Thoracodorsal artery perforator (TAP) type I V–Y advancement flap in axillary hidradenitis suppurativa

doi:10.1016/j.bjps.2004.10.022

British Journal of Plastic Surgery

Volume 58, Issue 4, June 2005, Pages 441-444

https://doi.org/10.1016/j.bjps.2004.10.022 Get rights and content

Summary

Hidradenitis suppurativa is a chronic debilitating disease. Surgical removal of all apocrine glands in the affected region is the definitive treatment. The resulting wound may either be left to heal secondarily or closed primarily. Secondary healing in the axilla may cause contractures and stiffening of the shoulder. Primary healing requires direct closure, split-skin grafting or local flap application. Direct closure is associated with a high incidence of recurrence compared to skin grafting or flaps. Local flap cover is the ideal method of wound closure after excision of the glands. We have used a thoracodorsal artery perforator (TAP) V–Y advancement flap (type I) to achieve closure as a single-stage procedure successfully in four cases. It is a single stage procedure capable of closing large axillary defects whilst preserving the axillary contour.

Section snippets

Method

With the patient in the lateral position and the ipsilateral arm abducted at 90°, 2–3 perforators along the anterior border of the latissimus dorsi were located using a hand-held Doppler device. The vascular territory encompasses a quadrilateral area (Fig. 1) bordered superiorly by the third rib, inferiorly by the seventh rib, posteriorly by the lateral scapular border and anteriorly by the mid-axillary line.¹⁴ A single V–Y advancement flap based on the marked out musculo-cutaneous perforators

Case 1

A 51-year-old woman who was diabetic, hypertensive and a smoker presented with a seven history of recurrent abscesses in the right axilla. After excision of hair-bearing skin, the defect was closed with a TAP V–Y advancement flap. She was discharged within 2 days post-operatively and was given peri-operative antibiotics for a week.

Case 2

A 36-year-old woman who was a smoker presented with bilateral axillary and groin abscesses for 12 years, resistant to antibiotic treatment. The lesion on the left was

Discussion

Several different types of advancement and transposition flaps for reconstruction after excision of axillary hidradenitis have already been described.3, 7 We describe a simple convenient and reliable flap to preserve form and function. Niranjan et al. have described two techniques, the lateral perforator based V–Y advancement flap⁹ and the double-opposing V–Y advancement flap based on the posterior arm and the lateral chest wall perforators.¹ However, the narrow vascular pedicle and the

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Cited by (49)

