A comparative study for tension-reducing effect of Type I and Type II keystone perforator island flap in the human back.

The keystone perforator island flap (KPIF) is popular in reconstructive surgery. However, despite its versatility, its biomechanical effectiveness is unclear. We present our experience of KPIF reconstruction in the human back and evaluate the tension-reducing effect of the KPIF. Between September 2019 and August 2020, 17 patients (51.82 ± 14.72 years) underwent KPIF reconstruction for back defects. In all cases, we measured wound tension at the defect and donor sites before and after KPIF reconstruction using a tensiometer. All defects occurred after complete excision of complicated epidermoid cysts and debridement of surrounding tissues. The defects were successfully covered with Type IIA KPIFs. All flaps survived, and there were no significant postoperative complications. The mean "tension change at the defect after Type I KPIF" and "tension change at the defect after Type II KPIF" were - 2.97 ± 0.22 N and - 5.59 ± 0.41 N, respectively, (P < 0.001). The mean "rate of tension change at the defect after Type I KPIF" and "rate of tension change at the defect after Type II KPIF" were - 36.54 ± 1.89% and - 67.98 ± 1.63%, respectively, (P < 0.001). Our findings confirm the stepwise tension-reducing effect of KPIF and clarify the biomechanics of this flap.

Keystone design perforator island flap in facial defect reconstruction.

Facial defect coverage is a common subject in the field of reconstructive surgery. There are many methods for facial defect reconstruction, and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement. Among various options for facial reconstruction, the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture, which is consistent with the ideal goal of reconstruction (replacement of like-with-like). Keystone design perforator island flap (KDPIF), devised by Behan in 2003, has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity, robust vascular supply, and reproducibility. Several studies have reported KDPIF reconstruction of facial defects, such as large parotid defects, small-to-moderate nasal defects, and eyelid defects. However, KDPIF has been used relatively less in facial defects than in other body regions, such as the trunk and extremities. The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF, modifications, physiology, mechanism of flap movement, consideration of facial relaxed skin tension lines and aesthetics, surgical techniques, clinical applications, and precautions for successful execution of KDPIF reconstruction.

Reconstruction of bilateral inferomedial gluteal defects after resection of hidradenitis suppurativa with symmetrical keystone flaps designed parallel to relaxed skin-tension lines: A case report.

RATIONALE: Surgical treatment of hidradenitis suppurativa (HS) is challenging. Wide excision of affected lesions followed by skin graft or flap coverage has been recommended to achieve remission and prevent recurrence. Herein, we present our experience of bilateral inferomedial gluteal defects coverage using symmetrical keystone flaps (KFs) designed parallel to relaxed skin-tension lines (RSTLs). PATIENT CONCERNS: An 18-year-old man was admitted for chronic inflammatory lesions in both inferomedial gluteal areas. DIAGNOSES: Physical examination revealed multiple sinuses with broad surrounding scars in both inferomedial gluteal areas, which led to a diagnosis of HS. INTERVENTIONS: We performed wide excision on all affected lesions. The size of the final defects was 6 × 10 cm on the right side, and 5 × 9 cm on the left side. We covered the defects with KFs 9 × 15 cm (right) and 8 × 12 cm (left), which were based on the hotspots of the interior gluteal artery and internal pudendal artery perforators, and parallel to RSTLs. OUTCOMES: The flaps were inset without tension on each side, and the donor sites were closed primarily. All flaps fully survived and there were no postoperative complications. The patient was satisfied with the final outcome after 6 months of follow-up. LESSONS: Successful reconstruction of bilateral inferomedial gluteal defects was achieved after resection of HS using symmetrical KFs designed parallel to RSTLs. The KF technique considering RSTLs could be a good reconstructive option for gluteal HS.

Circumferential penile defect reconstruction with pull-up double-opposing keystone-designed perforator island flaps: A case report.

