الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Each year, more than 240,000 American women face the reality of breast cancer. Today, the emotional and physical results are very different from what they were in the past. Great strides have been made in understanding of this disease and its treatment. New approaches in treatment, as well as advances in reconstructive surgery mean that women who have breast cancer today have new and better choices.
Today, more women with breast cancer choose surgery that removes only part of the breast tissue. This is called breast conservation surgery (or lumpectomy or segmental mastectomy). But, some women have a mastectomy, which removes the entire breast. Many women who have a mastectomy choose reconstructive surgery to restore the breast’s appearance.
The TDAP flap has emerged as a workhorse flap for reconstruction of various soft tissue defects.(98) This flap is a popular perforator flap among reconstructive surgeons and it is the first flap choice in some clinics for the coverage of breast defects. The advent of microsurgical techniques has allowed this versatile flap to be transposed to reconstruct soft‑tissue defects all around the body.(167)
In our study, we found that the TDAP flap has many advantages in the reconstruction of breast defects after conservative surgery; these could be summarized as follow:
1) It has a long vascular pedicle (range 14 to 23 cm, mean 16.75 cm in our study). Its long pedicle helps in breast reconstruction.
2) The presence of perforators is consistent. We found that the 1st perforator arising from the lateral branch of thoracodorsal artery is almost always present in all cases.
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3) A large skin paddle can be harvested on a single perforator ( in our study a flap of 26 x 11 cm dimensions was harvested on a single perforator without any complications)
4) The TDAP flap offers an excellent contour and color match for the breast.
5) The TDAP flap preserves the LD muscle and TD nerve, this limits the donor site morbidity largely in comparison with the LD muscle or myocutaneous flap. The incidence of post-operative seroma is decreased (5 % in our study) and shoulder function is preserved.
6) The TDAP flap donor site is well hidden and concealed. If the flap is transversely oriented, the scar is hidden in the brassiere line posteriorly so we recommend to use that design.
7) The skin paddle can be fashioned in any way (vertically, obliquely and transversely) over the latissimus dorsi muscle. This facilitates tailoring of the skin paddle in relation to the recipient defect.
8) The TDAP flap contains no muscle allowing more reconstructive precision in long-term follow up. No contour change due to muscle atrophy that occurs with LD muscle or myocutaneous flap because of muscle denervation.
The perforators are safe to be eccentrically positioned in the skin paddle; this increases the effective pedicle length. In addition, we found that the, we found that the 2nd perforator from the descending branch of the thoracodorsal artery is sometimes reliable (by loud audible Doppler sound pre-operatively and visible pulsations intra-operatively). In these cases, we used it as the main perforator and this enables us for a more length of the thoracodorsal pedicle particularly in pedicled flaps (length of pedicle in that case was 23 cm by this technique).
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Regarding the disadvantages of the TDAP flap, we found in our study that the main drawback of that flap is the meticulous and time-consuming retrograde intramuscular dissection of the TDA perforators through the LD muscle. We found that these technical difficulties were attributed to the following causes
a) Small perforator size in many cases.
b) The long intramuscular course of the perforators that may reach about 5 cm inside the muscle.
c) The numerous side branches of the perforators.
d) The delicate TD nerve branches and their close relation to the perforators. Sometimes sparing of the nerve branches is very difficult and in these cases we have to divide these nerve branches to dissect the perforators and then coapt them again.
We recommend using the technique described by Kim et. al (182) as described earlier.
The change of the anatomical landmarks (posterior axillary fold, scapular tip) and perforator positions with the change of arm position is another drawback of the TDAP flap. So that a uniform position of the patient’s arm must be maintained throughout the flap harvesting. In addition, the positioning of the patient in the lateral decubitus obviate the two-team approach and lengthens the operative time. The harvesting of the flap in the supine position with elevation of the ipsilateral hemi-back with a sand bag had solved that issue but obviated the ability to tailor a transverse flap design and incorporate branches from the medial branch of TDA.
Another drawback of that flap is the frequent donor site hypertrophic scar and scar widening. This is found to be more common in
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large flap dimensions exceeding a 10 cm width due to donor site closure under tension. We recommend to harvest TDAP flaps of a maximum 10 cm width and to close the donor site immediately after complete isolation of the skin paddle and the pedicle (by either skin staples or towel clips).
In conclusion, the TDAP flap is a versatile alternative in breast reconstruction. This flap should be one of the workhorse flaps in breast reconstruction owing to its great advantages and versatility. The drawbacks of the TDAP flap can be manipulated by some technical modifications.
Recommendations:
Thoracodorsal artery perforator flap represents a valid and safe option, which adds to the reconstructive arsenal of oncoplastic surgeons. This technique combines the advantages of perforator flaps in reducing donor site morbidities to an absolute minimum, and the advantages of pedicled flaps, which do not require sophisti-cated microvascular anastomoses. Thus, it can achieve an acceptable cosmetic outcome with minimal donor site morbidity. Finally, proper case selection and preoperative Doppler mapping are recommended to ensure good results.