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

Introduction: 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. Methods: A literature search was performed via PubMed, Medline, and Cochrane. Studies reporting the use of the TDAP flap after breast conserving surgery were included. Patient characteristics, topography and size of breast defect, flap size and design, number of perforators, and operative time were analyzed. Moreover, aesthetic and functional (shoulder morbidity) results, patient satisfaction, postoperative complications, and donor site morbidity were registered. Results: Twelve articles fulfilled inclusion criteria, and 337 patients were included. All articles except 1 described the use of the TDAP flap for defects in every breast quadrant. The mean weight of resected breast tissue was 97.28 g, and patients with over 20% of volume deficiency were considered eligible for TDAP flap volume replacement. The ellipse-shaped skin paddle (oriented oblique downward, transversal or oblique upward in most cases) was extended over the anterior border of the latissimus dorsi muscle to include possible septocutaneous perforator vessels. Most authors began the dissection from the anterior and caudal border of the flap to reserve the possibility to convert the TDAP to a musculocutaneous flap and check for septocutaneous perforators. Flap size ranged from 4 x 12 to 21 x 9 cm. The mean procedure time was 192.21 minutes. Mean follow-up was 17.42 months. Evaluation by way of a 5-point Likert scale reported overall mean values of over 4 points. Satisfactory outcomes were reported in 92.85%-100% of cases. Patient satisfaction ranged from 80% to 94% of cases. The incidence of seroma (1 case) and "shoulder-related" donor site morbidity was very low. Conclusions: Despite the heterogeneity of the evaluation methods, our review suggested that the use of the TDAP flap in oncoplastic surgery allows for satisfactory aesthetic outcomes and quite high levels of patient satisfaction. The TDAP flap represents an effective and versatile tool that amplifies the oncoplastic surgeon's arsenal, which allows for satisfactory outcomes.