Efficacy of the pedicle trapezius muscle flap for the multisurgical removal of pediatric posterior fossa anaplastic ependymoma.

OBJECTIVE: Exceedingly refractory, pediatric anaplastic ependymoma in many cases requires multisurgical removal. The high risk of poor wound healing and CSF leakage especially at the posterior fossa make this tumor difficult to treat. CASE: A 9-year-old girl has had 4th ventricular anaplastic ependymoma since the age of 3. She experienced tumor removal 8 times including 4 posterior fossa craniotomies because tumors were disseminated not only to the posterior fossa but also to the cerebral hemispheres. She also underwent a dermal graft using a free flap. She experienced CSF leaks and meningitis frequently because the wound healing was poor. We performed a dermal flap closure using a pedicle trapezius muscle flap with a plastic surgeon when we performed the 5th tumor removal. RESULT: We achieved complete wound closure in spite of broad deficiencies in subcutaneous and epidermal tissues. After that, recurrences of posterior fossa tumors presented within a short term, and tumor removal via an incision of a pedicle trapezius muscle flap was performed without recurrence of CSF leaks and meningitis. DISCUSSION AND CONCLUSION: For the first time, we are able to report on the efficacy of using the pedicle trapezius muscle flap for multisurgical removal of pediatric posterior fossa anaplastic ependymoma. The muscle flap was found to be effective because of the multiple surgeries expected, and the pedicle trapezius muscle flap was found to be resilient to multiple surgical procedures. Although advantageous, the dorsal scapular artery which is required for flap creation is actually difficult to harvest. Compared to a flee flap, the pedicle trapezius muscle flap maintains vascular supply. Furthermore, this technique has the possibility of being applied to defective dura mater closure that cannot be watertight due to multiple surgeries. However, it is very important to inform the patient's family not only about the improved efficacy of surgery, but also to raise awareness on consequential cosmetic issues.

Anatomical study of the latissimus dorsi muscle flap / Estudio anatómico del colgajo del músculo latísimo del dorso

SUMMARY: The latissimus dorsi is a broad muscle that originates from the inferior thoracic spinous processes, thoracolumbar fascia, iliac crest, and inferior ribs. It inserts on the inferior aspect of the intertubercular groove of the humerus through a thin tendon. The study was conducted on 10 cadavers (7 male and 3 female). These specimens were dissected and examined to study the gross anatomical characteristics of the latissimus dorsi muscle. The dimensions of the latissimus dorsi muscle and its surface area were measured in all the cadavers. The branching pattern of the thoracodorsal vessels was recorded. The pedicle length and caliper were measured using Vernier calipers. On the 20 dissected sides, the thoracodorsal artery was found to be one of the terminal branches of the subscapular artery that originates in the axillary region. In 19 (95 %) cases, the thoracodorsal artery terminated in a bifurcation, giving off a medial and a lateral branch. The average size of the elevated flap of the latissimus dorsi muscle was 18 cm x 36 cm. The average pedicle length was 9.5 cm (range: 5 cm-14 cm), and the average diameter at its origin was 2.5 mm (range: 1.5 mm-3.5 mm). The average diameter of the vena comitans was 3.3 mm. The current study focuses on the anatomical features of the latissimus dorsi muscle and its blood supply to increase the success rate of operations in clinical practice.

