Computed Tomographic Angiography–guided Zero-CO2 Endoscopic Thoracodorsal Artery Perforator Flap for Salvage Breast Reconstruction After Deep Inferior Epigastric Perforator Flap Loss

Summary: Total loss of a free deep inferior epigastric perforator flap is a devastating complication in autologous breast reconstruction, particularly in low–body mass index Asian patients with limited salvage options. A reliable pedicled alternative that minimizes donor-site morbidity is therefore essential. We report a case of a 47-year-old woman who developed complete deep inferior epigastric perforator flap necrosis and was successfully salvaged using a computed tomographic angiography–guided endoscopic thoracodorsal artery perforator (TDAP) flap based on the lateral thoracodorsal artery. Through a single 8-cm posterior axillary incision, the TDAP pedicle was skeletonized endoscopically with minimal muscle harvest and without gas insufflation. The flap survived completely without seroma or shoulder dysfunction, and the donor-site scar was inconspicuous at 6-month follow-up. This case demonstrates that computed tomographic angiography–guided endoscopic TDAP flap harvest without CO 2 insufflation is a practical, low-morbidity salvage option after microsurgical failure and is particularly suitable for Asian centers with limited access to standard insufflation equipment.