Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design

Abstract

Background: The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. Methods: This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. Results: Contralateral flaps used included the internal mammary perforator flap (n = 28) superficial superior epigastric artery flap (n = 8), superior epigastric perforator flap (n = 2), and the second or ninth dorsal intercostal artery perforator flap (n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. Conclusion: The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.