RATIONALE: The challenges with reconstruction of penile defects are plenty. In addition, no single and universally accepted reconstructive method exists for penile defect repair. Herein, we present the application of a circumferential penile shaft defect reconstruction using pull-up double-opposing keystone-designed perforator island flaps (KDPIFs) in one patient. This is the first case report of a circumferential penile shaft defect reconstruction using KDPIFs. PATIENT CONCERNS: A 43-year-old man who injected petroleum jelly into his penis 10 years ago presented with multiple firm nodular mass-like lesions adherent to the overlying skin along the penile shaft. Our urologic surgeon removed the foreign bodies and performed a primary closure with undermining. However, wound dehiscence developed, and skin necrosis was exacerbated 5 days postoperatively. DIAGNOSES: We performed debridement, and the final post-debridement defect was circumferential (5.5 × 12 cm) from the base of the glans to the midpoint of the penile shaft. INTERVENTIONS: We covered the defect using pull-up double-opposing KDPIFs (10 × 13 cm each) based on the hot spots of the superficial external pudendal artery perforators on each side from the suprapubic area to the scrotum. OUTCOMES: The flaps survived perfectly, with no postoperative complications. The patient was satisfied with the final outcome and had no erectile dysfunction or shortening of penile length after a 6-month follow-up. LESSONS: We successfully reconstructed a circumferential penile defect with pull-up double-opposing KDPIFs both esthetically and functionally. Our technique can be a good alternative modality for extensive penile defect reconstruction.

Keystone-design perforator island flaps for the management of complicated epidermoid cysts on the back.

Complicated epidermoid cysts (ECs) occur commonly on the back, but few reports have described their management. We present our experience in managing patients with ECs on the back using a keystone-design perforator island flap (KDPIF) reconstruction, thereby focusing on reduction and redistribution of wound tension. Altogether, 15 patients (average age, 48.067 ± 14.868 years) underwent KDPIF reconstructions after complete excision of complicated ECs on the back. We retrospectively reviewed the medical records and clinical photographs of all patients. Final scar appearance was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). All patients had ruptured ECs, while 6 patients also had cellulitis of the surrounding tissues. All defects, after complete excision of ECs and debridement of surrounding unhealthy tissues, were successfully covered with KDPIF. The mean 'tension-change' at the defect and donor sites was -4.73 ± 0.21 N and -4.88 ± 0.25 N, respectively (p < 0.001). The mean 'rate of tension-change' at the defect and donor sites was -69.48 ± 1.7% and -71.16 ± 1.33%, respectively (p < 0.001). All flaps survived with no postoperative complications. The mean observer scar assessment scale (OSAS) summary score and patient scar assessment scale (PSAS) total score were 14.467 ± 5.069 and 15.6 ± 6.512, respectively. Overall, we suggest that KDPIF reconstruction is a good surgical modality for the management of complicated ECs on the back.

Relaxed skin tension line-oriented keystone-designed perforator island flaps considering the facial aesthetic unit concept for the coverage of small to moderate facial defects.

A variety of reconstructive options including skin grafts, loco-regional flaps, and free flaps exist for the coverage of facial defects. Each technique has advantages and disadvantages. In this study, we present our experience with relaxed skin tension line (RSTL)-oriented, keystone-designed perforator island flap (KDPIF) reconstructions, in consideration of the facial aesthetic unit concept for coverage of small to moderate facial defects.Between May 2016 and February 2018, 17 patients (11 men and 6 women), with an average age of 63.53 years (range: 37-83 years) underwent KDPIF reconstructions to cover facial defects. We performed the KDPIF reconstructions in consideration of the RSTLs and facial aesthetic unit concept. We retrospectively reviewed the defect causes, locations, and sizes, and flap sizes, types, and survivals, as well as the complications. Cosmetic outcomes were evaluated using the Harris 4-stage scale from 3 independent plastic surgeons' point of view, and postoperative satisfactory surveys from all patients.All defects were successfully covered with KDPIF. The defect sizes varied from 1.5 × 1.5 cm to 3 × 3.5 cm. The flap sizes varied from 1.5 × 3 cm to 3 × 5.5 cm. All flaps fully survived and there were no postoperative complications. The average subjective patient satisfaction score was 8.29 (range: 7-10) and the objective cosmetic outcomes were favorable (fair, good, or excellent).Considering its simplicity and safety, the KDPIF is a good reconstruction option with few complications and high reproducibility. The RSTL-oriented KDPIF reconstruction is a good reconstructive option for covering small to moderate facial defects with superior aesthetic outcomes.