RESUMEN: El músculo latísimo del dorso se origina en los procesos espinosos de las vértebras torácicas inferiores, la fascia toracolumbar, la cresta ilíaca y las costillas inferiores y se inserta en el surco intertubercular del húmero a través de un delgado tendón. El estudio se realizó en 10 cadáveres (7 mujeres y 3 hombres). Estos especímenes fueron disecados y examinados para estudiar las características anatómicas macroscópicas del músculo latísimo del dorso. En todos los cadáveres se midieron las dimensiones del músculo y su superficie. Se registró el patrón de ramificación de los vasos toracodorsales. La longitud del pedículo y el calibre se midieron con paquímetro Vernier. En los veinte lados disecados, se encontró que la arteria toracodorsal era una de las ramas terminales de la arteria subescapular que se originaba en la región axilar. En 19 (95 %) casos, la arteria toracodorsal terminaba bifurcándose en dos ramas, una rama medial y otra lateral. El tamaño promedio del colgajo elevado del músculo latísimo del dorso era de 18 cm x 36 cm. La longitud promedio del pedículo era de 9,5 cm (rango: 5 cm-14 cm), y el diámetro promedio en su origen era de 2,5 mm (rango: 1,5 mm-3,5 mm). El diámetro medio de la vena comitans era de 3,3 mm. El estudio actual se centra en las características anatómicas del músculo latísimo del dorso y su irrigación para aumentar la tasa de éxito de las operaciones en la práctica clínica.

Propeller and Pre-expanded Propeller Use of a Transversely Oriented Upper Trapezius Perforator Flap in Head and Neck Reconstruction: Clinical Experience and Review of Vascular Anatomy of the Supraspinal Trapezius Muscle.

Conventionally, trapezius musculocutaneous flap is raised to harbour perforators located inferior to the scapular spine (i.e. 'lower trapezius flap'). In this clinical study, we aimed to use trapezius perforators located superior to the scapular spine to raise a transversely oriented propeller fasciocutaneous flap based on the superficial cervical artery to reconstruct head and neck defects. Patients with head and neck defects who underwent reconstruction with a propeller trapezius perforator flap between August 2014 and October 2019 were evaluated. Demographic data of the patients, topographic data on defects and the flaps were analysed. A total of 14 patients underwent reconstruction with upper trapezius perforator flap with equal gender distribution. Defects were due to tumour resections, burn contractures and exposed foreign materials; located in occipital, temporal, parietal, midfacial and cervical areas; with sizes ranging between 8 × 7 cm and 22 × 19 cm. Overall patient satisfaction was assessed subjectively using a pre-determined set of questions. The sizes of the flaps ranged between 15 × 8 cm - 20 × 9 cm in non-expanded and 26 × 15 cm - 30 × 16 cm in expanded cases. One flap suffered distal superficial flap loss, which was treated with wound care. Follow up period of the patients ranged between 3 and 40 months with an average of 29 months. Using trapezius perforators located above the scapular spine provides thin transversely oriented propeller flaps to be used in head and neck reconstruction. In our series, this flap is further enhanced by pre-expansion for wider uses, e.g. facial resurfacing and releasing neck contractures.

Effects of Transcatheter Arterial Microembolization on Persistent Trapezius Myalgia Refractory to Conservative Treatment.

PURPOSE: To evaluate the safety and efficacy of transcatheter arterial microembolization for patients with trapezius myalgia. MATERIALS AND METHODS: We retrospectively evaluated the prospectively collected data of patients with trapezius myalgia for > 6 months who were refractory to conservative treatment and were treated by transcatheter arterial microembolization between October 2017 and January 2019. Transcatheter arterial microembolization was performed using imipenem/cilastatin on the vessels of the transverse cervical artery, suprascapular artery, and circumflex scapular artery according to the region of pain. RESULTS: Forty-two patients were treated by transcatheter arterial microembolization and followed up for 6 months. No major adverse events occurred related to the procedures. The brief pain inventory worst pain scores significantly improved at 1, 2, 3, and 6 months after transcatheter arterial microembolization (8.6 ± 1.3 (before procedure) vs. 5.1 ± 2.9, 4.4 ± 2.9, 4.1 ± 2.8, and 3.9 ± 2.9, respectively, P < 0.001). The brief pain inventory pain interference scores, including general activity, mood, walking ability, normal work, relations with others, sleep, and enjoyment of life, also significantly decreased at 1, 2, 3, and 6 months after transcatheter arterial microembolization compared to those at baseline (all P < 0.01). The clinical success rate at 6 months after transcatheter arterial microembolization was 71.4% (95% confidence interval, 55.4-84.3%). CONCLUSION: Transcatheter arterial microembolization is a safe and effective treatment for persistent trapezius myalgia. Further evaluation with a control group is needed to confirm the effects of transcatheter arterial microembolization. LEVEL OF EVIDENCE: Level 4, Case Series.

