Trunk defects can be approached through a multitude of regional flaps that can be harvested from the shoulder girdle, the epigastric axis, the paraspinal region, or the pelvic girdle. The aim of the reconstruction is to provide adequate and tension-free restoration of tissue integrity with minimal functional morbidity, water- and airtight closure of cavities, and coverage of exposed vital structures. Potential donor sites should be estimated for their tissue quality and anticipated donor site morbidity. The prototypical pedicled flap has a constant, reliable anatomy; however, the pedicled flap should have a configuration that is versatile and adequate for coverage and should resist infection. Also, the surgical technique should be uncomplicated.
Trunk defects can be approached through a multitude of regional flaps that can be harvested from the shoulder girdle, epigastric axis, paraspinal region, or pelvic girdle. The aim of the reconstruction is to provide adequate and tension-free restoration of tissue integrity with minimal functional morbidity, water- and air-tight closure of cavities, and coverage of exposed vital structures. The reconstructive modus operandi is directed by the location, size, and cause of the defect as well as the availability of healthy, adjacent autogenous graft tissue. Potential donor sites should be estimated for their tissue quality and anticipated donor site morbidity in proportion to the surgical indication and general condition of the patient. The patency of the source vessels of likely flaps should be acknowledged for impairment by previous surgery. However, the larger the defect the greater the need to include several pedicled flaps or consider free microsurgical tissue transfer. The prototypical pedicled flap has a constant, reliable anatomy. However, it should have a versatile configuration that is adequate for coverage and resistant to infection. Also, the surgical technique should be uncomplicated.
Choice of flaps
Muscle Flaps
In the late nineteenth century, Tansini used a latissimus dorsi (LD) muscle flap for primary breast and chest wall reconstruction, and the reliable pedicled LD flap with its modifications has become a time-honored constituent of the reconstructive armamentarium. Although several investigators have largely described the use of muscle flaps to manage tissue defects of the trunk, some more-complicated defects in specific areas on the trunk can be difficult to reach with pedicled muscle or myocutaneous flaps. These regions are (1) the posterolateral iliac crest region, especially when associated with a volume of iliac bone loss, (2) the epigastric axis and upper quadrants, which can require great effort to reconstruct with pedicle flaps because the rib cage makes mobilization of local flaps difficult (omentum is available if soft tissue coverage is needed in those areas as in the rectus abdominis muscle), (3) the lower lumbar and upper sacral regions can be difficult to approach because of distal reach and potential interference with muscles that are important for ambulation, and (4) the upper back and lower-cervical region may be problematic to reach with regional flaps, especially for larger defects, and the tissue bulk provided by the trapezius muscle or rhomboid muscles may be limited for such defects.
Axial Pattern Flaps
The repertoire of skin flaps used to be limited to random flaps, which were raised without regard to any known blood supply other than the subdermal plexus. Those flaps were restricted to rigid length-to-width ratios to ensure viability. After McGregor and Morgan introduced the concept of axial flaps, Ger and Duboys soon popularized the use of muscle as a carrier of overlying skin to create larger myocutaneous flaps. Knowledge of the intrinsic blood supply has been recognized as the most important determinant for ensuring success in elevating cutaneous flaps, and many of the previously described myocutaneous flaps can be harvested as skin flaps based on their perforators.
Perforator Flaps
Progress in reconstructive surgery has refined standard procedures, and the introduction of perforator flap surgery has extended the arsenal of reliable and safe surgical preferences to achieve primary closure of trunk defects. The concept of the freestyle perforator flap surgery offers even greater flexibility to choose the donor site, because flap selection is based on the quality and volume of soft tissue required at the recipient site ( Fig. 1 ). After evaluating the defect, an appropriate area adjacent to the injury site is selected and Doppler investigation and mapping are performed followed by custom-made flap design.
