- Email: [email protected]
TDAP: Island versus propeller
+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e6
TDAP: Island versus propeller Claudio Angrigiani a, Alberto Rancati b, Guillermo Artero a, Ezequiel Escudero c, Roger K. Khouri Jr d,* a Divison of Plastic Surgery, University of Buenos Aires School of Medicine, Viamonte 430 St, Buenos Aires, Argentina b Division of Plastic Surgery, Instituto Henry Moore, Aguero 1248, Buenos Aires, Argentine c Division of Plastic Surgery, Hospital Interzonal General de Agudos, Av Juan Bautista Justo 670, Mar de Plata, Argentina d Office of Medical Student Education, University of Michigan Medical School, 1113 Freesia Ct, Ann Arbor, MI, USA
Received 15 August 2015; accepted 15 November 2015
KEYWORDS TDAP; Breast reconstruction; Island TDAP; Propeller TDAP; Thoracodorsal artery perforator
Summary Background and aim: Thoracodorsal artery perforator (TDAP) island flap is a safe and reliable method for breast reconstruction. TDAP propeller flap has been described as a modification of the conventional island technique that saves time and does not require microsurgical skills. However, a substantial portion of the propeller flap remains under the axilla and is not used for breast augmentation. The aim of this study is to identify the differences in the reaching distances between the propeller and island TDAP flaps. Methods: In five cadaveric specimens and 10 breast reconstruction patients, an initial propeller flap was harvested and rotated to the anterior thorax; the distance from the tip of the flap to the anterior midline was recorded as the “midline-reaching deficit;” the flap was then converted into a conventional island flap, and the new midline-reaching deficit was recorded. Differences between groups were compared with paired two-tailed t-tests (a Z 0.05). Results: In the cadaveric specimens, the mean midline-reaching deficit was 4.8 2.4 cm with the propeller TDAP and 0.6 2.0 cm with the conventional island TDAP (P < 0.001). In the clinical cases, the mean midline-reaching deficit was 8.1 1.0 cm with the propeller TDAP and 0.3 1.1 cm with the island TDAP (P < 0.000000001). Discussion: We observed that the midline-reaching deficit could be reduced by 7e9 cm with the conventional island TDAP in comparison to the propeller TDAP. This should be considered when reconstructing the medial inner part of the breast. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. 1113 Freesia Ct, Ann Arbor, MI 48105, USA E-mail addresses: [email protected], [email protected] (R.K. Khouri). http://dx.doi.org/10.1016/j.bjps.2015.11.009 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
2
Introduction Thoracodorsal artery perforator (TDAP) island flap has been used for breast reconstruction and is considered to be reliable and safe.1e3 TDAP propeller flap has been described as a modification of the original technique to make it simpler as it is not necessary to dissect the perforator branch into the muscle up to the main vascular pedicle.4,5 The propeller flap saves about 30 min of operating time and does not require microsurgical skills. However, direct observation of clinical results reveals that a substantial portion of the propeller flap remains under the axilla as the flap leash is shorter. A considerable proportion of flap volume is not used for breast augmentation and is “lost” under the axilla. This might act as a disadvantage when it is necessary to reconstruct the medial part of the breast or when volume replacement is necessary in that area. This study aims to determine the anatomical and clinical differences between the TDAP island and propeller flaps. In five cadaveric specimens and 10 patients undergoing breast reconstruction, an initial propeller flap was harvested, measured, converted into a conventional island flap, and measured again; we compared the reaching distances between the two flaps.