Operative Techniques for Hidradenitis Suppurativa
2022, A Comprehensive Guide to Hidradenitis Suppurativa
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease. Treatment consists of conservative and surgical therapy options. In Hurley stages II and III, surgical intervention is regarded as the method of choice for areas with irreversible tissue destruction. The indication for surgical resection generally is reserved for irreversible tissue destruction in those that do not respond to anti-inflammatory medications. The choice of resection technique depends on patient characteristics such as age, comorbidities, localization, and size of destructed tissue. Localized areas in Hurley stages I and II can be removed with limited excisions and/or deroofing, whereas more scarred, fibrotic tissue with fistulas in Hurley stages II often needs radical excision. Although various resection techniques with different grades of invasiveness have been described in the literature, there is still no accepted general concept. Resection is, therefore, often planned individually in each patient. The same is true regarding the question of wound management and/or reconstruction of defects after tissue removal.
Surgical management of hidradenitis suppurativa with keystone perforator island flap
2020, Injury
Citation Excerpt :
Recently was described a systematic review by Mehdizadeh et al [15], where the postoperative recurrence rates were 15% for primary closure, 8% for skin flaps, and 6% for skin grafting. Local flaps, including transposition Limberg flaps, rotation flaps, or V-Y advancement flaps have been described as an excellent method of coverage after wide local excision of hidradenitis suppurativa of the axilla, and provide both sufficient coverage and good color matches [16–19]. However, their limited mobilization capacity makes these flaps inadequate for the reconstruction of larger defects.
Hidradenitis suppurativa is a chronic, relapsing disease of the skin, characterized by apocrine gland and pilosebaceous complex infections, causing recurrent superficial nodules and abscesses, fistula formation, scarring and fibrosis. It is accepted that wide local excision and local coverage is the crucial treatment to prevent recurrence of the disease.
All patients presenting for surgical treatment of hidradenitis suppurativa between 2014 and 2019 were identified from the hospital database. Only patients with hidradenitis suppurativa confined to the axillary, inguinal or sacrococcygeal regions in Hurley grade II and III were included. A total of 21 patients (11 male, 10 female) aged between 21 and 76 years were evaluated retrospectively. All of the 22 defects were reconstructed with keystone perforator island flap following wide local excision. We performed descriptive analysis of demographic data, comorbidities, topographic distribution of lesions, Hurley scoring, size of defect, specific type of reconstruction, complications, follow-up period, recurrences.
21 patients with localized axillary, inguinal or sacrococcygeal hidradenitis suppurativa were identified, and 22 keystone perforator island flaps were performed. All keystone perforator island flaps survived giving a durable cover to the affected regions. There were no complications. Functional and aesthetic results were satisfactory and there were no recurrences.
These findings confirm that the keystone perforator island flap procedure can be effective for immediate defect reconstruction after wide local excision of advanced hidradenitis suppurativa of the axillary, inguinal and sacrococcygeal regions and provides excellent aesthetic results.
Surgical Procedures in Hidradenitis Suppurativa
2016, Dermatologic Clinics
The versatility of the islanded posterior arm flap for regional reconstruction around the axilla
2015, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
More sophisticated flaps with a pedicle-oriented approach allow for easier flap rotation and inset. Pedicled perforator flaps such as the thoracodorsal artery perforator flap (TDAP) or the lateral thoracic fasciocutaneous island flap have recently been introduced as a new alternative for axillary defect coverage.3,8–11 Besides requiring side positioning of the patient for flap elevation a much more tedious flap dissection is needed, thus prolonging surgery.
Defects in the region of the axilla pose a difficult reconstructive problem. Various methods for restoration have been described. We present our experience with the islanded posterior arm flap for regional reconstruction around the axilla.
Between 2008 and 2013, all patients receiving a posterior arm flap for regional reconstruction around the axilla were entered in a prospectively maintained database. Patient data, surgical details, complications and the need for revisional procedures were recorded.
In the study period, 35 posterior arm flaps were used in 24 patients (f:m = 11:13; mean age at surgery: 41,3 ± 18,5 years; 11 bilateral procedures) with defects predominately due to hidradenitis suppurativa (n = 31). The remaining indications included tumor resection (n = 2), burn contracture release or thoracic surgery (n = 1 each). The majority of defects were located at the axilla, but also in the proximal upper arm or the adjacent thoracic wall. Major wound complications such as total or partial flap necrosis were not encountered in our series. Minor complications included partial superficial wound dehiscence (n = 4) and superficial wound infection (n = 1), all of which were managed conservatively. In 4 patients a secondary flap trimming procedure was required.
In our hands, the posterior arm flap is an excellent choice for axillary reconstruction due to its constant anatomy, robust vascularity, unrivaled freedom of flap insetting, excellent recipient site matching and favorable donor site morbidity. Besides axillary defects, the posterior arm flap may additionally be employed for defects of the adjacent thoracic wall or the proximal two thirds of the upper arm.
Application of the inner arm perforator flap in the management of axillary hidradenitis suppurativa
2014, Annales de Chirurgie Plastique Esthetique
Citation Excerpt :
Shoulder movement can be resumed soon after the surgery (in contrast to skin grafting). Compared with posterior arm [22], scapular [23], pectoralis major flaps [24], the thoracodorsal artery perforator flap [25] and the lateral thoracic fasciocutanous island flap [26], the donor site is well hidden when the upper limb rests along the chest wall. Furthermore, it provides excellent contour and texture matching whilst maintaining the axillary fold.
Axillary hidradenitis suppurativa is a chronic and debilitating disease that primarily affects the axillae, perineum, and inframammary areas. Surgical removal of all the diseased skin constitutes the only efficient treatment. Covering an axillary fossa defect is challenging, due to the range of shoulder movement required. Indeed, shoulder movement may be compromised by scar contraction after inadequate surgery. The present study is the first to apply an inner arm perforator flap to the treatment of twelve axillary skin defects in 10 patients. The defect originated from extensive excision of recurrent hidradenitis suppurativa in the axilla. The technique used to cover the defect is a V-Y advancement flap or a propeller flap from the inner arm based on one to three perforators arising from the brachial artery or the superior ulnar collateral artery. The flap provides a tensionless wound closure and a generally unremarkable postoperative course in a short hospital stay. No major complications occurred. Two patients had minor delayed wound healing. Outcomes (including donor site morbidity, function and the cosmetic outcome) were very satisfactory in all cases. We consider that the inner arm perforator flap is a valuable new option for the reconstruction of axillary defects.
L’hidrosadénite est une pathologie qui peut se révéler très handicapante. Elle peut toucher les régions axillaires, périnéales et sous-mammaires. L’ablation chirurgicale des zones atteintes reste le seul traitement radical. Cependant, la couverture de la perte de substance engendrée, en particulier en région axillaire, reste difficile à cause de l’impact fonctionnel et esthétique. Ce travail présente l’utilisation de 12 lambeaux perforants de face médiale de bras chez 10 patients. Dans cette indication, le lambeau perforant peut être disséqué soit en hélice, soit en avancement V-Y, vascularisé par 1 à 3 perforantes de l’artère brachiale ou de l’artère collatérale ulnaire supérieure. Ce lambeau permet une fermeture directe sans tension de première intention permettant une hospitalisation et une cicatrisation de courte durée. Par ailleurs aucune complication notable n’a été observée. Pour nous, ce lambeau a une place de choix dans la prise en charge des reconstructions du creux axillaire.
Clinical application of the thoracodorsal artery perforator flaps
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Thoracodorsal artery perforator (TAP) flaps without latissimus dorsi muscle – have been used for reconstruction of the extremities, head and neck as free style flaps, and as pedicled flaps for reconstruction of the chest wall and axillary wounds. This retrospective study aimed to analyse the clinical applications and relevant anatomic findings of TAP flaps.
From April 2007 to August 2011, 67 free or pedicled TAP flaps were transferred in 67 patients for reconstruction of wounds of the extremities, chest wall and axilla. Eight were used as free flaps for reconstruction of extremities, and 59 used as pedicled flaps for reconstruction of axillary or chest wounds. Patient ages ranged from 7 to 55 years (26.04 ± 12.83). Perforator arteries were detected and identified with a hand-held Doppler. The size of flaps ranged from 6 by 9 to 14 by 18 cm ((8.66 ± 2.05) by (12.62 ± 2.03)). Flaps were designed with the perforator artery included, with all flaps based on one or two perforator arteries.
All of the flaps survived. There were no problems with vascular spasm or occlusion. Significant venous congestion was not observed in any of the cases. Two cases developed minor wound dehiscence but healed with conservative therapy. None of the donor sites developed seromas.
The thoracodorsal artery flap without associated latissimus dorsi muscle can provide a thin, large and reliable flap with robust blood supply. The TAP flap can significantly reduce donor site morbidity.

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Thoracodorsal artery perforator (TAP) type I V–Y advancement flap in axillary hidradenitis suppurativa

Summary

Section snippets

Method

Case 1

Case 2

Discussion

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg