The Thoracodorsal Artery Perforator
Flap: Anatomic Basis and Clinical
Based on the dissection of 20 fresh cadavers, the authors have
detailed further the vascular anatomy of the thoracodorsal artery
and its cutaneous perforator vessels. The thoracodorsal artery
showed a constant bifurcation into a horizontal branch and a
lateral branch, located on the deep surface of the latissimus dorsi
muscle 4 cm (range, 3– 6 cm) distal to the inferior scapular
border and 2.5 cm (range, 1– 4 cm) medial to the lateral free
margin of the muscle. In 20 specimens there was a total of 64
musculocutaneous perforators larger than 0.5 mm. Thirty-six
perforators (56%) originated from the lateral branch and 28
perforators (44%) originated from the horizontal branch. All
perforators originated within a distance of 8 cm from the neuro-
vascular hilus and ran in proximity with the horizontal or lateral
branches. In 11 dissections (55%) there was also a direct
cutaneous branch originating from the extramuscular course of
the thoracodorsal artery before the neurovascular hilus. This
cutaneous branch did not pierce the latissimus muscle but
rounded the lateral muscle edge and supplied the overlying
subcutaneous tissue and skin. It is hoped that the constant
anatomy will encourage surgeons in the future to use the thora-
codorsal artery perforator flap more often.
Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodor-
sal artery perforator flap: anatomic basis and clinical application. Ann Plast
Surg. 2003;51:23–29
From the *Division of Plastic, Reconstructive, Maxillofacial and Oral
Surgery, Duke University Medical Center, Durham, NC; and the †Section of
Plastic Surgery, Louisiana State University Health Sciences Center, New
Orleans, LA.
Received Sep 13, 2002 and in revised form Nov 7, 2002. Accepted for
publication Nov 7, 2002.
Address correspondence and reprint requests to Dr Heitmann, Department
of Plastic, Reconstructive and Hand Surgery, BG Trauma Center Ludwig-
shafen, University of Heidelberg, Ludwig Guttman Str. 13, 67071 Lud-
wigshafen, Germany.
Since the clinical success of the deep inferior
epigastric artery flap, the whole body was quickly
screened for other perforator flaps.1 More and
more articles on the use of perforator flaps have
been published and, after some confusion result-
ing from the lack of proper terminology, a perfo-
rator flap was finally defined as a flap consisting
Copyright © 2003 by Lippincott Williams & Wilkins, Inc.
Application
Christoph Heitmann, MD*
Aldo Guerra, MD†
Stephan W. Metzinger, MD†
L. Scott Levin, MD*
Robert J. Allen, MD†
of skin or subcutaneous fat that receives its blood
supply from isolated perforator vessels of a
known source artery.2– 4 If the perforating vessel
traverses through muscle to supply the overlying
skin, the flap is classified as a muscle perforator
flap, such as the deep inferior epigastric perfora-
tor flap, the superior gluteal artery perforator flap,
and the thoracodorsal artery perforator (TDAP)
flap.5– 8 If the perforator vessel traverses through
septum only to supply the overlying skin, the flap
is named a septal perforator flap, such as the
radial artery perforator flap, the posterior tibial
artery perforator flap, and the lateral circumflex
femoral artery perforator (anterolateral thigh)
flap.9 –11 After these pioneering years the senior
author has experienced interest in and the diffi-
culties with one particular muscle perforator
flap—the TDAP flap. Therefore we performed an
anatomic study to clarify the distribution of the
cutaneous perforator vessels of the thoracodorsal
artery as it refers to the design of the TDAP flap.
Material and Methods
Twenty dissections were carried out on 16 fresh
cadavers. In each, the subscapular artery was
cannulated with a 16-Fr Foley catheter, the cir-
cumflex scapular artery was ligated, and the
remaining arterial system was irrigated with nor-
mal saline solution until the venous return was
clear. Twenty milliliters of full-strength Ward’s
Colored Latex (Ward’s, Rochester, NY) were then
injected under firm manual pressure. The cadav-
ers were then refrigerated at 4°C for 48 hours to
allow the latex to consolidate.
The cadavers were then positioned with the
ipsilateral arm abducted 90 deg at the shoulder
and with the elbow in 90 deg of flexion. The tip of
23
Annals of Plastic Surgery Volume 51 / Number 1 / July 2003

