The Thoracodorsal Artery Perforator Flap: A Powerful Tool in Breast Reconstruction

It was with great interest that I read the article published by Homsy et al., “The Thoracodorsal Artery Perforator Flap: A Powerful Tool in Breast Reconstruction,” in the October 2022 issue of Plastic and Reconstructive Surgery.1 The authors are to be congratulated on an outstanding series of reconstructions and for bringing the thoracodorsal artery perforator (TDAP) flap to the forefront for breast reconstruction and for other applications. The authors report no failures in a series of 174 TDAP flaps on 126 patients, which is an impressive achievement. I note that there were no exclusions during the 5-year study period for patients identified as having unfavorable perforator anatomy, such as poor or absent audible Doppler signal, or signals identified outside the topographic landmarks. Were any of these situations encountered by the authors, and if so, did the authors proceed with TDAP reconstruction anyway despite no imaging? Were there any instances where the authors had to adjust their plans intraoperatively such as lengthening or making additional incisions? Lastly, were the causes of the three “unsatisfactory reconstructions” related to eccentrically placed or diminutive perforators? There is a divide in the literature regarding the reliability of the TDAP flap. A number of authors report consistency and reliability of the perforators.2 Others report variabilities, inconsistencies, and sometimes absence of the perforators, thus prompting the caution for “careful surgical planning” or use of an alternate technique.3–5 The reason for the contrasting conclusions is probably multifactorial and could include varying microsurgical skill sets among surgeons; whether anatomical specimens were fresh or preserved; whether or not loupe magnification was used, and if so, the power of the magnification; and the technique of the injection studies. There are additional cautions in the literature as to whether or not to plan a flap procedure based on a Doppler signal, particularly if it is not within topographic landmarks.6 In addition, palpable topographic landmarks may not correlate to the locations of intermuscular or fascial planes.7 These concerns also apply to other perforator flaps. A plethora of studies have emerged over the past several years highlighting the utility of surgeon-led high-resolution ultrasound, whether tablet-based or traditional cart-based, in the imaging of perforators, their course, their flow velocity, and their size.8,9 In addition, muscular fascial planes and underlying parent vessels can be identified.10 This technology is now available in miniaturized, low-cost, and portable formats. Several iterations of the latest versions offer imaging with high frequency (15 to 20 MHz), which gives exceptional clarity to even small perforators (<1 mm).11 Use of this information could give real meaning to the phrase “careful surgical planning.” Ultrasound may be the “modern-day stethoscope” for the microsurgeon, and with the assistance of this technology, success as reported in this study will become routine.12 DISCLOSURE Dr. Lindsey has no financial interests to disclose. No funding was received for this communication.