Multidetector-Row computed tomography analysis of the anatomical characteristics of thoracoacromial artery perforator

Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 162 
MULTIDETECTOR-ROW COMPUTED TOMOGRAPHY 
ANALYSIS OF THE ANATOMICAL CHARACTERISTICS OF 
THORACOACROMIAL ARTERY PERFORATOR 
Tong Thanh Hai1, Vu Quang Vinh1, Tran Van Anh1 
SUMMARY 
Objectives: To analyze the anatomical characteristics of thoracoacromial artery perforators 
by using multidetector-row computed tomography (MDCT). Subjects and methods: The study 
was performed in 11 cases. For all cases, the origin of perforator vessel, the direction and the 
course also were determined. The concern of origin of perforator with local anatomical 
landmarks (acromion, clavicle) was described. Length of perforator, diameter of perforators at 
their origin, diameter of perforators at the point where the perforator pierces the fascia into 
overlying skin were also measured. Results: The perforator vessels were divided into deltoid 
branch of thoracoacromial axis (66.7%), acromial branch (23.8%) or pectoral branch (9.5%). As 
a result, the perforators ran to the humeral region in subdermal tissue in direction. The length 
from the origin of perforator artery to acromion was 66.53 ± 11.57 mm to acromion (69.30 ± 9.31 
mm on the right side and 63.49 ± 13.48 mm on the left) and was 54.72 ± 17.57 mm to clavicle 
(64.37 ± 11.11 mm on the right side and 44.11 ± 17.59 mm on the left). The mean diameter of 
perforator vessel at its origin was 1.63 ± 0.26 mm and that of the perforator piercing the fascia 
into overlying skin was 1.22 ± 0.23 mm. Our study also identified the mean length of artery 
pedicled perforator was 49.06 ± 17.86 mm (50.60 ± 22.22 mm on the right, 47.37 ± 12.42 mm 
on the left). Conclusion: Multidetector-row computed tomography is the powerful procedure to 
determine the anatomical features of perforator vessels. This is the first time in literature, 
we have also applied successfully this technique to analyze the characteristics of thoracoacromial 
artery perforators. 
* Keywords: Thoracoacromial artery; Perforator; Multidetector computed tomography. 
INTRODUCTION 
The thoracoacromial artery arises 
below the junction of the middle and 
lateral thirds of the clavicle as a large-
caliber vessel from the forepart of the 
axillary artery, with its origin being 
generally overlapped by the upper edge 
of the pectoralis minor. It gives rise to two 
large constant branches, the deltoid and 
pectoral branches, and two further 
branches with highly variable anatomy, of 
which the clavicular branch sometimes 
arises from the main thoracoacromial 
trunk itself and the acromial branch 
originates in almost all cases from the 
deltoid branch. These branches are 
probably the most commonly used 
perforator flaps for reconstruction [1]. 
1Le Huu Trac National Burn Hospital 
Corresponding author: Tong Thanh Hai (Drtonghai@gmail.com) 
 Date received: 19/02/2021 
 Date accepted: 25/4/2021 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 163 
A number of perforator-based flaps 
have been described in the previous 
articles. Although there have been in-
depth studies on this issue, there are no 
reports on the anatomical study for the 
effective and safe flap design [2]. To the 
best of my knowledge, research on the 
use of MDCT in identifying the anatomical 
characteristics of thoracoacromial artery 
perforators. Consequently, we conducted 
this study: To analyze the anatomical 
characteristics of perforators of 
thoracoacromial artery by using MDCT. 
SUBJECTS AND METHODS 
1. Subjects 
A total of 21 thoracoacromial artery 
perforators from 11 patients that were 
stored in the Department of Radiology, 
Hoa Hao Medical Centre, Ho Chi Minh 
city, Viet Nam between April, 2019 and 
July, 2020 underwent the anatomy by 
using the MDCT. These 11 cases were 
randomly selected for the purpose of 
examining the chest wall. Patients with 
acquired anatomical anomalies of the 
thoracoacromial artery and its branches 
and those who suffered from trauma 
and/or chest wall ulcers were excluded in 
this study. 
2. Methods 
The CT examination was performed by 
using a 320-slice MDCT scanner (Aquilion 
320, Toshiba, Japan) and Ultravist 300 as 
the contrast material. The patients were 
instructed to hold their breath during the 
CT-scan, which was performed with a 
rotation speed of 0.5 s/rot, a detector 
coverage of 100 mm. This acquisition 
protocol allowed for a table speed of 5 mm/s 
and a scan time of about 10s for CT 
angiography, axial images of 0.625mm 
thickness. The CT angiographic images 
were reconstructed by using the maximum 
intensity projection (MIP) technique of 
Vitrea software. 
The anatomical characteristics of 
perforator arteries consisted of the origin of 
perforator, its origin with local anatomical 
landmarks, the direction of perforator 
artery, the length and diameter of 
perforator vessel. 