Relationship between trapezius muscle hardness and transverse cervical artery flow in association with neck and upper-back stiffness.

Neck and upper-back stiffness is a common discomfort encountered occasionally in daily life among otherwise healthy subjects. The pathogenesis of this condition could be attributable to increased tension in muscles such as the trapezius muscle (TM). The transverse cervical artery (TCA) is one of the feeding arteries for the TM, and TCA flow is reportedly related to symptoms of neck and upper-back stiffness. This study quantitatively investigated relationships between TM hardness and TCA hemodynamics as evaluated on Doppler sonography. Questionnaires regarding neck and upper-back stiffness, muscle hardness measurements obtained using a muscle hardness meter and examinations of TCA hemodynamics using Doppler sonography were performed on 55 healthy young adults (25 males, 30 females; mean age, 22 ± 2 years). Subjects displaying neck and upper-back stiffness actually exhibited high muscle hardness (median, 14.0; interquartile range (IQR), 12.9-18.0) compared to those without the symptom (median, 12.0; IQR, 9.9-14.0; p = .002). Peak systolic velocity in the TCA on Doppler sonography was lower in subjects with the symptom (median, 65.1 cm/s; IQR 59.6-72.5 cm/s) than in those without the symptom (median, 72.5 cm/s; IQR 66.5-84.2 cm/s; p = .012). Resistive index in the TCA was high (r2  = .605, p = .014) with increasing TM hardness, particularly among male subjects with the symptom. The present study suggests that high resistance and low blood flow velocity in the TCA could be closely associated with the underlying pathogenesis of neck and upper-back stiffness.

Correlation between blood flow, tissue volume and microvessel density in the flap.

The purpose of this study was to assess the correlation between tissue volume and blood flow of the flap in an animal model. Using animal model, tissue volume can be attenuated, and precise change of blood flow could be evaluated. We further investigate the relationship between blood flow and vascular density in the tissue. In this study, we assessed flap conductance (ml/min/mm Hg) as to evaluate the conductivity of blood flow into the flap. Japanese white rabbit was used (n = 7) for this study. The amount of blood flow of jejunal and latissimus dorsi muscle (LD) flaps was measured while removing the distal portion of the flap sequentially. Conductance at each time was calculated from blood pressure and blood flow volume. The tissue volume at each time was also measured. The correlation between conductance and volume was analyzed using a linear mixed model. Immunohistochemical evaluation of microvessel densities (MVD) in these tissues was also performed for CD31/PECAM1 positive area. Conductance and tissue volume were significantly correlated in both jejunal and LD flaps. As the volume increases by 1 cm3, the conductance increased significantly by 0.012 ml/min/mm Hg in jejunum, and by 0.0047 ml/min/mm Hg in LD. Mean MVD was 1.15 ± 0.52% in the jejunum and 0.37 ± 0.29% in the LD muscle. In this study, we revealed that flap conductance is proportional to volume and proportional constant is different between the type of tissue. It suggests that the difference of MVD creates the unique conductance of each tissue.

Discomfort glare and psychological stress during computer work: subjective responses and associations between neck pain and trapezius muscle blood flow.

