Elzawawy Ehab Mostafa, Kelada Melad Naim, Al Karmouty Ahmed Farouk
From the Department of Anatomy and Embryology, Faculty of Medicine, and.
Department of Breast Surgery, Medical Research Institute, University of Alexandria, Egypt.
Ann Plast Surg. 2018 Jun;80(6):607-615. doi: 10.1097/SAP.0000000000001403.
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.
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.
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%.
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.
背阔肌（LD）皮瓣已用于肿瘤整形乳房手术的重建目的。将大部分肌肉用作皮瓣会导致残余功能丧失。保留肌肉的背阔肌皮瓣和微型背阔肌皮瓣使用后无功能后遗症。然而，这种皮瓣的设计具有挑战性。
对20具尸体的双侧进行解剖，以确定胸背（TD）蒂的不同血管模式。对血管进行计数，并进行以下测量：直径、长度、距肩胛下角的距离和椎体水平。收集数据并输入个人计算机。使用（SPSS/20版）软件进行统计分析。
发现TD蒂有五种血管模式。1型：长垂直下行蒂，40%的情况下向背阔肌发出3至4条横向内侧分支。2型：短蒂，在10%的情况下终止为1至2条前锯肌侧支和1至2条背阔肌横向外侧分支。3型：长垂直下行蒂，在10%的情况下向上部背阔肌发出2至3条小外侧分支，并在下部背阔肌处终止为内侧和外侧分支。4型：短蒂，在20%的情况下向背阔肌发出4至5条终末分支，其中一条是长垂直下行至下部背阔肌的分支。5型：短蒂，在20%的情况下终止为横向内侧分支和一条长垂直分支至背阔肌。
经典描述的TD蒂模式（5型）在20%的病例中发现，而最常见的模式是1型。这意味着TD分支模式不可预测，术前超声对于确定现有模式并为每位患者规划最佳背阔肌皮瓣设计至关重要。在1型和5型中，可使用横向内侧分支设计皮瓣。在2型中，可使用其中一条横向外侧分支。在3型、4型和5型中，可使用长下行垂直分支。它具有相当大的直径（1.8±0.23mm）、长度（12.3±1.64cm），且可位于肩胛下角下方6.5±0.96cm处。
