A defect-oriented approach to customizing the pedicled thoracodorsal artery perforator flap for chest wall and upper-extremity reconstruction: a case series

The pedicled thoracodorsal artery perforator (TDAP) flap has become a versatile reconstructive option for chest wall and upper-extremity defects because it preserves the latissimus dorsi muscle while providing reliable vascularity and a wide arc of rotation. However, little attention has been paid to a defect-oriented strategy for customizing pedicled TDAP flap design according to different reconstructive requirements. This retrospective case series included three women with complex soft-tissue defects of the anterior chest wall, breast, or proximal upper extremity who underwent reconstruction with pedicled TDAP flap between 2009 and 2011. Preoperative perforator selection was performed using handheld Doppler ultrasonography to identify perforators from the descending and transverse thoracodorsal branches. Flap design, pedicle length, and thickness were tailored to each defect. When needed, intramuscular perforator dissection and primary flap thinning were performed to increase pedicle mobility and optimize flap contour. Successful reconstruction was achieved in three anatomically distinct defects through individualized pedicled TDAP flap customization. With pedicle arcs ranging from 90° to 130°, the flap enabled tension-free transfer to distant sites without the need for microsurgery. Flap geometry was individualized according to defect characteristics, using elliptical, racket-shaped, or V-shaped skin paddles. Flap thinning from 25 mm to about 5 mm improved contour adaptation and tissue flexibility. This individualized approach enabled reconstruction of anatomically diverse defects using a single pedicled TDAP flap platform in this case series. This case series illustrates a defect-oriented strategy for customizing the pedicled TDAP flap through individualized perforator selection, pedicle dissection, flap thinning, and flap geometry according to the anatomical and functional demands of different defects.