PURPOSE: Exposure to additional environmental stress during computer work, such as visual and psychological demands, is associated with increased eye and neck discomfort, altered moods, and reduced well-being. The aim of this study is to elucidate further how subjective responses in healthy, young females with normal binocular vision are affected by glare and psychological stress during computer work, and to investigate possible associations between trapezius muscle blood flow and neck pain development. METHODS: 43 females participated in a laboratory experiment with a within-subject design. Four 10-min computer work conditions with exposure to different stressors were performed at an ergonomically optimal workstation, under the following series of conditions: no additional stress, visual stress (induced as direct glare from a large glare source), psychological stress, and combined visual and psychological stress. Before and immediately after each computer work condition, questionnaires regarding different visual and eye symptoms, neck and shoulder symptoms, positive and negative state moods, perceived task difficulty, and perceived ambient lighting were completed. Associations between neck pain and trapezius muscle blood flow were also investigated. RESULTS: Exposure to direct glare induced greater development of visual/eye symptoms and discomfort, while psychological stress exposure made participants feel more negative and stressed. The perception of work lighting during glare exposure was closely related to perceived stress, and associations between visual discomfort and eyestrain, and neck pain were observed in all conditions. Furthermore, participants with high trapezius muscle blood flow overall reported more neck pain, independent of exposure. CONCLUSIONS: Exposure to visual and psychological stresses during computer work affects the development of symptoms and negative moods in healthy, young females with normal binocular vision, but in different ways. The results also demonstrate the complex interactions involved in symptom development and lighting appraisal during computer work. When optimizing computer workstations, the complexity of the field must be taken into account, and several factors, including visual conditions, must be considered carefully.

Beneficial Effect of U-74389 G and Sildenafil in An Experimental Model of Flap Ischemia/Reperfusion Injury in Swine. Histological and Biochemical Evaluation of the Model.

Purpose of the study: Tissue reconstruction after burns, tumor excisions, infections or injuries is a frequent surgical challenge to avoid Ischemia-reperfusion injury. Lazaroids and sildenafil, through their mechanisms of action, have been studied for their protective effects on various organs subjected to IRI. In this study, we aimed to evaluate the therapeutic potential of U-74389G and sildenafil in a swine model of ischemia and reperfusion injury of latissimus dorsi flap. Materials and methods: Forty-two Landrace male pigs, weighing 28-35 kg, were equally (n = 6) randomized into the following groups: (a) Group I: control, (b) Group II: administration of U-74389G after ischemia, (c) Group III: administration of sildenafil after ischemia, (d) Group IV: administration of U-74389G and sildenafil after ischemia, (e) Group V: administration of U-74389G prior to ischemia, (f) Group VI: administration of sildenafil prior to ischemia, and (g) Group VII: administration of U-74389G and sildenafil prior to ischemia. Blood and tissue sampling was conducted before ischemia, 15 and 30 min after occlusion, 30, 60, 90, and 120 min after reperfusion. Results: Statistically significant reduction (p < 0.05) was detected in lymphocytes and polymorphonuclear leukocytes concentrations as well as in the appearance of edema after histopathologic evaluation of the ischemic tissue, especially in the groups of combined treatment. Measurements of malondialdeyde and tumour necrosis factor alpha in tissues revealed a significant decrease (p < 0.001) of these markers in the treatment groups when compared to the control, particularly in the latest estimated timepoints. Conclusions: The synergistic action of U-74389G and sildenafil seems protective and promising in cases of flap IRI during tissue reconstruction surgery.

Reverse-supercharged, distally based latissimus dorsi flap for lumbar defect: A case report.

Well-vascularized tissue is required for successful reconstruction of a soft tissue defect in the lumbar region. There are several options for reconstruction; however, controversy exists regarding the optimal technique. Here, we present a case of a lumbar defect following tumor resection in a 75-year-old patient that was repaired using a reverse-supercharged, distally based latissimus dorsi flap. The defect of size 15 × 12 cm2 was localized to the lumbar region. An 11 × 7 cm2 -sized, distally based latissimus dorsi flap was designed cephalad to the latissimus dorsi muscle. After the flap was tunneled to the defect, vascular insufficiency of the skin flap was observed. Supercharging was subsequently performed by anastomosing the serratus anterior branch in a reverse manner to the lumbar perforator. The diameters of the vessels at the end-to-end anastomosis site were 1.0 mm (artery) and 1.2 mm (vein), respectively, and there was slight discrepancy in their calibers. After microvascular anastomosis, the vascular supply of the flap improved, and the flap survived uneventfully, without venous congestion. The patient was discharged 17 days after the surgery, and no recurrence of the tumor was observed at the 2-year follow-up. We report a case of successful salvage of a distally based latissimus dorsi flap by the reverse-supercharge technique based on a serratus anterior branch. This flap might be a suitable alternative for use in the lumbar region in the case of limited availability of reconstructive choices.