Reconstruction of infected trunk wounds with pedicled rectus abdominis musculocutaneous flaps: a retrospective case series.

OBJECTIVE: To completely treat and cover extensively infected trunk defects, reconstruction should be performed using a sufficiently vascularised flap, such as a muscle or musculocutaneous flap after perfect debridement. These reconstructive surgeries are challenging in patients with severe comorbidities. In this case series, we describe extensively infected trunk defect reconstruction, in patients with severe comorbidities, using a pedicled rectus abdominis musculocutaneous flap and suggest an algorithm for reconstruction. METHOD: Between March 2011 and March 2015, participating patients underwent reconstruction of extensively infected trunk defects using a pedicled rectus abdominis musculocutaneous flap. All patients had diabetes and hypertension, and several patients had severe comorbidities, including heart and renal failure. Bacterial cultures revealed that meticillin-resistant Staphylococcus aureus (MRSA) was present in seven patients (with concurrent Pseudomonas aeruginosa in two patients), multidrug-resistant Acinetobacter baumannii in one patient and Mycobacterium tuberculosis in two patients. RESULTS: A total of 10 patients underwent the procedure. The pedicled rectus abdominis musculocutaneous flaps survived completely in all 10 patients. There were no complications related to the flaps, although two patients developed minor wound dehiscence, which may be due to their comorbidities. There were no signs of recurrent infection during the follow-up period in each case. CONCLUSION: Reconstruction using the pedicled rectus abdominis musculocutaneous flap is a good treatment option for extensively infected three-dimensional trunk defects, even for patients with severe comorbidities.

Validity of the use of a subfascial vessel as the recipient vessel in a second free flap transfer: A retrospective clinical review.

Performing a greater number of free flap procedures inevitably results in an increase in the number of cases that experience free flap failure. In cases that require a second free flap after the failure of the first, recipient vessel selection becomes difficult. Furthermore, recipient vessel selection can be complicated if the vessel is deep in the recipient site, or if there is an increased risk of vessel damage during the dissection. Thus, we present our experience where a subfascial vessel beneath the deep fascia was used as a recipient vessel for a second free flap in lower extremity reconstruction due to total or partial first flap failure.Between January 2010 and April 2015, 5 patients underwent second free flap reconstruction using a subfascial vessel as the recipient vessel. The flaps were anastomosed in a perforator-to-perforator manner, using the supermicrosurgery technique. We measured the sizes of the flaps, which varied from 5 × 3 to 15 × 8 cm, and the recipient subfascial vessel diameters.The mean time for the dissection of the recipient perforator was 45 minutes. All the flaps exhibited full survival, although a partial loss of the skin graft at the flap donor site was observed in 1 patient; this defect healed with conservative management.We recommend using a subfascial vessel as the recipient vessel for both first and second free flaps, especially if access to the major vessel is risky or challenging.

Keystone-Designed Perforator Island Flaps for the Coverage of Traumatic Pretibial Defects in Patients With Comorbidities.

Reconstruction of pretibial skin and soft-tissue defects remains a challenge because this area has less underlying tissues and limited tissue mobility. Here, we present a retrospective review of our experience with pretibial reconstruction using the keystone-designed perforator island flap (KDPIF) in patients with comorbidities. All defects resulted from nononcological causes. We describe the expanding versatility of KDPIF reconstruction for pretibial defects and suggest a simple algorithmic approach. The medical records of 9 patients who underwent reconstruction with a KDPIF to cover a pretibial defect between May 2016 and June 2017 were reviewed. Clinical and operative data were collected. All 9 KDPIFs fully survived. The defect size varied from 3 × 2 cm2 to 8 × 6 cm2. The flap size varied from 5 × 3 to 20 × 10 cm2. The mean operative time was 90.4 minutes (range = 37-127 minutes). No postoperative complications occurred. The cosmetic results were favorable, and all patients were satisfied with the final outcomes. Thus, the KDPIF is a good reconstruction modality with few complications and provides an alternative to free flaps for pretibial defect reconstruction in patients with comorbidities.

Keystone-designed buried de-epithelialized flap: A novel technique for obliterating small to moderately sized dead spaces.

