Extended thoracodorsal artery perforator flap for breast reconstruction

Optimizing thoracodorsal artery perforator flap outcomes in oncoplastic breast surgery: multidimensional assistive techniques mitigate learning curve and enhance feasibility

This study aims to evaluate the feasibility and postoperative outcomes of the thoracodorsal artery perforator (TDAP) flap in oncoplastic breast surgery (OBS), incorporating multidimensional assistive techniques. We retrospectively analyzed 14 breast cancer patients treated with TDAP flap OBS from May 2020 to August 2023. Patients were divided into two groups: Group A (first 7 cases) and Group B (last 7 cases). Preoperative perforator localization was performed using color Doppler ultrasound and handheld Doppler, with intraoperative comparisons. Blood perfusion was assessed intraoperatively with indocyanine green (ICG) fluorescence imaging and postoperatively with infrared thermal (IRT) imaging. Patient satisfaction was measured using the BREAST-Q scale. Group A had longer operation times (4.05 ± 0.61 h vs. 3.27 ± 0.31 h, P = 0.011) and longer hospitalization (9.14 ± 2.27 days vs. 7.71 ± 1.60 days, P = 0.199). No flap necrosis occurred. Preoperative and intraoperative perforator positions were consistent. ICG imaging showed good flap blood supply; edge trimming improved perfusion in two cases. IRT imaging confirmed good blood perfusion in the first 3 days post-op. BREAST-Q scores for psychological health and sexual satisfaction were lower post-op (P < 0.001), but no significant differences were found in scores for chest physical health, shoulder and back physical health, or breast satisfaction. While TDAP flap surgery involves a learning curve, it is a highly feasible technique for OBS. Multidimensional assistive technologies significantly enhance preoperative perforator localization and intraoperative flap blood perfusion monitoring, thereby improving flap survival rates and patient satisfaction.

Current status of autologous breast reconstruction in Argentina

Although the most common procedure for breast reconstruction in Argentina is tissue expansion and implant devices, autologous tissue is frequently utilized. Deep inferior epigastric artery perforator flap (DIEP) is the gold standard for autologous breast reconstruction and, whenever possible, it is the first option. However, there are clinical or other circumstances, when a local or vicinity flaps for autologous reconstruction is preferred, even if exists a surgical and hospital facility for doing microsurgical procedures. The purpose of this manuscript is to describe our experience with the use of local and vicinity flaps for volume and surface replacement in different requirements-autologous breast reconstructions post oncologic resections, volume replacement in weight loss patients and implant-explantation cases. We have utilized the modification of latissimus dorsi musculocutaneous flap (LD) described by Hammond with excellent results and high patient satisfaction. Thoraco-dorsal artery perforator flap is indicated on skin sparing mastectomies (SSMs), immediate reconstruction of the nipple areolar complex and simultaneous coverage of an implant or tissue expander, in irradiated or to be irradiated patients. Lateral intercostal artery perforator (LICAP) flap has gained popularity because the unique position of the perforator at the lower lateral corner of the breast. It allows harvesting immediate vicinity tissue and easy rotation to the breast mound. We have used a modification towards the lateral thoracic wall of the anterior intercostal artery perforator flap for volume reconstruction after implant explantation.in patients who required volume preservation. Medial intercostal artery perforator flap is advantageous whenever the sub-mammary tissue can be used deepithelialized for volume reconstruction with a medial base. The same submammary area harvested as a medially based flap can be irrigated by the LICAP as a reverse LICAP flap that might be designed toward any direction from the piercing point of its perforator. The rest of the donor areas described for breast autologous reconstruction are rarely reported. When surgical facilities and adequate surgical teams are available, the lower abdominal wall is the main donor area, and DIEP, the most common technique utilized.

Microsurgical breast reconstruction in the United States: a narrative review of the current state

Background and Objective

Breast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons.

Methods

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers.

Key Content and Findings

In this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications.

Conclusions

While implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.