The reverse latissimus dorsi flap: An anatomical study and retrospective analysis of its clinical application.

The segmental paraspinous and intercostal blood vessels form the blood supply and represent the pivot point for the reverse latissimus dorsi flap. Aim of this study was to confirm the exact location of the blood supply and the most caudal pivot point to assess the suitability of the reverse latissimus dorsi flap for pedicled reconstructions of the trunk as well as sacral area. Our study comprised a human cadaver study, where 30 latissimus dorsi flaps were assessed in 15 specimens, and a clinical study with 49 patients who underwent distally based latissimus dorsi flap reconstructions in our division. 74% of all perforators were located in a bilateral 7 cm broad area, which spread from the 6th intercostal space to the subcostal plane. In a second clinical part of this study we evaluated forty-nine patients, who underwent reconstruction with the reverse latissimus dorsi flap. We demonstrated that the pivot point can also be planned below the 12th rib, thus reaching tissue defects in the sacral area. To the best of our knowledge, this is the first study to define a caudal "hotspot" for the safest blood supply of the reverse latissimus dorsi flap.

[Harvesting method of thoracodorsal perforator flap: Adaptation]. / Technique de prélèvement d'un lambeau perforant thoracodorsal : mise au point.

The thoracodorsal artery perforator (TDAP) flap is a reliable method of reconstruction by which the indications were on a constant rise during the last few years. Several surgical variants exist and different harvesting techniques were described. However, with our experience using this flap for substance-loss coverage, we frequently faced a complex and relatively time-consuming pedicle dissection. This brought us to adapt our harvesting technique according to the anatomical situations of the neighboring structures. The purpose of this study is to revisit and adapt the method of the pedicle dissection for the TDAP flap. The conservation of both the nervous network and a section of a circumferential muscular collar with a diameter of two centimeters are the main keys of our study.

A new propeller trapezius muscle flap for reconstruction of posterior trunk defects: An anatomic study and report of three cases.

BACKGROUND: Reconstruction of complex back defects, especially after corrective spine surgery, is a challenging problem. In these patients hardware issues predominate and flap failure has serious consequences. Certain subunits of the back pose even greater problems, specifically the central region between T9 and T12. The purpose of this article is to present a novel technique for reconstruction of such spinal defects using a newly described trapezius muscle propeller flap based on the dorsal scapular vessels. METHODS: Four cadaveric trapezius muscle propeller flaps were raised to ensure appropriate rotation into central region of the posterior trunk between T9 and T12. Three patients all had similar presentations with a history of scoliosis, previous failed spinal instrumentation, prominent hardware, impending exposure, worsening kyphosis, and back pain. The patients underwent planned extension fusions from the upper thoracic to lumbar vertebrae by orthopedic surgery. All three patients lacked local reconstructive options and propeller trapezius muscle flaps were dissected. RESULTS: All cadaveric dissections demonstrated adequate rotation of the muscle flap without tension or kinking of the vascular pedicle. For the case studies, two patients had right sided trapezius flaps utilized, one patient had injury to the right dorsal scapular vessels during dissection, thus a left sided trapezius was rotated. One patient had complications including a seroma requiring aspiration and superficial wound breakdown. All had complete healing with no postoperative shoulder dysfunction noted. CONCLUSION: As a result, the trapezius muscle propeller flap is found to be a novel flap that provides a simple, yet robust solution to an otherwise difficult reconstructive problem.

Pedicled Thoracodorsal Artery Perforator and Muscle-Sparing Latissimus Dorsi Flaps in the Axillary Reconstruction After Hidradenitis Suppurativa Excision: Functional and Aesthetic Issues.