Fig 1. (A) Anatomic specimen showing the posterior surface of the latissimus dorsi muscle with the vascular
branching of the thoracodorsal artery that has been injected with blue latex. The thoracodorsal artery starts at the
bottom left, gives off the serratus branch, and then bifurcates into the lateral branch running in line with the
thoracodorsal artery and the horizontal branch running upward. (B) Anatomic specimen after Spalteholz clearing
demonstrating the intramuscular branching of the thoracodorsal artery. The branching pattern follows that of view A.

the scapular as well as the free lateral margin of
the latissimus dorsi muscle were marked and an
incision was made down to the fascia starting at
the tendinous insertion toward the iliac crest so
that the skin overlying the triangular shape of the
latissimus was divided in half. From this incision
the skin and subcutaneous tissues were elevated
above the fascia toward the free lateral and upper
margins of the latissimus muscle. All cutaneous
perforators larger than 0.5 mm were mapped if they
could be followed to the thoracodorsal artery.
When measurements of cutaneous perforators were
made, the outside diameter at the origin from the
thoracodorsal artery was recorded. Of further inter-
est was the branching pattern of the thoracodorsal
artery within the latissimus dorsi muscle. There-
fore one specimen underwent tissue clearing after
Spalteholz to illustrate the intramuscular branch-
ing of the thoracodorsal artery.12
Results
The thoracodorsal artery entered the deep surface
of the latissimus muscle at a clearly defined
vascular hilus 2.5 cm (range, 1– 4 cm) medial to
the lateral edge of the latissimus dorsi muscle
and approximately 4 cm (range, 3– 6 cm) distal to
the inferior scapular border. At that point the
thoracodorsal artery bifurcates. The horizontal
branch runs parallel to the superior border 3.5 cm
(range, 2–5 cm) from the edge, and the lateral
branch runs parallel to the lateral free border of
the muscle 2 cm (range, 1– 4 cm) from the lateral
margin. Both branches remain basically on the
deep surface of the latissimus dorsi muscle
throughout its course (Fig 1). The horizontal
branch had an external vessel diameter of 1.1 mm
(range, 0.8 –1.5 mm), and the lateral branch had
an external vessel diameter of 1.0 mm (range,
0.8 –1.5 mm). When searching the area overlying
the latissimus dorsi muscle in 20 specimens there
was a total of 64 musculocutaneous perforators
larger than 0.5 mm. Thirty-six perforators (56%)
originated from the lateral branch and 28 perfo-
rators (44%) originated from the horizontal
branch. There was an average of 1.8 perforators
(range, 1– 4 perforators) of the lateral branch and
a mean of 1.4 perforators (range, 1–3 perforators)
of the horizontal branch (Fig 2). Musculocutane-
ous perforators of that size were found only in
proximity of the horizontal and lateral branches
within a distance of 8 cm distal to the neurovas-
cular hilus. In addition, in 11 dissections (55%)
there was a direct cutaneous perforator originat-
ing directly from the thoracodorsal artery proxi-
mal to the neurovascular hilus. This perforator
made its way around the free lateral border of the
latissimus dorsi muscle to reach subcutaneous fat
and skin (Fig 3). A synopsis of the complete data
of the 20 dissections is given in the Table.

