The propeller thoracodorsal artery perforator flap-designs for breast reconstruction and perspectives

The propeller thoracodorsal artery perforator flap (pTDAP) is a further development and simpler version of the classic TDAP pioneered by Angrigiani C in 1995. The pTDAP can be used for immediate and delayed breast reconstruction in combination with an implant, fat grafting or in combination with other perforator flaps as an alternative to the latissimus dorsi flap. The pTDAP breast reconstruction can be performed and designed in several different ways regarding: (I) flap design, (II) axilla design and (III) breast design. The aim of this paper is to describe and illustrate different pTDAP designs and perspectives. We present the indications for use of the propeller TDAP in delayed as well as immediate breast reconstruction. The TDAP can be harvested from the back in various ways, horizontal and two different oblique techniques, upwards and downwards angled. The flap can be raised as an extended flap to include as much subcutaneous fat adjacent to the skin island as possible, either in the entire length of the flap or as the "Saturn" -design. The location of the dominant perforator(s) is predictable in most cases, but variations due occur and flap harvest can preferably be targeted by color Doppler ultrasonography for perforator identification. The propeller flap pedicle can be tunneled or left visible below/in the axilla. The flap can be augmented by an expander/ direct to implant technique or combined with fat grafting or other perforator flaps, an internal mammary perforator flap from the contralateral breast, a superior epigastric artery perforator (SEAP) flap or with a free TDAP as stacked flaps. The pTDAP can and should be designed, targeted and adapted to the individual patient when used for breast reconstruction. This entails the flap size and shape in the back, the choice and use of perforators, the design and rotation in the axilla and the breast reconstruction when using the flap for augmentation, shaping and draping using expanders, implants, fat grafting or in combined with other flaps.