Source Surgery of The Breast Principals and Art Volume: n/a Number: n/a 1999

The Thorocodorsal Artery Perforator Flap

This procedure transfers skin and fat from the back with-out sacrifice of the latissimus dorsi muscle. The flap is based on proximal musculocutaneous perforators of the thoracodorsal artery and vein. This is similar to the autogenous latissimus dorsi method of breast reconstruction, but without transfer of any muscle.

Moderately obese and obese patients are best suited for this procedure. A skin island is marked out over the proximal latissimus dorsi muscle using a Doppler probe to locate the perforators. Elevation of thin skin flaps peripherally allows a large flap to be harvested based on one, two, or three perforators of the thoracodorsal vessels. After identification of the perforators, the proximal latissimus dorsi muscle is split in the direction of its fibers. Loupe magnification is used to dissect the perforating artery and vein to the submuscular branches of the thoracodorsal artery and vein. Care must be taken to avoid injury to the thoracodorsal nerve. Pedicle dissection continues to the subscapular artery and vein. This results in a vascular pedicle length of approximately 15 cm. The skin and fat flap is then passed through the opening in the muscle and rotated anteriorly for breast reconstruction.

In summary, the thoracodorsal artery perforator flap pro-vides autogenous reconstruction without the need for microvascular anastomosis or a synthetic breast implant. Donor site morbidity should be significantly decreased by sparing the latissimus dorsi muscle (Figs. 19 and 20).

FIG. 19. A: A 56-year-old woman presents requesting immediate left breast reconstruction after planned left mastectomy for ductal carcinoma. Due to her extensive smoking history and moderate obesity, reconstruction using the T-DAP flap was planned in an effort to minimize donor site postoperative complications. The proposed excision site measured 15 x 4 cm, including the biopsy site and the nipple-areola complex. B: A skin island measuring 20 x 8 cm was marked on the thoracodorsal region. C: Intra-operative dissection of the thoracodorsal vessel perforator showing a pedicle length of approximately 12 cm. D: Donor site 5 months postoperatively. E: The patient is shown 8 months postoperatively.

FIG. 20. A: A 42-year-old woman requesting immediate left breast reconstruction after mastectomy for carcinoma. The patient had previous reconstruction of the right breast due to carcinoma with use of the superficial inferior epigastric artery free flap from the lower abdomen, which was thus no longer available. B: Thoracodorsal artery perforator (T-DAP) flap skin markings with marked sites of perforators obtained using Doppler. Skin island measured 16 x 7 cm. C: Intraoperative dissection showing identification of the first throacodorsal artery perforator. D and E: T-DAP flap being rotated anteriorly. F: Patient 1 year post-surgery.