RESULTS 
1. General characteristics of the patients 
There was a total of 11 patients including 21 perforator arteries with 11 arteries on the 
right and 10 on the left. The average age of the patients was 57.1 years (ranging 25 - 77 years). 
2. The anatomical characteristics of perforators of thoracoacromial artery 
* The origin of perforator artery: 
Table 1: The origin of perforator artery. 
Branches of 
thoracoacromial artery 
Acromial 
branch 
Deltoid 
branch 
Pectoral 
branch 
Clavicular 
branch 
Right 0 10 1 0 
Left 5 4 1 0 
Total (n, %) 5 (23.8) 14 (66.7) 2 (9.5) 0 
The perforator originating from the deltoid branch was seen in most patients (66.7%). 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 164 
* The direction of perforator vessel: 
On MDCT images, the perforator ran to the humeral region in subdermal tissue in 
most cases. 
3. The association between the origin of perforator with local anatomical landmarks 
In our study, we identified the distance from the origin of perforators to acromion 
and cla ...  = 11) 82.2 47.8 64.37 ± 11.11 
Left (n = 10) 73.9 20.2 44.11 ± 17.59 
0.0048 
Total (n = 21) 82.2 20.2 54.72 ± 17.57 
The distance from the origin to clavicle was 54.72 ± 17.57 mm (64.37 ± 11.11 mm 
on the side and 44.11 ± 17.59 mm on the left). 
* The length of perforators: 
Table 4: The length of perforator 
Length (mm) Maximum Minimum Average p 
Right (n = 11) 104.0 25.2 50.60 ± 22.22 
Left (n = 10) 66.7 25.6 47.37 ± 12.42 
0.6899 
Total (n = 21) 104 25.2 49.06 ± 17.86 
The length was identified by measuring the distance between the origin of perforator 
and the point where the perforator pierces the fascia into the skin. Mean length was 
49.06 ± 17.86 mm (50.60 ± 22.22 mm on the right and 47.37 ± 12.42 mm on the left). 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 165 
* The diameter of perforators: 
Table 5: Diameter of perforators at their origin 
Diameter (mm) Maximum Minimum Average p 
Right (n = 11) 2 1.2 1.58 ± 0.22 
Left (n = 10) 2.1 1.1 1.69 ± 0.29 
0.3369 
Total (n = 21) 2.1 1.1 1.63 ± 0.26 
Table 6: Diameter of perforators at the point where the perforator pierces the fascia 
into overlying skin. 
Diameter (mm) Maximum Minimum Average p 
Right (n = 11) 1.8 1.0 1.24 ± 0.22 
Left (n = 10) 1.8 1.0 1.21 ± 0.25 
0.7730 
Total (n = 21) 1.8 1.0 1.22 ± 0.23 
DISCUSSION 
1. Anatomy of branches of 
thoracoacromial artery 
The thoracoacromial artery arises 
below the junction of the middle and 
lateral thirds of the clavicle as a large-
caliber vessel from the forepart of the 
axillary artery, with its origin being 
generally overlapped by the upper edge 
of the pectoralis minor. It gives rise to two 
large constant branches, the deltoid and 
pectoral branches, and two further 
branches with highly variable anatomy, 
of which the clavicular branch sometimes 
arises from the main thoracoacromial 
trunk itself and the acromial branch 
originates in almost all cases from the 
deltoid branch [1]. 
* The pectoral branch: 
The pectoral branch runs between the 
2 pectoral muscles and is distributed to 
these muscles and to the mammary 
gland. It anastomoses with the intercostal 
branches of the internal thoracic artery 
and with the external thoracic artery. 
It irrigates in particular the sterno-costal 
portion of the pectoralis major muscle. It 
quickly divides into 3 branches: a lateral 
branch which runs in the direction of the 
lateral thoracic artery, and two medial and 
caudal branches which go towards the 4th 
intercostal space and anastomose with 
the anterior intercostal arteries and the 
perforators of the internal mammary 
artery [3]. 
* The deltoid branch: 
The deltoid branch crosses the upper 
part of the deltopectoral groove and is 
generally divided into two branches, one 
deep and the other superficial. The deep 
branch travels in the groove itself, inside 
a small channel formed by the doubling of 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 166 
the fascia. Arriving at the lower end of the 
intermuscular space, this deep branch 
perforates the superficial layer of the 
facial canal in which it is located. It thus 
arrives in the subcutaneous plane and 
quickly branches into the skin which 
covers the tendon of the pectoralis major 
and the distal insertion of the deltoid 
muscle. It irrigates the pectoralis major 
and deltoid muscles with numerous small 
branches. The superficial branch (which 
represents the acromial branch proper) 
goes obliquely down and laterally; its size 
is sometimes important, and its length 
can reach 12 cm [3]. Geddes et al 
identified the dominant perforator from the 
deltoid branch with an average length of 
7.9 ± 2.0 cm [4]. 