BACKGROUND: Wide axillary reconstruction after hidradenitis suppurativa (HS) excision still represents a great challenge. Thoracodorsal artery perforator flap is one of the most reliable local reconstructive techniques. Although its anatomy and harvesting technique have been well described, specific reconstructive criteria still lack. The aim of this study was to help surgeons in planning axillary reconstruction on flaps based on the thoracodorsal artery. METHODS: Twelve patients affected by HS at Hurley stage III underwent wide "en block" excision and immediate reconstruction with 15 local thoracodorsal artery perforator flaps and 2 muscle-sparing latissimus dorsi flaps. A thorough chart review has been performed with preoperative and postoperative photographic documentations. Early and late complications have been analyzed. RESULTS: A total of 15 perforator flaps on thoracodorsal artery and 2 muscle-sparing latissimus dorsi flaps have been raised. The early complication rate was 29%, whereas the late complication rate was 35%. Except for one, all patients declared they were satisfied or highly satisfied from both aesthetic and functional points of view. Analyzing specific aspects, we have described several important details to consider for the reconstruction of the axilla. Through a retrospective analysis, we have classified HS axillary patients into 4 categories to better plan surgical reconstruction. CONCLUSIONS: Axillary reconstruction is still a plastic surgery challenge. Peculiar surgical details should be considered when approaching this area. This new classification may help young surgeons during the reconstructive phase.

The Spider Limb Positioner in subscapular system free flaps.

BACKGROUND: The subscapular system is a versatile vascular network that can provide multiple flaps for reconstruction of the head and neck. A significant drawback of using the subscapular system is that patient positioning can preclude the use of simultaneous two-team ablative and reconstructive surgery. Herein, we describe a novel use of an upper extremity limb positioner (Spider Limb Positioner) used primarily in orthopedic surgery to facilitate concurrent two-team technique in head and neck surgery. METHODS: Using a bean bag and the Spider Limb Positioner for the upper extremity, a semidecubitus position was used for subscapular donor site dissection. Ablative and reconstructive teams worked concurrently in all cases. RESULTS: This technique was utilized 78 times on 73 patients, with chimeric flaps used in 38% of cases. The average operative time was 466 min. Only one patient required repositioning intraoperatively due to a change in the subscapular donor site side. There were no nerve compression injuries or positioning related complications. CONCLUSION: Scapular and parascapular free flaps are useful tools for reconstruction of the head and neck. In a two-team approach, the use of a semidecubitus position in conjunction with the Spider Limb Positioner facilitates exposure for the reconstructive team without compromising access for the ablative team.

Trapezius perforator flaps: anatomical basis using 58 dissections.

INTRODUCTION: The trapezius muscle is a good option for soft tissue defects in the cervical and thoracic regions. However, pedicled flaps raised from perforators in the trapezius are rare. Through a series of cadaver dissections, the authors aim to map the perforating arteries in the trapezius muscle. MATERIALS AND METHODS: Dissection of 58 anatomical regions in 32 cadavers was carried out. The perforating arteries of the trapezius were inventoried based on their location, dimensions and frequency using the scapular spine and spinous process line as landmarks. RESULTS: In 78% of cases, the main perforators of the trapezius were located along two vertical lines parallel to the spinous process line, 5-6 cm on either side of it, between the scapular spine laterally, the tip of the scapula caudally and the superior margin of the trapezius cranially. On each side of the spinous process line, we found an average of 16 perforators (range 5-27) with an average diameter of 0.6 mm (range 0.1-2.6 mm). CONCLUSION: Our study shows that surgeons can use fixed landmarks when developing trapezius perforator flaps.

Use of a Vertical Muscle-Sparing Latissimus Dorsi Flap in Implant-Based Breast Reconstruction Without Position Change.