Methods An anatomical and clinical study was performed on five formalin-preserved adult human cadavers and 10 female patients, respectively, with the approval of our local ethics committee, and informed consent was provided by the patients for their data and images to be published. Unilateral propeller TDAP flaps were harvested on five cadaveric specimens (Figure 1). A horizontal design was used, in which we placed the incision at approximately the bra support line. A distal-to-proximal elevation was performed on the flaps. The distal end was placed at the posterior midline. On reaching the first perforator of the descending branch of the thoracodorsal artery, the flaps were rotated 180 to the anterior thorax, as a propeller. The distance from the anterior midline to the tip of the flap was recorded as the “midline-reaching deficit.” When the flap reach passed the midline, the distance between the tip of the flap and the midline was recorded as a negative value. After measurements, the flap was replaced to its original position and transformed into a conventional island flap by continuing the dissection into the muscle and completely liberating the vascular pedicle. The flap was then transferred again to the anterior thorax and the new midlinereaching deficit was recorded. A similar method was used for 10 consecutive patients undergoing unilateral breast reconstruction. A TDAP flap was harvested, exposing the vessel, and the flap was rotated as a propeller; the midline-reaching deficit was recorded; and the flap was then repositioned in the back and converted into a conventional island TDAP flap, as previously described.6 The perforator was dissected free from the muscle, and the flap was passed under the medial fibers of the latissimus dorsi muscle, or the anterior fibers were sectioned. The thoracodorsal pedicle was then
C. Angrigiani et al. dissected proximally up to its origin at the inferior scapular trunk, thus obtaining the maximum possible flap “leash.” The flap was again transferred to the anterior thoracic cage, and the new midline-reaching deficit was measured. In the cadaver and clinical studies, we used paired twotailed t-tests to compare the mean flap reaching distances of the propeller TDAP to the conventional island TDAP (a Z 0.05).
Results In the cadaveric specimens, the mean midline-reaching deficit was 4.8 2.4 cm with the propeller TDAP and 0.6 2.0 cm with the conventional island TDAP (P < 0.001). In the clinical cases, the mean midlinereaching deficit was 8.1 1.0 cm with the propeller TDAP and 0.3 1.1 cm with the island TDAP (P < 0.000000001) (Figure 2). Thus, in our 10 clinical cases, by converting the propeller TDAP to an island TDAP, we extended the reach of the flap by 8.4 cm. There were no complications.
Clinical examples Case 1 (Figure 3): A 53-year-old woman had undergone unilateral expander-implant breast reconstruction after mastectomy with unsatisfactory results 12 months before consulting our unit. An envelope deficit was diagnosed. Both the patient and the surgical team decided against using expanders. The surface deficit was reconstructed with a 25 10 cm TDAP flap. The flap was first elevated as a propeller for efficiency, but, when transferred anteriorly, a significant midline-reaching deficit was encountered. The flap was then converted into a conventional TDAP after which the anterior midline was reached without difficulty. It healed completely without complications. Case 2 (Figure 4): A 46-year-old female patient presented to our unit with a severe upper lateral quadrant deformity secondary to a tumorectomy and radiotherapy. To liberate the breast completely, all scar tissues were removed. This resulted in an 11 5-cm coverage defect and an approximated 300-ml volume deficit that extended up to the medial part of the breast mound. To approximate the volume replacement needed, we packed soaked gauze into the defect until the nippleeareola complex was satisfactorily repositioned, removed the gauze, packed it into a sphere on the operating table, and visually compared it to silicone prostheses of various volumes. Based on a perforator previously observed during breast liberation, a thoracolateral flap (Holmstrom type) based on the lateral intercostal artery perforator (LICAP) flap was used for envelope reconstruction.7,8 For volume reconstruction, an extended TDAP with lipofilling was performed. A 22-cm long 5-cm wide TDAP was designed in the back, with the longitudinal axis of the flap placed on the bra line. The flap was initially harvested as an extended propeller TDAP, incorporating part of the lumbar and scapular fat compartments and yielding a 14-cm wide and 4-cm thick flap. As a propeller, the flap-reaching distance was insufficient to cover the medial portion of the breast (midline-reaching deficit Z 9 cm).