A before and after evaluation of patient reported outcomes assessed by Breast Q following LICAP turnover flap in breast conservative therapy

Chest-wall perforator-based techniques to replace volume for breast conservative therapy allow excision of large breast areas with minimal sequalae, such as the nipple-areolar complex displacement, parenchymal indentation or contour deformity. Furthermore, chest wall perforator flaps facilitate the maintenance of breast symmetry, hence decreasing the need for contralateral surgery. Lateral intercostal flap was described in numerous variants among which the most famous are the propeller flap and the turnover version. The turnover version is the easiest and fastest version that allows the replacement of large amount of volume. In this paper, we evaluate patients reported outcomes, before and after surgery, collected through the Breast Q. This study was conducted on 21 patients who were admitted to the plastic surgery department. A prospectively maintained database was used to identify the patients and their records were assessed retrospectively. The pre/post operative patients data were collected. The Breast-Q questionnaire was administered before the surgery and at least 1 year after. No major surgical complications were reported. Mean Breast-Q scores were evaluated at least 1 year after surgery and radiotherapy and compared with pre-surgical scores. Among all the modules, no significant differences between the pre-surgical and post-surgical Breast-Q scores were observed. Until now, the lateral intercostal artery perforator flap has not been widely used, due to a difficult dissection and a challenging preoperative planning. According to the reported surgical technique, the execution is easy. This technique provides the same breast-related quality of life compared to preoperative values, reduces the mastectomy rate and increases the overall survival.

Novel Patient-Reported Outcome Measures for the Assessment of Patient Satisfaction and Health-Related Quality of Life Following Postmastectomy Breast Reconstruction

BACKGROUND

Patient-reported outcome measures (PROMs) have become an integral part of the evaluation of reconstruction surgery outcomes. However, there are limitations in current PROMs when it comes to the assessment of well-being during inpatient stay, patient perception of health, relationship with partner, and vitality (i.e., mood and ability to work and pursue hobbies, carry out daily tasks, and sleep) following breast reconstructive surgery. The aim was to develop a novel set of measures to compare patient satisfaction and health-related quality of life following different types of postmastectomy breast reconstruction.

METHODS

A novel questionnaire was created and refined through cognitive interviews with patients and expert feedback. A field test study was conducted, including patients who had undergone delayed postmastectomy breast reconstruction with implant, autologous tissue, or combination of implant and autologous tissue. Based on the results, confirmatory factor analysis and examination of reliability of the questionnaire were conducted. Results of patient responses were analyzed using Chi-square test, Kruskal-Wallis test, and Mann-Whitney U test.

RESULTS

Confirmatory factor analysis showed good model fit, and Cronbach's alpha indicated high internal consistency of the questionnaire. Besides that, patients with combination reconstruction reported significantly lower vitality than patients with implant and autologous reconstruction (p = 0.048).

CONCLUSIONS

This novel questionnaire expands the current knowledge base of postmastectomy breast reconstruction PROMs. Results of the field test study showed that combination reconstruction was associated with lower patient vitality than other reconstruction types.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Extended Latissimus Dorsi Kite Flap (ELD-K Flap): Revisiting an Old Place for a Total Autologous Breast Reconstruction in Patients with Medium to Large Breasts

BACKGROUND

The latissimus dorsi (LD) flap represents one of the most reliable methods for autologous breast reconstruction. However, in many patients, the exclusive use of this technique may not guarantee the restoration of an adequate volume and projection. We report our experience with the extended latissimus dorsi kite flap (ELD-K flap), an alternative surgical approach to maximize the volume of the fleur-de-lis pattern LD flap, for total autologous breast reconstruction.

METHODS

Between 2016 and 2018, 23 patients were subjected to mastectomy and immediate autologous reconstruction with "extended latissimus dorsi kite flap" (ELD-K flap), technique that employs an extended version of the LD musculocutaneous flap, based on the skeletonized thoracodorsal pedicle and a trilobate skin incision with an inferiorly based vertical branch. The BREAST-Q questionnaire was administered preoperatively, and one year after surgery to evaluate the quality of life results of the patients. BREAST-Q latissimus dorsi module was also provided.

RESULTS

Average body mass index was 29.7 kg/m² (range 25-40 kg/m²). Mild complications occurred in only six cases, and eight patients underwent treatment to improve the donor site scar outcome. Patients indicated high scores in quality of life measures with an increase in all BREAST domains from the preoperative to the postoperative period. A statistically significant increase (p < 0.05) was noted in: "overall satisfaction with breasts" (p < 0.05), "psychosocial well-being" (p < 0.05), "physical impact of the surgery" (p < 0.05). Within the LD module, participants reported a mean score of, respectively, 73.8 and 67.9 for "satisfaction with back" and "satisfaction with shoulder and back function" domains.