Effective obliteration of dead space after reconstructive surgery facilitates a good cosmetic outcome and prevention of delayed wound healing and recurrent infection.We evaluated the efficacy of a keystone-designed buried de-epithelialized (KBD) flap for the obliteration of small to moderately sized surgical dead spaces.We reviewed the medical records of patients who received a KBD flap following removal of a mass or debridement of necrotic tissue from September 2015 to February 2016. The diagnosis, site, dead space dimensions, flap width, drain data, complications, and follow-up duration were recorded.Twenty-eight KBD flaps were evaluated, including 9 cases of fat necrosis, 7 cases of epidermal cyst, and 12 cases of lipoma. Dead space dimensions ranged from 2 × 1.5 × 1 cm to 10 × 5 × 3 cm, with a mean depth of 2.01 cm. Flap sizes ranged from 2.5 × 1 cm to 11 × 3 cm, with a mean flap width of 2.01 cm. No postoperative complications, such as seroma or hematoma, occurred. The cosmetic results were favorable, and all patients were satisfied with their final outcomes.The KBD flap is useful for the obliteration of small to moderately sized surgical dead spaces both spatially and physiologically and shows excellent cosmetic outcomes.

Neuroanatomical distribution of galectin-3 in the adult rat brain.

Galectin-3 is a member of the lectin subfamily that enables the specific binding of ß-galactosides. It is expressed in a broad spectrum of species and organs, and is known to have various functions related to cell adhesion, signal transduction, and proinflammatory responses. Although, expression of galectin-3 in some activated neuroglia under neuroinflammation has been well documented in the central nervous system, little is known about the neuronal expression and distribution of galectin-3 in normal brain. To describe the cellular and neuroanatomical expression map of galectin-3, we performed galectin-3 immunohistochemistry on the entire normal rat brain and subsequently analyzed the neuronal distribution. Galectin-3 expression was observed not only in some neuroglia but also in neurons. Neuronal expression of galectin-3 was observed in many functional parts of the cerebral cortex and various other subcortical nuclei in the hypothalamus and brainstem. Neuroanatomical analysis revealed that robust galectin-3 immuno-signals were present in many hypothalamic nuclei related to a variety of physiological functions responsible for mediating anxiety responses, energy balance, and neuroendocrine regulation. In addition, the regions highly connected with these hypothalamic nuclei also showed intense galectin-3 expression. Moreover, multiple key regions involved in regulating autonomic functions exhibited high levels of galectin-3 expression. In contrast, the subcortical nuclei responsible for the control of voluntary motor functions and limbic system exhibited no galectin-3 immunoreactivity. These observations suggest that galectin-3 expression in the rat brain seems to be regulated by developmental cascades, and that functionally and neuroanatomically related brain nuclei constitutively express galectin-3 in adulthood.

Augmentation of the Nipples Reconstructed with Modified Top-Hat Flap Using Dermal Grafts in Implant-Based Breast Reconstruction: A Comparative Study.

BACKGROUND: Nipple reconstruction in implant-based breast reconstruction remains challenging, as the remaining thin skin envelope results in a less projected neo-nipple with a reduced volume. This study presents a modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings for augmenting reconstructed nipples during implant-based breast reconstruction. METHODS: Between April 2011 and December 2014, among 34 patients who underwent immediate post-mastectomy reconstruction with a direct silicone implant, nipple reconstruction was performed using the modified top-hat flap technique in only 21 patients (group A), whereas 13 patients underwent the modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings (group B). The projection and width of the neo-nipple were measured at the time of surgery and at 1 year post-surgery, respectively. RESULTS: All modified top-hat flaps were successful without any complications. The mean nipple projections at the time of surgery were 0.75 ± 0.107 cm (range 0.5-0.9 cm) and 1.29 ± 0.064 cm (range 1.2-1.4 cm) in groups A and B, respectively (p < 0.001). The mean nipple widths at the time of surgery were 0.90 ± 0.184 cm (range 0.6-1.2 cm) and 1.43 ± 0.076 cm (range 1.3-1.5 cm) in groups A and B, respectively (p < 0.001). The maintenance of nipple projection and width was significantly increased in group B compared with group A. CONCLUSION: The modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings is a useful and easy method to expand and augment the volume of reconstructed nipples in implant-based breast reconstruction. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Popliteal fossa reconstruction with a medial sural artery perforator free flap using the medial sural vessel as the recipient.