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
TDAP: Island vs propeller
3
Figure 1 Cadaveric comparison of propeller and island TDAP. (Top Left) TDAP flap was harvested as a propeller up to the posterior midline. (Bottom Left) The flap was rotated to the anterior thorax, and a significant midline-reaching deficit was observed. (Top Right) The same propeller flap was transformed into a conventional island flap by continuing the dissection into the muscle and completely liberating the vascular pedicle. (Bottom Right) The flap was then rotated again to the anterior thorax, and the midline-reaching deficit was eliminated.
The flap was then converted into a conventional island TDAP by complete dissection of the vascular pedicle up to its origin in the subscapular artery and vein. With a longer flap leash, we were able to use sterile saline volume
displacement to determine the flap volume (250 ml). The flap was then passed under the most lateral fibers of the latissimus dorsi muscle and placed in the anterior thoracic wall. The flap then extended all the way to the midline, allowing for full coverage of the medial breast (midlinereaching deficit Z 0 cm). Using previously described fat grafting techniques, the flap was then de-epithelialized and lipofilled with 75 ml of adipose tissue aspirated from the lateral abdominal area, maintaining “micro-ribbon” diameters of <4 mm.9e11 The flap was completely inset at the base of the breast mound.
Discussion
Figure 2 Midline-reaching deficits in cadaveric and clinical studies for propeller and island TDAP flaps. The island TDAP flaps had significantly less reaching deficit in the cadaveric (P < 0.001) and clinical studies (P < 0.000000001).
Autologous volume replacement in conservative mastectomy reconstruction and breast envelope reconstruction with autologous tissue may be a safe and reliable procedure with TDAP flaps.1e3 The proximal perforating branch of the descending branch of the thoracodorsal artery is consistently present and can be used as a vascular pedicle.12e15 In addition, in the mastectomy sequela cases with axillary exploration and/or lymph node resection, the extramuscular cutaneous perforators are frequently coagulated or sectioned, creating a beneficial delay procedure as the remaining cutaneous muscular perforators take up the irrigation of the area. Although we did not perform any comparative studies, we have observed that the muscular perforator has consistently been of excellent caliber in these cases.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
4
C. Angrigiani et al.
Figure 3 (Top Left) A 53-year-old woman presented with an envelope defect 12 months following unilateral postmastectomy breast reconstruction. (Middle Left) TDAP flap was harvested as a propeller up to the posterior midline. (Bottom Left) The flap was rotated to the anterior thorax, and a midline-reaching deficit was observed. (Middle Right) The same propeller flap was transformed into a conventional island flap by continuing the dissection into the muscle and completely liberating the vascular pedicle. (Bottom Right) The flap was then rotated again to the anterior thorax, and the midline-reaching deficit was eliminated. (Top Right) One week postoperatively, the envelope defect was corrected without complications.
The TDAP flap can be transferred as a propeller, which reduces operating time by approximately 30 min and represents a simpler procedure. It has been observed that the propeller technique leaves a substantial portion of the flap in the axillary region behind the anterior axillary line. This portion of the flap is not used for breast volume or envelope reconstruction and produces a negative outcome. Our data suggest that the distal portion of the propeller TDAP flap reaches about 8.4 cm shorter in comparison to the conventional island TDAP. This is problematic when the medial part of the breast must be reconstructed. This area corresponds with the most distal part of the flap that might have a damaged tissue. The “flap-reaching distance” varies in each individual depending on several factors, such as the flow through the perforators and the status of the vascular network in the subcutaneous tissue. After complete elevation, the flap-reaching distance can be defined by direct observation or intraoperative fluorescence imaging modalities. The under-irrigated part is discarded, and only
the well-vascularized living flap tissue is used. The anterior midline-reaching deficit is then checked. The only way to increase this distance is by converting the propeller into a conventional island TDAP, which decreases the midlinereaching deficit by about 8 cm. This study only compares conventional island TDAP to propeller TDAP with one variable: midline-reaching deficits. Ideally, other variables could be taken into account when deciding between the two approaches. Future studies could perform a randomized control trial and compare operating time, postoperative volume, complication rate, and patient satisfaction.
