005;21:137–143.

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