PROPELLER DICAP FLAP FOR A LARGE DEFECT ON THE BACK—CASE REPORT AND REVIEW OF THE LITERATURE VANI PRASAD, M.B.B.S., M.R.C.S.Ed. and STEVEN F. MORRIS, M.D., M.Sc., F.R.C.S.C. * Reconstruction of large soft tissue defects of the back is a challenging problem. Large defects of the back were reconstructed with multiple random pattern or local pedicled muscle (and skin graft) or musculocutaneous flaps. The clinical use of perforator flaps has demonstrated that harvesting of flaps on a single perforator is possible for reconstruction of large defects. We present a 71-year-old male with a lesion on his left mid back that measured 10 3 10 3 4 cm 3 . Biopsy of the lesion was consistent with dermatofibrosarcoma protruberans. Wide local excision of the lesion with 4 cm margin was performed. The soft tissue defect, 20 cm in diameter, was reconstructed with a large propeller dorsal intercostal artery perforator (DICAP) flap. The DICAP flap measured 40 3 15 cm 2 based on a single perforator—lateral branch of dorsal rami of the seventh posterior intercostal artery on the right side. The perforator flap was elevated at the subfascial level and transposed 1808 into the defect. The donor site on the right side of the back was closed directly. This case illustrates the size of the propeller DICAP flap that could be safely harvested on a single perforator from the dorsal rami of the posterior intercostal artery. To our knowledge this is the largest reported pedicled perforator flap harvested on a single perforator on the posterior trunk. V V C 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012. Local perforator flaps based on a single cutaneous perfo- rator have recently become a popular method to close wounds in the extremities and trunk. The propeller flap variation is a local perforator flap that is turned 1808 to close a defect. In 1982, Katsaros 1 was the first to report the concept of a propeller flap. An islanded tensor fascia lata flap was propelled 1808 to reconstruct a defect in the lower chest. Hyakusoku 2 popularized the concept of propel- ler flaps for reconstruction of scar contractures to the elbow secondary to burns. Since then, the propeller concept has been used for reconstruction of the distal third of the lower limb trauma defects, 3 burns, pressure ulcers, and defects secondary to the excision of benign and malignant tumors. Because of the wide variety of cutaneous perforators avail- able, local perforator flaps have become widely used. Daniel et al. described the vascular anatomy of the posterior intercostal arteries. 4 The posterior intercostal ar- tery (PICA) was divided into four segments—vertebral, costal, intermuscular, and rectus, based on the neurovas- cular branching pattern. Dorsal rami arise from the verte- bral segment along with the nutrient artery to the rib and collateral branch of PICA. 5 The dorsal ramus divides into medial and lateral branches supplying the erector spinae muscles and the overlying skin. Medial branches are located 1–5 cm 2 from the posterior midline while the lat- eral branches are located between 5 and 8 cm. 6 Perfora- tors of the dorsal ramus of PICA were well described. 6,7 Kerrigan and Daniel found that the size of the dorsal rami was 1.5 mm. 5 The dorsal rami of PICA have exten- sive axial choke anastomoses with the circumflex scapu- lar artery, thoracodorsal artery and the branches of poste- rior intercostal arteries of the adjoining intercostal spaces. 7 Based on the vascular anatomical knowledge, a pedicled propeller perforator flap of the lateral branch of the dorsal rami of PICA was used to reconstruct a defect of the posterior trunk secondary to a malignant tumor. This case report demonstrates the application of a large propeller flap to reconstruct a soft tissue defect on the back that would otherwise have been reconstructed with multiple local flaps or a free tissue transfer. In the article, the current literature on the use of DICAP flaps to recon- struct the defects on the posterior trunk is reviewed. CASE REPORT A 71-year-old male presented with a lesion on his left mid back that has been gradually increasing in size for a number of years. Past medical problems include hyperten- sion, nephrectomy for renal cell carcinoma and atrial fi- brillation. On examination, a large raised lesion meas- uring 10x10x4cm was present on his left mid back area (Fig. 1a). The lesion was mobile and slightly tender. MRI showed a subcutaneous lesion measuring 10.8 3 9 3 3.6 cm 3 overlying the trapezius muscle at the level of the sixth thoracic vertebra. The underlying muscles and fas- cia were not involved. Biopsy of the lesion was consist- ent with dermatofibrosarcoma protruberans. Under general anesthesia, a wide local excision of the lesion was per- formed with a 4 cm margin. Frozen sections of the exci- sion margins were free of tumor. The tumor was excised at a submuscular plane including the trapezius, latissimus dorsi, and serratus that were directly deep to the tumor. The soft tissue defect was about 20 cm in diameter (Fig. Division of Plastic and Reconstructive Surgery, Department of Surgery, Dal- housie University, Halifax, NS B3H 3A7, Canada *Correspondence to: Steven Morris, Division of Plastic Surgery, 4443-1796 Summer Street, Halifax, Nova Scotia, Canada B3H 2A7. E-mail: sfmorris@dal.ca Received 11 May 2012; Revision accepted 11 July 2012; Accepted 20 July 2012 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22039 V V C 2012 Wiley Periodicals, Inc.