Conclusions Conventional island TDAP requires complete liberation of the vascular pedicle under loupe magnification, and it is a more difficult and time-consuming procedure in comparison
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
TDAP: Island vs propeller
5
Figure 4 (Top Left): A 46-year-old woman presented with a severe upper lateral quadrant deformity secondary to tumorectomy and radiotherapy. (Top Right) Lateral view. (Middle Left) A propeller TDAP was harvested and rotated to the anterior thorax, and a major midline-reaching deficit was observed. (Middle Right) The same flap was transformed into an island flap and rotated to the anterior thorax, and the midline-reaching deficit was greatly decreased. (Bottom Left) Two weeks postoperatively, the upper lateral quadrant deformity was greatly improved. (Bottom Right) Lateral view.
to the propeller TDAP. However, reconstruction with a conventional island TDAP flap increases the reaching distance of the flap by an average of 8.4 cm. This should be considered when reconstructing the medial inner part of the breast.
References 1. Hamdi M, Decorte T, Demuynck M. Shoulder function after harvesting a thoracodorsal artery perforator flap. Plast Reconstr Surg 2008;122(4):1111e7. 2. Hamdi M, Salgarello M, Barone-Adesi L, Van Landuyt K. Use of the thoracodorsal artery perforator (TDAP) flap with implant in breast reconstruction. Ann Plast Surg 2008;61(2):143e6. 3. Santanelli F, Longo B, Germano S, Rubino C, Laporta R, Hamdi M. Total breast reconstruction using the thoracodorsal artery perforator flap without implant. Plast Reconstr Surg 2014;133(2):251e4.
4. Thomsen JB, Bille C, Wamberg P, Jakobsen EH, Arffmann S. Propeller TAP flap: is it usable for breast reconstruction? J Plast Surg Hand Surg 2013;47(5):379e82. 5. Angrigiani C, Rancati A, Escudero E, Artero G, Gercovich G, Deza EG. Propeller thoracodorsal artery perforator flap for breast reconstruction. Gland Surg 2014;3(3):174e80. 6. Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P, Monstrey S. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 2008;121(5):1632e41. 7. Holmstrom H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 1979;13(3):423e7. 8. Hamdi M, Spano A, Van Landuyt K, D’Herde K, Blondeel P, Monstrey S. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg 2008;121:389e96. 9. Khouri RK, Rigotti G, Cardoso E, Khouri Jr RK, Biggs TM. Megavolume autologous fat transfer: part I. Theory & principles. Plast Reconstr Surg 2014;133(3):550e7.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
6 10. Khouri RK, Rigotti G, Cardoso E, Khouri Jr RK, Biggs TM. Megavolume autologous fat transfer: part II. Practice & techniques. Plast Reconstr Surg 2014;133(6):1369e77. 11. Khouri Jr RK, Khouri RR, Lujan-Hernandez JR, Khouri KR, Lancerotto L, Orgill DP. Diffusion and perfusion: the keys to fat grafting. Plast Reconstr Surg Glob Open 2014;2(9):e220. 12. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional arterial and venous anatomies of the thoracodorsalartery perforator flap. Plast Reconstr Surg 2008; 121(5):1578e87.
