Chest wall perforator flaps in partial breast reconstruction after breast conservation surgery: an additional oncoplastic surgical option

Chest Wall Perforator Flaps in Breast Conservation: Versatile, Affordable, and Scalable: Insights from the Largest Single-Surgeon Audit from India

Chest wall perforator flaps (CWPFs) are a promising option for partial breast reconstruction but are underutilized, particularly in resource-limited settings. This retrospective observational study explores the feasibility and impact of CWPFs in breast-conserving surgery at our single-surgeon center, where 203 procedures were performed between 2018 and 2023. We evaluate 200 cases treated after multidisciplinary tumor board discussions and shared decision-making, assessing clinicopathological data, surgical outcomes, oncological results, cosmetic outcomes, and patient-reported outcome measures (PROMs). The median age of patients was 52.5 years. Single CWPFs were used in 75.9% and dual flaps in 24.1%. Sentinel node biopsy was performed in 76.9% of malignant cases, with no positive margins. Minor complications occurred in 11%, and no major complications were reported. At a 27-month median follow-up, the overall survival rate was 97.5%, with a disease-free survival of 92.1%. Cosmetic outcomes were good-to-excellent, and PROMs indicated high satisfaction. This largest single-surgeon study from Asia demonstrates the transformative role of CWPFs in breast conservation surgery for Indian women with sizable, locally advanced tumors. The technique offers excellent oncological and cosmetic outcomes, reduced costs, and a shorter operative time, highlighting the need for oncoplastic algorithms in resource-limited settings to improve breast conservation accessibility.

Application of chest wall perforator flaps in oncoplastic breast-conserving surgery

OBJECTIVE

This study aims to explore the application value of chest wall perforator flaps (CWPF) in oncoplastic breast-conserving surgery.

METHODS

A retrospective review was conducted on 22 early-stage breast cancer patients who underwent oncoplastic breast-conserving surgery using CWPF between January 2021 and December 2022. This included 4 cases (18.2%) utilizing lateral intercostal artery perforator (LICAP) flaps, 10 cases (45.4%) employing lateral thoracic artery perforator (LTAP) flaps, 4 cases (18.2%) combining LICAP and LTAP flaps, and 4 cases (18.2%) using anterior intercostal artery perforator (AICAP) flaps. The perforators used in this study included lateral thoracic artery perforators (LTAP), anterior intercostal artery perforators (AICAP), and lateral intercostal artery perforators (LICAP). In some cases, a combination of LICAP and LTAP was employed to ensure adequate blood supply. All flaps were supplied by dominant perforators, with some cases using multiple perforators to enhance flap perfusion and survival. Our single-center experience with CWPF, including surgical details, complications, aesthetic, and oncological outcomes, is reported.

RESULTS

Among all patients, tumors were located in the outer quadrant (68.2%), central quadrant (13.6%), and inner quadrant (18.2%) of the excision cavity. In the 22 patients, 15 tumors were located in the outer quadrant: 6 in the left upper outer quadrant (1-2 o'clock), 4 in the right upper outer quadrant (10-11 o'clock), and 5 in the outer quadrants (3 o'clock in 3 cases and 9 o'clock in 2 cases). Four tumors were in the lower inner quadrant: 2 in the left lower inner quadrant (7-8 o'clock) and 2 in the right lower inner quadrant (4-5 o'clock). Three tumors were in the central area extending toward the outer quadrant. All tumors were located more than 2 cm from the nipple-areola complex (NAC), and intraoperative frozen sections confirmed negative margins behind the NAC. All patients had negative surgical margins. The average operative time was 100.5 ± 10.2 min, with flap lengths ranging from 10 to 18 cm and widths from 4 to 10 cm. All flaps survived, with only one instance of surgical site infection, which improved with conservative treatment. Overall patient satisfaction was rated as excellent or good in 85.6%, and physician evaluation was 89.0% excellent or good. In addition to subjective patient and surgeon satisfaction surveys, objective aesthetic outcomes were evaluated using the BCCT.core software. This tool provided a standardized assessment of breast symmetry, contour, and cosmetic outcomes, enhancing the objectivity and reproducibility of the cosmetic evaluation in the study. The median follow-up period was 14.5 months, with one case of tumor recurrence and no patient mortality.