BACKGROUND: The use of various latissimus dorsi (LD) flap types in combination with implants is a safe and reliable 1-stage breast reconstruction method. However, 1 or more positional changes are generally required during the procedure. We designed a vertical skin paddle that was centered along the midaxillary line and harvested the required LD muscle amount based on the thoracodorsal artery descending branch, thereby completing flap elevation, inset, and donor-site closure in the supine position following skin-sparing mastectomy. METHODS: Between July 2017 and September 2017, we enrolled patients who underwent breast reconstruction using the vertical muscle-sparing LD (ms-LD) flap with an implant. The vertical ms-LD flap was selected when the nipple-areolar complex could not be spared or when adjuvant radiation therapy was anticipated. RESULTS: Eleven patients were enrolled in the study. All patients underwent skin-sparing mastectomy (with excision of the nipple-areolar complex for oncological reason). The mean mastectomy specimen weight was 402.3 g. The average flap length and width were 15.2 and 5.5 cm, respectively. The mean implant size was 290 mL. The average operative time was 112 minutes. All surgical procedures were performed in the supine position, and the flap reached the most medial part of the breast without any tension in all cases. The mean follow-up length was 87 days, and no complications such as infection, partial flap loss, or donor-site seroma were observed. CONCLUSIONS: Vertical ms-LD flaps can be harvested and utilized in direct-to-implant reconstructions when a skin paddle (or banking) is required, or when acellular dermal matrix use is precluded, or when additional soft tissue coverage is mandatory in high-risk patients not requiring intraoperative position changes. This technique can shorten the operation time and may reduce donor-site morbidity and associated complications.

Design of Mini Latissimus Dorsi Flap Based on Thoracodorsal Vascular Patterns.

INTRODUCTION: Latissimus dorsi (LD) flap has been used for reconstructive purposes in oncoplastic breast surgery. Using large part of the muscle as a flap leads to a residual functional loss. Muscle sparing and mini LD flaps can be used with no functional sequelae. However, the design of such flap presents a challenge. METHODS: Twenty cadavers were dissected on both sides to identify the different vascular patterns of the thoracodorsal (TD) pedicle. The vessels were counted, and the following measurements were taken: diameter, length, distance from inferior angel of scapula, and vertebral level. Data were collected and entered into the personal computer. Statistical analysis was done using (SPSS/version 20) software. RESULTS: Five vascular patterns of TD pedicle were found. Type 1: a long vertically descending pedicle giving 3 to 4 transverse medial branches to LD in 40%. Type 2: a short pedicle terminating into 1 to 2 serratus anterior collaterals and 1 to 2 transverse lateral branches to LD in 10%. Type 3: a long vertically descending pedicle giving 2 to 3 small lateral branches to upper part of LD and terminating into medial and lateral branches in the lower part of LD in 10%. Type 4: a short pedicle that gives 4 to 5 terminal branches to LD, one of them is a long vertically descending branch to lower part of LD in 20%. Type 5: a short pedicle that terminates into a transverse medial and a long vertical branch to LD in 20%. CONCLUSION: The classically described pattern of TD pedicle (type 5) was found in 20% of cases, whereas the most commonly found pattern was type 1. This means that the pattern of TD branching is unpredictable, and a preoperative ultrasound is essential to define the existing pattern and plan the best LD flap design for each patient. In types 1 and 5, the flap can be designed using the transverse medial branch or branches. In type 2, one of the lateral transverse branches can be used. In types 3, 4, and 5, the long descending vertical branch can be used. It has a sizeable diameter (1.80.23 mm), length (12.31.64 cm), and can be located 6.50.96 cm below the inferior angle of scapula.

A rare case of atypical thoracodorsal artery: a challenge for flap reconstruction.

The thoracodorsal artery mainly supplies the latissimus dorsi muscle. Anatomical details pertaining to the origin and distribution of thoracodorsal artery are important because the latissimus dorsi myocutaneous flap is one of the most reliable and versatile flaps used in reconstructive surgery. Atypical origin and course of the thoracodorsal artery is, therefore, a challenge for flap reconstruction surgeries. In the present case, we report multiple variations in the branching pattern of axillary artery. The thoracodorsal artery had an unusual origin from the second part of axillary artery. The trunk of thoracoacromial artery was absent. The thoracodorsal artery after its origin, descended downwards over the lateral pectoral region lying deep to pectoralis minor but superficial to teres major muscles. It terminated by supplying the latissimus dorsi muscle. Due to the presence of atypical thoracodorsal branch, the subscapular artery continued as the circumflex scapular artery.