C. Angrigiani et al. 13. Lin CT, Huang JS, Yang KC, et al. Reliability of anatomical landmarks for skin perforators of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2006;118(6):1376e86. 14. Schwabegger AH, Bodner G, Ninkovic M, et al. Thoracodorsalartery perforator (TAP) flap: report of our experience andreview of the literature. Br J Plast Surg 2002;55(5):390e5. 15. Thomas BP, Geddes CR, Tang M, Williams J, Morris SF. The vascular basis of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2005;116(3):818e22.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e6
TDAP: Island versus propeller Claudio Angrigiani a, Alberto Rancati b, Guillermo Artero a, Ezequiel Escudero c, Roger K. Khouri Jr d,* a Divison of Plastic Surgery, University of Buenos Aires School of Medicine, Viamonte 430 St, Buenos Aires, Argentina b Division of Plastic Surgery, Instituto Henry Moore, Aguero 1248, Buenos Aires, Argentine c Division of Plastic Surgery, Hospital Interzonal General de Agudos, Av Juan Bautista Justo 670, Mar de Plata, Argentina d Office of Medical Student Education, University of Michigan Medical School, 1113 Freesia Ct, Ann Arbor, MI, USA
Received 15 August 2015; accepted 15 November 2015
KEYWORDS TDAP; Breast reconstruction; Island TDAP; Propeller TDAP; Thoracodorsal artery perforator
Summary Background and aim: Thoracodorsal artery perforator (TDAP) island flap is a safe and reliable method for breast reconstruction. TDAP propeller flap has been described as a modification of the conventional island technique that saves time and does not require microsurgical skills. However, a substantial portion of the propeller flap remains under the axilla and is not used for breast augmentation. The aim of this study is to identify the differences in the reaching distances between the propeller and island TDAP flaps. Methods: In five cadaveric specimens and 10 breast reconstruction patients, an initial propeller flap was harvested and rotated to the anterior thorax; the distance from the tip of the flap to the anterior midline was recorded as the “midline-reaching deficit;” the flap was then converted into a conventional island flap, and the new midline-reaching deficit was recorded. Differences between groups were compared with paired two-tailed t-tests (a Z 0.05). Results: In the cadaveric specimens, the mean midline-reaching deficit was 4.8 2.4 cm with the propeller TDAP and 0.6 2.0 cm with the conventional island TDAP (P < 0.001). In the clinical cases, the mean midline-reaching deficit was 8.1 1.0 cm with the propeller TDAP and 0.3 1.1 cm with the island TDAP (P < 0.000000001). Discussion: We observed that the midline-reaching deficit could be reduced by 7e9 cm with the conventional island TDAP in comparison to the propeller TDAP. This should be considered when reconstructing the medial inner part of the breast. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. 1113 Freesia Ct, Ann Arbor, MI 48105, USA E-mail addresses: [email protected], [email protected] (R.K. Khouri). http://dx.doi.org/10.1016/j.bjps.2015.11.009 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
2
Introduction Thoracodorsal artery perforator (TDAP) island flap has been used for breast reconstruction and is considered to be reliable and safe.1e3 TDAP propeller flap has been described as a modification of the original technique to make it simpler as it is not necessary to dissect the perforator branch into the muscle up to the main vascular pedicle.4,5 The propeller flap saves about 30 min of operating time and does not require microsurgical skills. However, direct observation of clinical results reveals that a substantial portion of the propeller flap remains under the axilla as the flap leash is shorter. A considerable proportion of flap volume is not used for breast augmentation and is “lost” under the axilla. This might act as a disadvantage when it is necessary to reconstruct the medial part of the breast or when volume replacement is necessary in that area. This study aims to determine the anatomical and clinical differences between the TDAP island and propeller flaps. In five cadaveric specimens and 10 patients undergoing breast reconstruction, an initial propeller flap was harvested, measured, converted into a conventional island flap, and measured again; we compared the reaching distances between the two flaps.