BACKGROUND: Reconstruction of the popliteal fossa using a free flap is challenging. Therefore, to facilitate easier free flap reconstruction of the popliteal fossa, we use a medial sural artery perforator (MSAP) free flap with a medial sural vessel as the recipient vessel, as it provides several advantages based on many reports. METHODS: This report describes the authors' experience and outcomes with this technique. Between October 2010 and January 2015, 10 patients with medium-sized defects in their popliteal fossa underwent MSAP free flap reconstruction using the medial sural vessel as the recipient vessel. The flap size and thickness were evaluated, as well as the pedicle length, for each case. RESULTS: The skin flap sizes ranged from 60-112 cm2. The average flap thickness was 6 mm (range = 4-8 mm), and the average pedicle length was 7.5 cm (range = 6-9 cm). Full flap survival was observed in nine cases, and flap tip necrosis was observed in one case during a mean follow-up of 15 months (range = 3-36 months). MSAP free flap reconstruction was performed for moderate-sized defects in the popliteal fossa, using the medial sural vessel as the recipient vessel. CONCLUSION: The obvious advantages of this technique included simple vascular anastomosis (minimal size discrepancy), no intraoperative position changes, and good aesthetic outcomes (replacing like with like).

Modified lumbar artery perforator flaps for gluteal pressure sore reconstruction.

BACKGROUND: Gluteal perforator flaps (GPFs) are the most useful for gluteal region pressure sore reconstruction. However, application is difficult if the surrounding area has scar tissue from previous operations or trauma, especially with recurrent sores. We describe the use of modified lumbar artery perforator flaps when GPFs cannot be used. METHODS: Between May 2009 and April 2014, 51 patients underwent gluteal pressure sore reconstructions with gluteal (n = 39) or modified lumbar artery (n = 12) perforator flaps. Patients in the modified lumbar artery perforator group had scar tissue from trauma or previous surgery. In this retrospective review, we analyzed patient age and sex, defect size and location, operative time, follow-up duration, immediate postoperative issues, flap necrosis, dehiscence, re-operation, donor-site morbidity and recurrence. Complications and clinical outcomes were compared between groups. RESULTS: We found no significant differences in patient demographics, surgical complications or clinical outcomes. There were eight cases of temporary congestion (20.51%) and four of partial flap necrosis (10.25%) in the gluteal perforator group. In the modified lumbar artery perforator group, there were three cases of temporary congestion (25%) and one of partial flap necrosis (8.33%). No pressure sores recurred during follow-up in either group. CONCLUSION: GPFs are the gold standards for gluteal pressure sores, but modified lumbar artery perforator flaps are relatively easy and useful when GPFs cannot be used due to scar tissue.

Mini-breast reconstruction with an omental flap: a retrospective clinical study.

INTRODUCTION: Potential challenges associated with immediate small breast reconstruction include an inadequate size of the donor site, a thinner skin envelope and limited selection of implants. We present immediate postmastectomy reconstruction of small breasts with a laparoscopically harvested pedicled omental flap (LHPOF) in five Korean women. METHODS: From December 2014 to July 2015, we performed immediate postmastectomy reconstruction with an LHPOF in five breast cancer patients. Data on the patients' age; body mass index; tumour size; site, type and weight of the mastectomy specimen; operative time; hospital stay; complications; postoperative chemotherapy or radiation therapy; and follow-up duration were reviewed in this retrospective clinical study. RESULTS: The mean mastectomy specimen weight was 212 g (range: 104-272 g). The mean operative time was 298 min (range: 240-380 min), and the mean harvesting time was 75 min (range: 65-90 min). There were no flap-related complications such as fat necrosis or flap loss and no donor site-related complications such as bowel dysfunction, an epigastric bulge or hernia during the follow-up period (average: 8.2 months, range: 5-11 months). The cosmetic results were satisfactory. DISCUSSION: The LHPOF can be useful for immediate postmastectomy reconstruction of small breasts, because it provides a soft and naturally ptotic appearance of the reconstructed breast (versus implant-based reconstruction) with low donor-site morbidity (versus other autologous tissue reconstruction approaches).