* The acromial branch: 
The acromial branch is directed above 
the coracoid process and under the 
deltoid muscle, to which it gives several 
branches. It pierces the deltoid muscle 
towards the acromion to participate in an 
arterial network to which the suprascapular 
artery, the deltoid branch and the posterior 
humeral circumflex artery contribute. It ends 
at the lateral part of the deltoid region. 
Along its route, it gives a series of small 
branches on both sides of its trunk that 
quickly join the skin. This acromial branch 
presents many variations: it can be short 
from 2 to 3 cm, or very long and reach the 
posterior face of the deltoid region; it remains 
deep in 25% of cases and then pierces 
the deltoid at a greater or lesser distance 
from its anterior border. 
* The clavicular branch: 
The clavicular branch moves cranially 
and medially towards the sternoclavicular 
joint which it irrigates, as well as the 
subclavian muscle. It is usually of small 
caliber. Nyemb PMM et al [5] researched 
in 24 thoracoacromial arteries showed that 
the clavicular branch was absent in more 
than half of the dissections. The length of 
its extrafascial pedicle varied between 0.5 
and 2.5 cm. The length of the pedicle after 
transmuscular dissection varied between 3 
and 6 cm. The general direction of this 
clavicular branch was ascending and 
medial. Geddes et al [4] measured the 
average pedicle length of the clavicular 
perforators being 6.0 ± 2.1 cm. 
2. Clinical application 
In clinical application, the pectoralis 
major and the deltopectoral have been two 
workhorse flaps in reconstruction based 
on the pectoral artery [1]. Although, both 
flaps have demonstrated several advantages, 
they have shown several shortcomings. 
Geddes CR et al in 2003 [4] had found 
the perforators through the pectoralis 
muscle to the overlying skin separated 
from perforators of the thoracoacromial 
axis; perforators of the medial intercostal 
vessels; and perforators of the lateral 
thoracic artery. However, author believed 
that the pectoral branch of the 
thoracoacromial artery was not a good 
donor site for pedicled perforator flaps. 
However, musculocutaneous perforator 
flaps are possible from the clavicular and 
deltoid branches of the thoracoacromial 
artery. 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 167 
In a study by Portenard AC et al [6], 
the mean distances from the origin of the 
perforator artery on the abTAA were 
14.25 cm to the sternum, 3.45 cm to the 
acromion, 5.65 cm to the clavicle. The 
mean diameter of the abTAA was 1.20 ± 
0.2 mm and the length of the perforator 
pedicle could be extended to 7.46 cm ± 
1.15 mm. Authors also suggest that the 
acromial branch of the TAA perforator is 
constant and provides a reliable blood 
supply to a cutaneous flap. 
3. Role of multidetector-row computed 
tomographic angiography in the study 
of the perforator flap 
The introduction of perforator flaps into 
the surgical practice over the last decades 
has expanded the reach of plastic surgery. 
The use of these flaps greatly simplifies 
the reconstruction procedures and decreases 
the number of surgical stages and 
minimizes the amount of trauma at the 
site of the flap harvesting. In addition, the 
utilization of the perforator flaps shortens 
the duration of operations and allows for 
the maintenance of the intactness of the 
great vessels at both the donor and the 
recipient sites. However, surgery challenges 
remain, as the perforator vessels are highly 
variable in number, localization type, 
hemodynamic specifications, and their 
anatomical interactions with other structures. 
For these reasons, the identification of the 
best perforator before the procedure is 
very important for the choice of the main 
feed vessel and the design of the 
perforator flap [7]. 
In recent years, the flap design 
techniques have begun to incorporate the 
preoperative evaluation, localization, and 
calibration of the perforator. Such approach 
enables the best perforator to be selected 
before the dissection has begun. 
Therefore, the diagnostic value of the 
ultrasound and radiological methods for 
the preoperative flap evaluations has 
been widely discussed in the plastic 
surgery community lately [7]. 
In the last 15 years, the development 
of MDCT has radically changed the way 
the computed tomography angiography is 
used for the study of the vascular 
pathology. Interestingly, over the years, 
MDCT proved to be not only a very useful 
tool for the study of aorta and peripheral 
arteries but also a very promising 
noninvasive method for the localization, 
visualization, and characterization of the 
coronary artery stenosis. Moreover, 
MDCT allows for the investigation of the 
coronary vessels, the lumen diameter, 
and the occlusion site. Consequently, the 
idea of studying the perforator vessels by 
MDCT has emerged as a natural 
extension of its current applications and 
as a reliable method for the precise 
localization of the vessels most suitable 
for the flap formation. 