Methods An anatomical and clinical study was performed on five formalin-preserved adult human cadavers and 10 female patients, respectively, with the approval of our local ethics committee, and informed consent was provided by the patients for their data and images to be published. Unilateral propeller TDAP flaps were harvested on five cadaveric specimens (Figure 1). A horizontal design was used, in which we placed the incision at approximately the bra support line. A distal-to-proximal elevation was performed on the flaps. The distal end was placed at the posterior midline. On reaching the first perforator of the descending branch of the thoracodorsal artery, the flaps were rotated 180 to the anterior thorax, as a propeller. The distance from the anterior midline to the tip of the flap was recorded as the “midline-reaching deficit.” When the flap reach passed the midline, the distance between the tip of the flap and the midline was recorded as a negative value. After measurements, the flap was replaced to its original position and transformed into a conventional island flap by continuing the dissection into the muscle and completely liberating the vascular pedicle. The flap was then transferred again to the anterior thorax and the new midlinereaching deficit was recorded. A similar method was used for 10 consecutive patients undergoing unilateral breast reconstruction. A TDAP flap was harvested, exposing the vessel, and the flap was rotated as a propeller; the midline-reaching deficit was recorded; and the flap was then repositioned in the back and converted into a conventional island TDAP flap, as previously described.6 The perforator was dissected free from the muscle, and the flap was passed under the medial fibers of the latissimus dorsi muscle, or the anterior fibers were sectioned. The thoracodorsal pedicle was then
C. Angrigiani et al. dissected proximally up to its origin at the inferior scapular trunk, thus obtaining the maximum possible flap “leash.” The flap was again transferred to the anterior thoracic cage, and the new midline-reaching deficit was measured. In the cadaver and clinical studies, we used paired twotailed t-tests to compare the mean flap reaching distances of the propeller TDAP to the conventional island TDAP (a Z 0.05).
Results In the cadaveric specimens, the mean midline-reaching deficit was 4.8 2.4 cm with the propeller TDAP and 0.6 2.0 cm with the conventional island TDAP (P < 0.001). In the clinical cases, the mean midlinereaching deficit was 8.1 1.0 cm with the propeller TDAP and 0.3 1.1 cm with the island TDAP (P < 0.000000001) (Figure 2). Thus, in our 10 clinical cases, by converting the propeller TDAP to an island TDAP, we extended the reach of the flap by 8.4 cm. There were no complications.
Clinical examples Case 1 (Figure 3): A 53-year-old woman had undergone unilateral expander-implant breast reconstruction after mastectomy with unsatisfactory results 12 months before consulting our unit. An envelope deficit was diagnosed. Both the patient and the surgical team decided against using expanders. The surface deficit was reconstructed with a 25 10 cm TDAP flap. The flap was first elevated as a propeller for efficiency, but, when transferred anteriorly, a significant midline-reaching deficit was encountered. The flap was then converted into a conventional TDAP after which the anterior midline was reached without difficulty. It healed completely without complications. Case 2 (Figure 4): A 46-year-old female patient presented to our unit with a severe upper lateral quadrant deformity secondary to a tumorectomy and radiotherapy. To liberate the breast completely, all scar tissues were removed. This resulted in an 11 5-cm coverage defect and an approximated 300-ml volume deficit that extended up to the medial part of the breast mound. To approximate the volume replacement needed, we packed soaked gauze into the defect until the nippleeareola complex was satisfactorily repositioned, removed the gauze, packed it into a sphere on the operating table, and visually compared it to silicone prostheses of various volumes. Based on a perforator previously observed during breast liberation, a thoracolateral flap (Holmstrom type) based on the lateral intercostal artery perforator (LICAP) flap was used for envelope reconstruction.7,8 For volume reconstruction, an extended TDAP with lipofilling was performed. A 22-cm long 5-cm wide TDAP was designed in the back, with the longitudinal axis of the flap placed on the bra line. The flap was initially harvested as an extended propeller TDAP, incorporating part of the lumbar and scapular fat compartments and yielding a 14-cm wide and 4-cm thick flap. As a propeller, the flap-reaching distance was insufficient to cover the medial portion of the breast (midline-reaching deficit Z 9 cm).
