Initial Temporary Congestion in Latissimus Dorsi or Thoracodorsal Perforator Flaps

Temporary flow disturbance has been observed in perforator flap reconstruction as a phenomenon of initial flap congestion. This initial temporary congestion is considered to be an adaptation to new flow redistribution through the narrow perforator pedicle, overcoming the flow overload by expanding its own angiosome. Its clinical course is quite variable, from mild congestion to marginal necrosis. Sometimes, the vascular pedicle of the perforator flap is spastic, and temporary ischemic changes of the flap are also observed. Even though such congestion or ischemia are not serious enough to cause flap failure, several maneuvers during flap elevation have been considered to prevent these conditions.

Initial temporary congestion was observed in the latissimus dorsi perforator flap (11.9%) and thoracodorsal perforator flap (14.3%). To prevent it, a T-anastomosis can be considered for flow balance with dispersion. Inclusion of an additional perforator as a pedicle can also be done, such as using two musculocutaneous perforators or two septocutaneous perforators. If available, another vein can be prepared apart from the main pedicle for venous supercharge, especially in extraordinarily long perforator flaps. Inclusion of a small portion of muscle can be another option in a large or inappropriately long flap. More frequent irrigation of vasodilators is required during the operation, and the application of a warm temperature to the flap may be helpful after surgery. Such congestion should be distinguished from the congestion related to vascular insufficiency under a monitoring system.

Initial temporary congestion in perforator flaps can occur according to the reliability or diameter of the perforator selected, and it depends on flap size and pedicle length. Therefore, appropriate selection of a reliable perforator and sophisticated dissection of the pedicle are requisite for successful reconstruction with the perforator flap. Vasodilators, an appropriate position of the reconstructed site, and local heating can be helpful to prevent congestion after operation. Selection of a reliable perforator is important to the successful fabrication of a large perforator flap (> 10 cm in diameter).