CONCLUSION

CWPF can be effectively used in small-to-medium volume, non-ptotic breasts for oncoplastic surgery, yielding high patient satisfaction. In the era of oncoplastic breast surgery, chest wall perforator flaps are a reliable and safe option for partial breast reconstruction with acceptable aesthetic results.

Chest wall perforator flap reconstruction in breast conserving surgery: quality of life and limited complications in outpatient treatment

BACKGROUND

Breast conserving surgery (BCS) with partial breast reconstruction (PBR) results in less morbidity, better cosmetic outcomes, and improved patient satisfaction compared to mastectomy. Perforator flap reconstruction can attenuate defects prone to breast deformity after BCS. Usually, postoperative drains and inpatient admission are part of this treatment. The main objective of this study is to report on postoperative complications and patient satisfaction after drainless perforator flap reconstruction by a dedicated breast surgeon.

METHODS

In a retrospective case series, 42 patients were included. All patients underwent BCS with drainless perforator flap reconstruction, planned and performed by a single breast surgeon. Outcomes were complication incidence and patient satisfaction reported in the Breast-Q Breast Conserving Therapy (BCT) module.

RESULTS

In the study cohort, the median age was 59.5 (49.8-71.3) years. Tumour types were ductal carcinoma in situ (DCIS, four patients, 9.5%), invasive no special type (NST, 22 patients, 52.4%), invasive lobular (12 patients, 28.6%), and other invasive cancers (4 patients, 9.5%). Complication incidence was seven of 42 patients (16.7%), including hematoma, seroma, wound dehiscence, fat necrosis, and lymphedema, all Clavien Dindo grade 0-1, without readmission or reoperation. Reported Breast-Q scores (median of 17 months after surgery) were 87/100 for psychosocial well-being, 82/100 for breast satisfaction, and 71/100 for physical well-being. Outpatient treatment was successful in 38 patients (90.5%), and 13 patients (31.0%) had an unplanned visit to the outpatient clinic.

CONCLUSION

Drainless perforator flap reconstruction performed by the breast surgeon results in high patient satisfaction and limited complications, both in number and severity. The use of drains and hospital stays after perforator flap reconstruction must be discouraged.

Bilobed lateral artery perforator-based flap for partial breast reconstruction - Technique description and results from a ten-year cohort

INTRODUCTION

We present a new technique, the bilobed lateral artery perforator-based flap, for breast-conserving surgery of large central tumors or nearby, combining Zymany's bilobed flap and a Lateral Intercostal Perforator (LICAP) flap, and its 10-year outcomes.

MATERIALS AND METHODS

We studied 37 patients with malignant breast tumors near or involving the central skin, without ptosis or desire to correct it, who avoided mastectomy with this modified bilobed flap from 2013 to 2022. The same surgeon operated on them in different institutions. This research project was approved by our ethical committee (n. 2.322.212).

RESULTS

The mean age was 57.17 (±12.60) years. The mean specimen weight was 74.32 (±25.84)g, and the mean tumor size was 40.35 (±15.81) mm. Fourteen (37.84 %) tumors were larger than 5 cm and one was multicentric. Thirty-two (86.49 %) patients had invasive ductal carcinomas. Nipple areola complex was removed in 19 (51.35 %) cases due to clinical involvement, and immediately reconstructed in two cases with contralateral free grafting. Twenty-one (56.76 %) patients received neoadjuvant chemotherapy. Three (8.11 %) patients had immediate contralateral mastopexy. Radiotherapy was indicated in all cases. There were 3 (8.11 %) minor complications, one positive margin, and no surgical revisions. In a mean follow-up of 39.97 (±29.43) months, there were no local recurrences, 2 metastasis, and one death. Satisfaction and aesthetic results were good or excellent in most cases.

CONCLUSIONS

The new technique enabled breast conservation, with high rates of free margins, high levels of satisfaction, few complications in women with large central tumors on small breasts with limited ptosis.

Combined perforator flaps for total breast reconstruction-a narrative review and insights from massive weight loss cases

Background and Objective

Perforator flaps have revolutionized autologous breast reconstruction, introducing both free and pedicled options as well as the potential for combining flaps. These versatile techniques can be utilized in massive weight loss (MWL) patients, effectively addressing both functional and aesthetic challenges by using their excess skin. This review aims to explore literature on combined pedicled and free perforator flaps for total breast reconstruction, and share our own experience in the field.