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
TDAP: Island vs propeller
3
Figure 1 Cadaveric comparison of propeller and island TDAP. (Top Left) TDAP flap was harvested as a propeller up to the posterior midline. (Bottom Left) The flap was rotated to the anterior thorax, and a significant midline-reaching deficit was observed. (Top Right) The same propeller flap was transformed into a conventional island flap by continuing the dissection into the muscle and completely liberating the vascular pedicle. (Bottom Right) The flap was then rotated again to the anterior thorax, and the midline-reaching deficit was eliminated.
The flap was then converted into a conventional island TDAP by complete dissection of the vascular pedicle up to its origin in the subscapular artery and vein. With a longer flap leash, we were able to use sterile saline volume
displacement to determine the flap volume (250 ml). The flap was then passed under the most lateral fibers of the latissimus dorsi muscle and placed in the anterior thoracic wall. The flap then extended all the way to the midline, allowing for full coverage of the medial breast (midlinereaching deficit Z 0 cm). Using previously described fat grafting techniques, the flap was then de-epithelialized and lipofilled with 75 ml of adipose tissue aspirated from the lateral abdominal area, maintaining “micro-ribbon” diameters of <4 mm.9e11 The flap was completely inset at the base of the breast mound.
Discussion
Figure 2 Midline-reaching deficits in cadaveric and clinical studies for propeller and island TDAP flaps. The island TDAP flaps had significantly less reaching deficit in the cadaveric (P < 0.001) and clinical studies (P < 0.000000001).
Autologous volume replacement in conservative mastectomy reconstruction and breast envelope reconstruction with autologous tissue may be a safe and reliable procedure with TDAP flaps.1e3 The proximal perforating branch of the descending branch of the thoracodorsal artery is consistently present and can be used as a vascular pedicle.12e15 In addition, in the mastectomy sequela cases with axillary exploration and/or lymph node resection, the extramuscular cutaneous perforators are frequently coagulated or sectioned, creating a beneficial delay procedure as the remaining cutaneous muscular perforators take up the irrigation of the area. Although we did not perform any comparative studies, we have observed that the muscular perforator has consistently been of excellent caliber in these cases.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
4
C. Angrigiani et al.
Figure 3 (Top Left) A 53-year-old woman presented with an envelope defect 12 months following unilateral postmastectomy breast reconstruction. (Middle Left) TDAP flap was harvested as a propeller up to the posterior midline. (Bottom Left) The flap was rotated to the anterior thorax, and a midline-reaching deficit was observed. (Middle Right) The same propeller flap was transformed into a conventional island flap by continuing the dissection into the muscle and completely liberating the vascular pedicle. (Bottom Right) The flap was then rotated again to the anterior thorax, and the midline-reaching deficit was eliminated. (Top Right) One week postoperatively, the envelope defect was corrected without complications.
The TDAP flap can be transferred as a propeller, which reduces operating time by approximately 30 min and represents a simpler procedure. It has been observed that the propeller technique leaves a substantial portion of the flap in the axillary region behind the anterior axillary line. This portion of the flap is not used for breast volume or envelope reconstruction and produces a negative outcome. Our data suggest that the distal portion of the propeller TDAP flap reaches about 8.4 cm shorter in comparison to the conventional island TDAP. This is problematic when the medial part of the breast must be reconstructed. This area corresponds with the most distal part of the flap that might have a damaged tissue. The “flap-reaching distance” varies in each individual depending on several factors, such as the flow through the perforators and the status of the vascular network in the subcutaneous tissue. After complete elevation, the flap-reaching distance can be defined by direct observation or intraoperative fluorescence imaging modalities. The under-irrigated part is discarded, and only
the well-vascularized living flap tissue is used. The anterior midline-reaching deficit is then checked. The only way to increase this distance is by converting the propeller into a conventional island TDAP, which decreases the midlinereaching deficit by about 8 cm. This study only compares conventional island TDAP to propeller TDAP with one variable: midline-reaching deficits. Ideally, other variables could be taken into account when deciding between the two approaches. Future studies could perform a randomized control trial and compare operating time, postoperative volume, complication rate, and patient satisfaction.
