Types of oncoplastic breast-conserving surgery: TDAP flap

Breast-conserving surgery is a method of removing cancer from the breast while retaining as much natural tissue as possible. Oncoplastic breast-conserving procedures use cosmetic surgery techniques to remove cancerous tumours and reconstruct affected breasts in a single operation. They can use either a volume replacement approach using autologous tissue from elsewhere on the patient’s body, or a volume displacement technique that uses the patient’s remaining breast tissue to fill in the defect caused by tumour removal.

One type of oncoplastic surgery is the thoracodorsal artery perforator flap, or TDAP flap for short. This guide will explain what TDAP flap surgery is and the type of patient it is suited to, the benefits of this particular procedure as part of an oncoplastic treatment plan, as well as some limitations to bear in mind.

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What is TDAP flap surgery?

When a tumour is removed from the breast, healthy breast tissue is usually removed around it to inhibit the spread of cancer. There is a subsequent loss of volume in the breast which can make the breast appear distorted in both shape and size. Oncoplastic reconstructive surgery can be used to restore this lost volume after a lumpectomy or mastectomy.

The TDAP flap reconstruction method involves the removal of skin and fat from the lateral chest wall (the armpit area) and a side of the back to reconstruct defects in the outer breast area. This is a pedicled perforator flap breast reconstruction technique, meaning the natural tissue remains connected to its blood flow from the thoracodorsal artery, and both the tissue and the blood supply are tunnelled from the back under the skin and onto the chest. Tissue from the latissimus dorsi muscle is not used, so shoulder strength is not affected.

The TDAP flap is proven to be an effective method for partial breast reconstruction following lump removal for patients with early-stage breast cancer. Patients are usually advised to still undergo radiotherapy following oncoplastic surgery.

What are the benefits of TDAP flap surgery?

A full mastectomy tends to result in extensive scarring and loss of sensation in the breast(s) and nipple(s). Since TDAP flap surgery retains as much of the natural breast as possible, scarring and loss of sensation is minimised. Patients report more natural-looking results and higher rates of satisfaction with the cosmetic appearance of their reconstructed breasts after oncoplastic surgery.

Compared to some other perforator procedures such as the DIEP flap or latissimus dorsi flap (usually used for total reconstruction), the TDAP flap technique is less invasive and usually requires only one night’s stay in hospital instead of up to a week. Tissue from the latissimus dorsi muscle is not used, so arm and shoulder strength is not affected and less physical therapy is required to support a full recovery.

The cosmetic outcomes of TDAP flap surgery are often better than with other types of reconstructive breast surgery following a lumpectomy. The natural shape of the breast is retained as much as possible without the need for an implant or large flap since the flap provides additional volume to fill the defect left by the removal of the tumour. Additionally, the incisions for this surgery are generally along the bra line, meaning scars can be easily hidden.

What are the limitations of TDAP flap surgery?

It’s important to note that there are risks involved in TDAP flap surgery. Patients will experience some bruising and swelling following surgery, but these will ease gradually and heal after several weeks. In rare cases, patients experience irregular contours of the breast following surgery, but generally this type of procedure offers better symmetry and cosmetic appearance compared to total breast removal and reconstruction.

As with all surgeries, there is a small risk of infection of the wounds, but again this is very uncommon. Furthermore, in rare instances, patients can experience delays in wound healing, which can pose complications. Other risks include fat necrosis, haematoma, deep vein thrombosis and loss of blood supply to the TDAP flap, but these problems rarely occur.

Who would be a suitable candidate for TDAP flap surgery?

The surgery is suitable for patients with small to medium-sized breasts and may be less suited to women with breasts which are very large or have significant ptosis (sagging of the breast tissue). It can treat cancers in any part of the breast. Patients with very large breasts may be better suited to a mammoplasty, in which healthy breast tissue is used to restore volume to the portion of the breast in which the tumour was removed.

If you’re considering TDAP flap surgery as part of your breast cancer treatment, contact the Stephen McCulley team to arrange a consultation. Stephen McCulley is an expert in this type of breast reconstruction and will assess you for your suitability.

Frequently asked questions

What’s the difference between the TDAP flap and the LICAP flap?

A TDAP flap reconstruction uses a perforator from the thoracodorsal artery to transfer skin and fat from the back and armpit area. The lateral intercostal artery perforator (LICAP) flap is similar, but uses blood flow from the lateral intercostal artery instead. Both surgeries are used in the treatment of outer breast defects, although the TDAP can also cover most areas of the breast.

What are the benefits of using a lateral chest flap instead of the stomach?

Lateral chest flap surgery affects a smaller portion of the body overall compared to using a flap from the stomach. This can make recovery more comfortable for patients. Furthermore, scarring from lateral chest flap surgery can often be restricted to the bra line to make it less visible, while scarring on the stomach may be harder to conceal.

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