Methods

A PubMed search up to June 2023 employed Medical Subject Headings (MeSH) terms such as (("combined") OR ("stacked") OR ("conjoined") AND ("perforator flaps")) AND ("breast reconstruction"). Publications in English and Scandinavian languages were manually screened for relevance, and supplemental sources were also reviewed.

Key Content and Findings

Limited studies exist on using combined pedicled and free flaps for total breast reconstruction, although combined free flaps are more common. Perforators around the breast base, offer multiple flap options for single or combined use. In our series of 10 women, four underwent total breast reconstruction with a combination of flip-over internal mammary artery perforator (IMAP) flap and thoracodorsal artery perforator (TDAP) flap. Another subset of four, who were MWL patients, received combined TDAP and superior epigastric artery perforator (SEAP) flaps, along with body contouring procedures such as upper body lifts and vertical abdominoplasties, addressing excess skin and improving silhouette. One remaining MWL patient had deflated breasts restored using TDAP and SEAP flaps, along with an upper and lower body lift and vertical abdominoplasty. The last MWL patient underwent a risk-reducing mastectomy, also reconstructed with TDAP and SEAP flaps, and received an upper body lift and vertical abdominoplasty.

Conclusions

Combined perforator flap techniques for combined body contouring and breast reconstruction seems safe and especially suitable for MWL patients. They offer a surgical alternative merging body contouring and breast reconstruction in cases where free flap procedures seem less favorable due to skin laxity and deflation of donor sites. However, limited literature on the topic calls for further studies.

Combining Wise-pattern Volume Displacement and Autologous Volume Replacement to Facilitate Oncoplastic Breast Conservation

Background

Oncoplastic breast conservation has been classically divided into volume displacement (VD) or volume replacement (VR) techniques. There have been few descriptions of merging these two approaches. This report describes our experience combining Wise-pattern VD and autologous VR to repair extensive partial mastectomy defects in patients with ptosis.

Methods

A retrospective chart review was performed for patients who underwent combined Wise-pattern VD surgery and autologous VR by the author from June 2017 to June 2023, with at least 6 months follow-up. Patient demographics, oncological and intraoperative details, and complications were recorded.

Results

Forty patients underwent Wise-pattern VD surgery combined with a medial intercostal artery perforator flap (five patients), lateral thoracic artery perforator/lateral intercostal artery perforator flap (18 patients), anterior intercostal artery perforator flap (five patients), or muscle-sparing latissimus dorsi flap (12 patients). The average tumor size was 4.0 cm (range, 1.5-9.1 cm), and specimen weight was 152 g (range, 33-415 g). Six patients (15%) required re-operation for positive margins. There was delayed healing of three (7.5%) donor sites. There were no flap failures. Two (5%) patients had clinically apparent fat necrosis without requirement for surgical revision.

Conclusions

This report demonstrates the feasibility of combining Wise-pattern VD and autologous VR. We propose that oncoplastic breast-conserving surgery be no longer divided into two mutually exclusive approaches and that surgeons make liberal use of combining these approaches to address challenging cases of breast-conserving surgery.

Chest wall perforator flap partial breast reconstruction: a retrospective analysis of surgical, cosmetic and survival outcome

Introduction

Oncoplastic breast surgery includes volume replacement as well as volume displacement. Autologous tissue is the preferred approach for volume replacement and includes chest wall perforator flaps (CWPF). Although described more than a decade ago, CWPFs have not been adopted widely in clinical practice till recently. We report the largest single-centre institutional data on CWPFs.

Patients and methods

The study includes all patients who underwent breast conservation surgery (BCS) using CWPFs from January 2015 to December 2022. Data were retrieved from the institutional electronic record and Redcap database. The analysis was done using SPSS 23 and STATA 14.

Results

150 patients were included in the study. The mean age was 48.8 years (SD 10.4), and the body mass index was (26.6 kg/m2, SD 4.3). >50% of patients had breasts with small cup sizes (A&B) and mild ptosis (Non-ptotic and Grade 1 ptosis). 44.7% of patients underwent lateral intercostal artery perforator flap (LICAP), anterior intercostal artery perforator flap in 31.3%, lateral thoracic perforator flap (LTAP) in 12%, LICAP + LTAP in 11.3% and thoracodorsal artery perforator flap in 1%. Post-operatively, haematoma was seen in 1.3%, complete flap necrosis in 1.3%, seroma in 7%, wound dehiscence in 12%, and positive margin in 6.7%. 92 patients responded to the satisfaction assessment, of which >90% were happy with the surgical scars, comfortable going out in a public place, satisfied with the symmetry of the breast, and no one chose mastectomy in hindsight. The 5-year predicted disease free survival and overall survival were 86.4% and 94.7%, respectively.