Indeed, since 2003, MDCT has been 
proving itself as a highly reliable 
technique for the preoperative planning of 
Deep Inferior Epigastric Perforator (DIEP) 
flap for breast reconstruction. Notably, 
this application of MDCT has been shown 
to yield great results, including the 
significant decrease in the duration of the 
surgery and the amount of the postsurgical 
complications. Consequently, over the 
past few years, a number of reports have 
mentioned the possibility of employing 
MDCT for the planning of various flap 
types, and/or the identification of perforators 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 168 
in various body parts, even including 
those that are smaller in diameter than 
the perforators in the front abdominal 
wall. Herein, we share our experience of 
using MDCT with 3-dimensional (3D) 
visualization in the planning of the local 
perforator flaps in various body parts and 
demonstrate the effectiveness and 
precision of this method. 
4. Anatomical characteristics of 
thoracoacromial artery perforators 
on MDCT 
Identifying the anatomical features of 
the perforator vessels of flap is important 
before taking surgical procedures. For 
perforator skin flap based on 
thoracoacromial artery, the numerous 
reseaches have showed the characteristics 
of perforator vessels reported in literature. 
Although these studies just restrictedly 
provided information in basic features, 
other features have not showed. 
Nowadays, MDCT technique is a new 
powerful procedure to provide the hidden 
information applied in clinical practice. 
As far as we know, there have been no 
reports on the use of MDCT in identifying 
the anatomical characteristics of 
thoracoacromial artery perforators. 
Because there were no previous studies 
to compare, we have just introduced 
again the features of this perforator vessel. 
The origin of perforator vessel: Our 
data showed that the perforator vessels 
were divided into deltoid branch of 
thoracoacromial axis (66.7%), acromial 
branch (23.8%) or pectoral branch (9.5%). 
As a result, the perforators ran to the humeral 
region in subdermal tissue in direction. 
The original point of perforator was 
66.53 ± 11.57 mm to acromion (69.30 ± 
9.31 mm on the right side and 63.49 ± 
13.48 mm on the left), and 54.72 ± 17.57 
mm to clavicle (64.37 ± 11.11 mm on the 
right side and 44.11 ± 17.59 mm on the 
left). The mean diameter of perforator 
vessel at its origin was 1.63 ± 0.26 mm, 
and 1.22 ± 0.23 mm at the point where 
the perforator pierces the fascia into 
overlying skin. Our study also identified 
the mean length of perforator vessel being 
49.06 ± 17.86 mm (50.60 ± 22.22 mm on 
the right and 47.37 ± 12.42 mm on 
the left). 
CONCLUSION 
Multidetector-row computed tomography 
is a powerful procedure to determine the 
anatomical features of perforator vessels. 
This is the first time in literature, we have 
also applied successfully this technique to 
analyze the characteristics of 
thoracoacromial artery perforators. This 
technique provided the significant 
information in clinical application. 
REFERENCES 
1. Zhang YX, Yongjie H, Messmer C, et al. 
Thoracoacromial artery perforator flap: 
Anatomical basis and clinical applications. 
Plastic and Reconstructive Surgery 2013; 
131(5):759e-770e. 
2. Ono S, Ogawa R, Hayashi H, et al. 
Multidetector-row computed tomography 
analysis of the supra-fascial perforator 
directionality (SPD) of the occipital artery 
perforator (OAP). Journal of Plastic, 
Reconstructive and Aesthetic Surgery 2010; 
63(10):1602-1607. 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 169 
3. Nyemb PMM, Fontaine C, Duquennoy-
Martinot V, et al. Anatomical study of the 
acromial branch of the thoracoacromial artery 
summary 2020. 
4. Geddes CR, Tang M, Yang D, et al. An 
assessment of the anatomical basis of the 
thoracoacromial artery perforator flap. 
Canadian Journal of Plastic Surgery 2003; 
11(1): 23-27. 
5. Nyemb PMM, Fontaine C, Duquennoy-
Martinot V, et al. Anatomical study of the clavicular 
branch of the thoracoacromial artery 2020. 
6. Portenard AC, Auquit-Auckbur I, Gardeil L, 
et al. Anatomical study of the perforator flap 
based on the acromial branch of the thoraco-
acromial artery (abTAA flap): A cadaveric 
study. Surgical and Radiologic Anatomy 2019; 
41(11):1361-1367. 
7. Badiul PO, Sliesarenko SV. 
Multidetector-row computed tomographic 
angiography in the planning of the local 
perforator flaps. Plastic and Reconstructive 
Surgery Global Open 2015; 3(9). 
CASE REPORT 
The perforator vessel of thoracoacromial artery. 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 170 
The source, direction and course of perforator vessel. 
The distance from its origin to clavicle The distance between its origin and acromion 
The length of perforator. Diameter of perforator. 
Journal OF MILITARY PHARMACO - MEDICINE N04 - 2021 
 171 
Brand tree of perforator.