CONCLUSIONS

The extended incision allows the recruitment of additional tissue to provide enough volume to complete the reconstruction without implants. The isolation of the vascular pedicle allows for extreme freedom and mobilization of the flap, ensuring adequate filling of the breast. ELD-K flap may expand the indications for a total autologous LD immediate breast reconstruction, representing an additional and reliable alternative in selected cohorts of patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Thoracodorsal artery flaps for breast reconstruction-the variants and its approach

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

Thoracodorsal Artery Perforator Flap in Partial Breast Reconstruction: A Systematic Review

Breast conserving surgery followed by radiation therapy represents the standard of care for early stage breast cancer. Oncoplastic breast surgery includes several reconstructive techniques essentially summarized in 2 categories: volume displacement and volume replacement procedures. These latest procedures have evolved over time from the use of the entire latissimus dorsi muscle to the use of pedicled perforator flaps, namely the thoracodorsal artery perforator (TDAP) flap. The aim of this article is to provide a comprehensive review of the literature regarding the use of the TDAP flap in partial breast defects.

The Value of Dynamic Infrared Thermography in Pedicled Thoracodorsal Artery Perforator Flap Surgery

Dynamic infrared thermography (DIRT) is a noninvasive imaging technique that can provide indirect and real-time information on skin perfusion by measuring skin temperature. Although used in flap surgery, there are no reports on its value in procedures using a pedicled thoracodorsal artery perforator (TDAP) flap. The aim of this study was to assess the usefulness of DIRT in preoperative perforator mapping and in monitoring intra- and postoperative flap perfusion of pedicled TDAP flaps.

Thoracodorsal Artery Perforator and Superior Epigastric Artery Perforator Flaps for Volume Replacement Oncoplastic Breast Surgery

Introduction  Breast conservation therapy (BCT) and oncoplastic breast surgery (OBS) are now established modalities of treatment for breast cancer, with proven oncological safety. Traditionally, latissimus dorsi (LD) flaps have been the one-stop solution workhorse when volume replacement is needed. We present our experience with thoracodorsal artery perforator (TDAP) and superior epigastric artery perforator (SEAP) flaps. These flaps allow the preservation of muscle structure and function.

Material and Methods  Data were collected prospectively of patients in whom pedicled perforator flaps after BCT were used. A handheld 8-MHz audio Doppler was used to locate the perforators. TDAP flaps were used in four patients, whereas SEAP flaps were used in two patients. Skin paddle sizes ranged from 10 × 3 cm to 21 × 7 cm.

Results  TDAP flaps were used in four patients, whereas SEAP flaps were used in two patients All flaps survived. No flap had partial necrosis or fat necrosis. All donor sites were closed primarily and healed uneventfully, and none had a seroma requiring aspiration.

Conclusion  TDAP flaps can be selectively employed when the LD muscle function needs to be preserved. SEAP flaps can also be employed as a rare option in case of lower inner quadrant defects. Pedicled perforator flaps are a useful and reliable option for volume replacement OBS in select patients for reconstructing partial mastectomy defects.

Oncoplastic Volume Replacement for Breast Cancer: Latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap

Volume replacement oncoplastic breast techniques have become one of the standard lines in the treatment of early breast cancer. They have better cosmetic outcome and patient satisfaction. Latissimus dorsi (LD) flap is one of the most commonly used flaps for these techniques. Although it shows satisfactory surgical outcomes, postoperative shoulder dysfunction is an obvious drawback. The aim of this study was to compare LD flap with thoracodorsal artery perforator (TDAP) flap after breast-conserving surgery regarding surgical outcomes, patient satisfaction, and impact on shoulder function.

Anatomical basis of the extended TDAP flap: study of its territories of vascularization and its volume

INTRODUCTION

The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap.

MATERIALS AND METHOD

Ten extended TDAP flaps were dissected on 5 fresh human cadavers. Around the classical skin paddle of a TDAP flap, the dissections were performed in a subfascial level, including the muscular fascia and the adipose tissue compartments to increase the volume of the flap. After injection of methylene blue in the thoracodorsal artery, we measured the length and width, the surface and the volume of the coloured flap.

RESULTS

The mean sizes of the extended TDAP flap were 24.9 cm × 20.1 cm. The mean surface of the total vascularization zone was 441 cm². The mean volume of the vascularized flap was 193 ml.

CONCLUSION

The thoracodorsal artery perforator via the deep muscular fascial network allows us to harvest a flap of 25 cm × 20 cm with a mean surface of 441 cm² and a mean volume of 193 ml. The extended TDAP flap is a credible option in breast reconstruction.