Conclusion

BCS with CWPF is an excellent option for reconstruction in small to medium-sized breasts. It is associated with minimal morbidity and comparable patient-reported cosmetic and survival outcomes.

The Extended Chest Wall Perforator Flap: Expanding the Indication for Partial Breast Reconstruction

Background

The intercostal artery perforator flap has traditionally been used to reconstruct small or moderate-sized single defects in the lateral or lower medial breast during breast-conserving surgery. We report a modification of the intercostal artery perforator flap that allows for reconstruction of larger breast tumors than previously described flap designs.

Methods

A retrospective study of breast cancer patients undergoing breast-conserving surgery and immediate partial breast reconstruction with an extended chest wall perforator flap. Primary outcomes were successful tumor excision, adequate radial margins, postoperative complications, and delays to adjuvant radiotherapy.

Results

Thirty patients were included. Mean radiological tumor size was 27 mm (11-56 mm) and excision volume, 123 cm3 (18-255 cm3). All tumors had satisfactory excision margins, and no patient required further surgery for re-excision. In the early postoperative period, one patient required radiological drainage of seroma, and one returned to theater for debridement of fat necrosis affecting the flap. Ten other patients were managed on an outpatient basis for minor wound complications. All patients were followed up annually for 5 years. No patients had a delay to adjuvant treatment or required revisional procedures for cosmesis.

Conclusions

The modified chest wall perforator flap allows for breast conservation for larger tumors from all quadrants of the breast, including centrally located tumors and reconstruction of the axillary defect following lymph node clearance. The length of the flap allows for the use of multiple perforators in the pedicle area and freedom of the flap to reach the defects. This can be performed with low morbidity and no delay to adjuvant radiotherapy.

Local Flaps to Cover Skin Necrosis after Skin-sparing Mastectomy and Prepectoral Reconstruction from PreQ-20 Trial

Background

In recent years, mastectomy has increasingly been indicated for women at high risk and those with breast cancer. Prepectoral reconstruction with polyurethane implant is an option for these patients. Nevertheless, this procedure can become complicated with exposure of the implant. The aim of this article is to describe the feasibility of local flaps to treat skin necrosis and dehiscence after prepectoral reconstruction and its impact on implant loss.

Methods

This study includes the women who met the inclusion/exclusion criteria of the PreQ-20 protocol (12), which assessed patients with exposed implant who required a local flap for its coverage. Three types of flaps were used: thoracoepigastric, lateral thoracic, and batwing.

Results

The study included 226 skin-sparing mastectomies and immediate reconstruction using prepectoral implants (52.7% bilateral mastectomies). Some 20.9% of the patients showed complications, with wound dehiscence the most frequent. Thirteen local flaps to cover the implant were performed. All flaps presented appropriate perfusion; however, the implant cover failed in six patients (46.2%).

Conclusions

The use of local flaps can be a low-morbidity option for preventing implant loss when skin dehiscence or necrosis occurs and delays in oncology treatments.

Practical oncoplastic surgery techniques needed for practice

Oncoplastic breast surgery (OPS) is a form of breast conservation surgery that includes immediate breast reconstruction. OPS has previously been shown to be a safe and effective treatment for breast cancer. In a special series on Breast Reconstruction, we aimed to describe oncoplastic breast reconstruction options and the corresponding technical details. Sections were divided by descriptions of OPS specific preoperative workup, volume displacement techniques, volume replacement techniques, and postoperative considerations. In addition, to sharing expert surgical pearls gained through performing OPS procedures over the years. Innovations in breast reconstruction offer women treatment options that are both oncologically safe and aesthetically preferred. The rise in reconstructive procedures is changing how patients make decisions based on their diagnosis. The ultimate surgical decision should be determined by the patient's anatomy, patient's personal preferences, tumor characteristics, and clinical presentation in a shared decision-making fashion with a multidisciplinary team. However, with both volume displacement and volume replacement techniques, women of all breast sizes can achieve an aesthetic outcome without sacrificing oncologic resection.