24
 Heitmann et al: The Thoracodorsal Artery Perforator Flap

Fig 2. Anatomic specimen showing two musculocutaneous

perforators of the lateral branch. The main vascular
pedicle and the axilla would be to the right side.
Patient Reports
Patient 1
A 33-year-old patient sustained a shotgun injury
to the lower leg that resulted in skin necrosis and
osteitis of the fibula (Figs 4A, B). After repeated
debridement the area was resurfaced with a free
TDAP flap. The flap was harvested from the
lateral branch of the thoracodorsal artery and had
three musculocutaneous perforator vessels.
Anastomoses were performed on the posterior
Fig 3. Anatomic specimen with the axilla to the right.
The vascular pedicle of the latissimus dorsi muscle is
injected with red latex (artery) and blue latex (veins).
The photograph demonstrates the lateral branch of the
thoracodorsal artery at the lateral free border of the
latissimus dorsi muscle that gives off two
musculocutaneous perforators and one direct cutaneous
branch that runs in the opposite direction. The direct
branch originates from the extramuscular course of the
thoracodorsal artery before the bifurcation at the
neurovascular hilus.
tibial artery (end to side) and on the vena comi-
tans (end to end). Figures 4C, D show the result
18 months after this one-stage reconstruction.

Data of the Thoracodorsal Artery Branching and Cutaneous Perforators in 20 Dissections

Location of Distance to External
the Hilus Muscle Edge Diameter Number of
Direct
(cm) (cm) (mm) Perforators
Cutaneous
No. A B HB LB HB LB HB LB Perforator
1 1 4 4.0 2.0 1,0 1.2 2 1 ⫺
2 3 4 3.0 3.0 0.9 0.9 1 1 ⫹
3 4 6 2.5 1.5 1.2 1.0 2 3 ⫺
4 3 5 4.0 2.5 0.8 0.8 1 1 ⫹
5 3 4 2.0 4.0 1.2 1.5 4 2 ⫹
6 2 4 5.0 2.0 1.5 1.0 2 1 ⫹
7 1 3 3.5 1.5 1.1 0.9 1 1 ⫺
8 4 5 3.0 2.0 0.9 1.2 2 1 ⫺
9 3 4 4.0 1.0 1.2 1.0 2 2 ⫹
10 2 4 3.5 1.5 0.9 0.9 2 2 ⫺
11 2 3 2.5 2.0 1.4 1.0 1 1 ⫹
12 1 3 3.0 3.0 1.0 1.0 3 1 ⫹
13 3 4 4.0 1.0 1.2 1.0 1 1 ⫺
14 3 4 3.5 1.0 1.0 1.0 2 2 ⫺
15 4 5 4.5 2.0 1.2 0.9 2 1 ⫹
16 2 3 4.0 2.5 0.9 1.2 1 1 ⫹
17 2 4 3.0 2.0 1.2 1.0 2 2 ⫹
18 3 4 3.0 1.5 1.0 0.8 2 1 ⫹
19 3 3 3.0 3.0 0.9 1.2 1 1 ⫺
20 2 4 4.0 2.0 1.0 1.0 2 2 ⫺
Averages: 2.5 4 3.5 2 1.1 1.0 1.8 1.4

Abbreviations: A, distance from lateral muscle edge; B, distance from horizontal muscle edge; HB, horizontal branch; LB, lateral branch.

25
Annals of Plastic Surgery Volume 51 / Number 1 / July 2003
Patient 2
A 28-year-old patient had a chronic elbow wound
after an open fracture caused by a motor vehicle
accident (Fig 5A). There were no local options for
wound coverage, and simple skin grafting had
failed. After radical debridement a TDAP flap
from the lateral branch of the thoracodorsal artery
with two perforator vessels was harvested (Fig
5B). Vascular anastomoses were performed to the
common interosseous artery and a vena comi-
tans. The free TDAP flap transfer resulted in
stable wound conditions (Fig 5C).
26
Fig 4. (A, B) Clinical aspect and
radiograph of the right lower leg 3
months after shotgun injury. (C, D)
Result 18 months after free
thoracodorsal artery perforator flap
transfer.
Discussion
The latissimus dorsi muscle is one of the largest
muscles in the human body. It is one of the most
versatile and widely used tissue transfers in re-
constructive surgery. Previous anatomic studies
have elucidated clearly the gross anatomy of the
latissimus dorsi muscle.13,14 Therefore it is a
known fact that the main vascular supply comes
from the thoracodorsal vessels, whereas the
lower and medial parts of the latissimus dorsi
muscle are supplied by intercostals and paraspi-