Severe Irreversible Diastasis Recti Abdominis and Abdominal Hernia in Postpartum Women: Rare Case Report.

Diastasis recti abdominis is a condition defined as the separation between the rectus abdominis and the linea alba, which leads to weakness in the abdominal muscles. Diastasis may be slight or severe, sometimes resulting in herniation of the abdominal viscera. Following childbirth, most women develop some extent of muscle separation in the postpartum period. However, if the diastasis recti abdominis in the postpartum period remain severe, it should be corrected to prevent concurrent abdominal hernia, strangulation or incarceration. We herein present two Korean cases of postpartum women with severe diastasis recti abdominis with abdominal hernia; it is the first report of its kind from Korea. Two women were referred to our clinic with severe abdominal bulge. Computerized tomography scan showed widening of the linea alba with abdominal hernia. The standard abdominoplasty with multiple wide longitudinal plications of the abdominal wall was performed in each patient under general anesthesia. There was no recurrence of diastasis recti abdominis or abdominal hernia during follow-up periods. The application of abdominoplasty in postpartum women with severe diastasis recti abdominis with abdominal hernia is thus considered to be an efficient management option. We hope these cases can provide a reference for the treatment of similar situations.

Selective salvage of zones 2 and 4 in the pedicled TRAM flap: a focus on reducing fat necrosis and improving aesthetic outcomes.

The introduction of microsurgery has decreased the frequency of using the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, owing to its higher incidence of fat necrosis and limitations in flap insetting (vs. the free TRAM flap). We devised an efficient method of using zones 2 and 4, based on the pedicled flap's vascular anatomy, to reduce fat necrosis and achieve superior aesthetic outcomes during immediate breast reconstruction using the pedicled TRAM flap. Between April 2011 and February 2015, we performed immediate breast reconstruction using the contralateral unipedicled TRAM flap for 136 breast cancer patients. The conventional method (insetting by removing zone 4 and part of zone 2) was used for 83 patients (Group A), and selective salvage of zones 2 and 4 (our proposed method) was used for 53 patients (Group B). Fat necrosis was observed in 17 patients (20.48 %) and 4 patients (7.55 %) from Groups A and B, respectively (p = 0.033). The average patient satisfaction scores at 6 months (comparing the reconstructed and contralateral breasts) were 7.01 and 8.02 in Groups A and B, respectively (p < 0.001). Liposuction to improve the upper-pole contour was performed at 6 months for 13 patients in Group A, although no patients in Group B required a secondary procedure (p = 0.002). Fat necrosis can be reduced via selective salvage of zones 2 and 4, based on the pedicled TRAM flap's vascular anatomy. Furthermore, superior aesthetic outcomes can be achieved via flap insetting using the three-dimensional concept. Level of evidence Procedure comparison, Level II.

Modification of the Elevation Plane and Defatting Technique to Create a Thin Thoracodorsal Artery Perforator Flap.

BACKGROUND: Perforator flaps have been used extensively in the field of reconstruction, and the thoracodorsal artery perforator (TDAP) flap is very popular. However, the perforator flap can be relatively bulky in some cases, depending on the defect's location. Thus, several methods have been developed to address this bulkiness, including modification of the flap elevation, application of an ultrathin flap using microdissection, and the defatting technique. However, these methods have various disadvantages, so we developed an adjustable thin TDAP flap using modification of the flap elevation and defatting technique. METHODS: Between January 2012 and February 2015, 13 patients underwent reconstruction of defects of their upper and lower extremities using TDAP flaps. We measured all the flap dimensions, except for thickness, because it was adjusted for the target defect. RESULTS: The mean flap size was 94 cm(2) (range: 48-210 cm(2)), and all flaps were ≤10 cm wide to facilitate primary donor-site closure. Two subjects with a history of diabetes exhibited partial flap loss, so we performed secondary skin graft surgery. CONCLUSIONS: The TDAP flap elevation was modified at the superficial fascia plane, and the defatting technique was used to adjust the flap volume. This technique provided more natural contours and minimized the need for secondary debulking.