Conclusions Conventional island TDAP requires complete liberation of the vascular pedicle under loupe magnification, and it is a more difficult and time-consuming procedure in comparison
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
TDAP: Island vs propeller
5
Figure 4 (Top Left): A 46-year-old woman presented with a severe upper lateral quadrant deformity secondary to tumorectomy and radiotherapy. (Top Right) Lateral view. (Middle Left) A propeller TDAP was harvested and rotated to the anterior thorax, and a major midline-reaching deficit was observed. (Middle Right) The same flap was transformed into an island flap and rotated to the anterior thorax, and the midline-reaching deficit was greatly decreased. (Bottom Left) Two weeks postoperatively, the upper lateral quadrant deformity was greatly improved. (Bottom Right) Lateral view.
to the propeller TDAP. However, reconstruction with a conventional island TDAP flap increases the reaching distance of the flap by an average of 8.4 cm. This should be considered when reconstructing the medial inner part of the breast.
References 1. Hamdi M, Decorte T, Demuynck M. Shoulder function after harvesting a thoracodorsal artery perforator flap. Plast Reconstr Surg 2008;122(4):1111e7. 2. Hamdi M, Salgarello M, Barone-Adesi L, Van Landuyt K. Use of the thoracodorsal artery perforator (TDAP) flap with implant in breast reconstruction. Ann Plast Surg 2008;61(2):143e6. 3. Santanelli F, Longo B, Germano S, Rubino C, Laporta R, Hamdi M. Total breast reconstruction using the thoracodorsal artery perforator flap without implant. Plast Reconstr Surg 2014;133(2):251e4.
4. Thomsen JB, Bille C, Wamberg P, Jakobsen EH, Arffmann S. Propeller TAP flap: is it usable for breast reconstruction? J Plast Surg Hand Surg 2013;47(5):379e82. 5. Angrigiani C, Rancati A, Escudero E, Artero G, Gercovich G, Deza EG. Propeller thoracodorsal artery perforator flap for breast reconstruction. Gland Surg 2014;3(3):174e80. 6. Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P, Monstrey S. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 2008;121(5):1632e41. 7. Holmstrom H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 1979;13(3):423e7. 8. Hamdi M, Spano A, Van Landuyt K, D’Herde K, Blondeel P, Monstrey S. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg 2008;121:389e96. 9. Khouri RK, Rigotti G, Cardoso E, Khouri Jr RK, Biggs TM. Megavolume autologous fat transfer: part I. Theory & principles. Plast Reconstr Surg 2014;133(3):550e7.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009
+
MODEL
6 10. Khouri RK, Rigotti G, Cardoso E, Khouri Jr RK, Biggs TM. Megavolume autologous fat transfer: part II. Practice & techniques. Plast Reconstr Surg 2014;133(6):1369e77. 11. Khouri Jr RK, Khouri RR, Lujan-Hernandez JR, Khouri KR, Lancerotto L, Orgill DP. Diffusion and perfusion: the keys to fat grafting. Plast Reconstr Surg Glob Open 2014;2(9):e220. 12. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional arterial and venous anatomies of the thoracodorsalartery perforator flap. Plast Reconstr Surg 2008; 121(5):1578e87.
C. Angrigiani et al. 13. Lin CT, Huang JS, Yang KC, et al. Reliability of anatomical landmarks for skin perforators of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2006;118(6):1376e86. 14. Schwabegger AH, Bodner G, Ninkovic M, et al. Thoracodorsalartery perforator (TAP) flap: report of our experience andreview of the literature. Br J Plast Surg 2002;55(5):390e5. 15. Thomas BP, Geddes CR, Tang M, Williams J, Morris SF. The vascular basis of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2005;116(3):818e22.
Please cite this article in press as: Angrigiani C, et al., TDAP: Island versus propeller, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.11.009