Single-stage delayed hybrid reconstruction after failed implant-based breast surgery using the pedicled thoracodorsal artery perforator flap: a report of three cases.

The thoracodorsal artery perforator (TDAP) flap is established in immediate and early breast reconstruction, but its role in single-stage, hybrid (flap-plus-implant) reconstruction performed ≥12 months after failed implant-based surgery is not well described. Three consecutive patients underwent pedicled TDAP flap reconstruction combined with a subpectoral Becker-35 expandable implant more than one year after failed implant-based reconstruction in scarred fields with poor skin quality. Pre-operative planning included CT angiography (CTA) for perforator mapping, complemented by handheld Doppler; intra-operative indocyanine green (ICG) angiography was unavailable. Mean flap size was 17 × 8 cm, pedicle 13-15 cm, mean operative time 247 min, and estimated blood loss <250 mls. Two patients achieved durable, satisfactory outcomes with no donor-site morbidity at 24 months. One flap failed after inadvertent division of the dominant perforator, underscoring technical risks in fibrotic planes. Key lessons include meticulous intramuscular dissection, preservation of a secondary perforator until inset, creation of a generous tunnel to prevent kinking, and early management of venous congestion. In patients unsuitable for abdominal flaps or latissimus dorsi sacrifice, a pedicled TDAP combined with an expandable implant offers a muscle-sparing, single-stage option for delayed reconstruction after implant failure.