nal vessels. In addition, Tobin and colleagues15
described a constant branching of the thoracodor-
sal vessels in a horizontal and a lateral branch,
which run on the deep surface of the muscle.
These anatomic findings led to the clinical refine-
ment of the split latissimus dorsi flap.16 Some
authors even proposed to fillet the muscle in a
horizontal plane with transfer of just the deep
segment to reduce bulkiness.17
A fresh and different approach to address bulk-
iness of flaps was initiated with the advent of
perforator flaps. In anatomic studies Taylor and
Palmer18 found 374 cutaneous perforators larger
than 0.5 mm throughout the body, and the sche-
matic diagrams revealed five to nine of these
perforators in the area of the latissimus dorsi
muscle. However there were no further details
given regarding the specific location and origin of
the perforators. Angrigiani and colleagues19 were
the first who applied the principle of the perfo-
rator flaps to the latissimus dorsi muscle. The
perforators were followed through the muscle to
Heitmann et al: The Thoracodorsal Artery Perforator Flap
Fig 5. (A) Chronic elbow wound after open fracture.
(B) Intraoperative view showing two
musculocutaneous perforators of the lateral
thoracodorsal artery perforator flap. (C) Result 12
months postoperatively showing stable coverage.
the thoracodorsal vessels, creating an adipocuta-
neous flap without sacrifice of the muscle. Angri-
giani and colleagues,19 among others,20 –23 used
the Doppler probe to localize the perforators and
to determine flap design.
We revisited the latissimus dorsi muscle to
provide a comprehensive synopsis of its anat-
omy. The focus was on cutaneous perforator
vessels of the thoracodorsal artery and the goal
was to describe a pattern of how they might be
distributed. We found the neurovascular hilus on
the deep surface of the latissimus dorsi muscle
approximately 4 cm distal to the inferior scapular
border and 2.5 cm medial to the lateral free
border of the latissimus muscle. At that point
there was a constant bifurcation into a horizontal
branch and a lateral branch. This is in line with
the findings of Barlett and associates13 and
Friedrich and coworkers.14 The dissections were
then focused on cutaneous perforator vessels
overlying the latissimus muscle that could be
traced to the thoracodorsal artery and had a
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Annals of Plastic Surgery Volume 51 / Number 1 / July 2003
Fig 6. Drawing illustrating the flap design of the
thoracodorsal artery perforator flap.
caliber greater than 0.5 mm. We found these
perforators always in proximity to the horizontal
or lateral branch. There were two or more such
perforators per latissimus, with a slightly higher
percentage originating from the lateral branch.
All thoracodorsal cutaneous perforators origi-
nated within a distance of 8 cm distal to the
neurovascular hilus. In addition there was a
direct cutaneous branch originating from the tho-
racodorsal artery before the neurovascular hilus
in 55% of the specimens. This branch was also
described by Cabanie and colleagues24 in 75% of
30 cadaveric dissections but remains somewhat
variable in origin. Rowsell and associates25 ob-
served this direct cutaneous branch in 81% of
100 cadaveric dissections, but found that it arose
from the thoracodorsal artery in only 47%. In the
remainder of the specimens it arose from the
subscapular (27%) and axillary (7%) arteries.
This branch does not pierce the latissimus mus-
cle but rounds the lateral edge of the muscle to
contribute to the blood supply of the lateral
thoracic skin and subcutaneous tissue.
The results of this anatomic study have a direct
impact on our flap design. We center the skin
island of the TDAP flap above the free upper or
preferably lateral border of the latissimus dorsi
muscle (Fig 6). It is crucial to place the skin
island rather high to be in the area of the thora-
codorsal perforators and not the paraspinal and
intercostal perforators. It is hoped that this ana-
tomic study will expand the flexibility and the
use of the TDAP flap in the future.
28
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29