The Versatility of Lateral Chest Wall Perforator Flaps in Immediate and Delayed Breast Reconstruction: Retrospective Study of Clinical Experience with 26 Patients

Rationale: Lateral chest flaps represent versatile reconstructive options, especially valuable in times of global healthcare resource restriction. In this series, we present our experience with the use of lateral chest wall flaps in both immediate and delayed reconstruction from both breast conserving and mastectomy surgery. Methods: A retrospective cohort study of patients who had undergone a lateral chest wall flap for immediate or delayed breast reconstruction of a lumpectomy or mastectomy defect was performed. Data collected consisted of patient demographics, procedure type, tumor/oncological characteristics, as well as postoperative complications. Findings: Between September 2015 and April 2021, 26 patients underwent breast reconstruction using a lateral chest wall flap. Fifteen patients (58%) underwent immediate reconstruction (9 lumpectomy; 6 mastectomy) and 11 (42%) underwent delayed breast reconstruction. All flaps survived, though 1 patient required partial flap debridement following venous compromise hours after surgery. There were no incidences of hematoma, seroma, infection, or wound healing delay at either the donor site or breast. There was one positive margin which occurred in a mastectomy patient. Significance: This study describes the use of lateral chest wall flaps in a wide variety of reconstructive breast surgery scenarios. This technique can be safely performed in an outpatient setting and does not require microvascular techniques. Review of our outcomes and complications demonstrate that this is a safe and effective option. Our experience is that this is an easy to learn, versatile flap that could be a valuable addition to the surgeon's arsenal in breast reconstruction.

Risk Factors for Postoperative Complications Following Aesthetic Breast Surgery: A Retrospective Cohort Study of 4973 Patients in China

BACKGROUND

The popularity of aesthetic breast surgery in China results in greater demand for assessing risk factors for complications and mortality.

OBJECTIVES

To determine the incidence and independent risk factors for postoperative complications following aesthetic breast surgery in China.

METHODS

A retrospective cohort study on 4973 patients who had aesthetic breast surgery between 2012 and 2021 was performed. Postoperative complications include minor complications (incision healing impaired, hematoma, or fat liquefaction) and surgical site infection (SSI), which were recorded within 30 days after surgery. The follow-up time was expanded to 1 year only after prosthesis implantation procedures. Potential risk factors including age, weight, length of hospital stay, operation time, volume resection, incision location, and other clinical profile information were evaluated.

RESULTS

Among 4973 patients who underwent aesthetic breast surgery, the minor complication rate was 0.54%, and SSI was 0.68%. Augmentation with prosthesis implantation had the highest SSI rate (4.23%), which was significantly associated with increasing age (relative risk [RR] 1.12; P < 0.01) and periareolar incision (RR 5.87, P < 0.01). After augmentation with autologous fat transplantation, postoperative antibiotic use (RR 6.65, P < 0.01) was an independent risk factor for SSI. After adjusting for weight, volume resection over 1500 g (RR 14.7, P < 0.01) was an independent risk factor for SSI of reduction-mastopexy surgery. The complication rate of reduction mammaplasty (1.01%) and gynecomastia correction was lower (0.75%), and there was no record of complication in mastopexy procedures (n = 161).

CONCLUSION

The incidence of postoperative complications following aesthetic breast surgery is low. Risk factors for complications mainly include increasing age, perioperative antibiotic use, periareolar incision, and extensive volume resection. Much more attention should be focused on those high-risk patients in clinical practice to decrease breast infection.

LEVEL OF EVIDENCE IV

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 .

Safety and efficacy of anterior intercostal artery perforator flaps in oncoplastic breast reconstruction

INTRODUCTION

Partial breast reconstruction based on the anterior intercostal artery perforators (AICAP) has been suggested to avoid the unsightly 'bird's beak' deformity for lower pole breast cancers. The aims of this study were to evaluate the initial clinical experience of AICAP flaps in terms of safety and efficacy in oncoplastic breast reconstruction.

METHODS

Between October 2013 and April 2020, AICAP flaps were offered to 30 patients with lower pole breast cancers. Hand-held Acoustic Doppler assessments were undertaken to confirm adequate perforators. Surgical results were evaluated in terms of safety and efficacy. Patients were invited to complete sections of the Breast-Q questionnaire at least 12 months postoperatively to assess patient satisfaction in terms of cosmetic outcome, physical and psychosocial wellbeing.

RESULTS

Median operating theatre time for AICAP flap harvesting and positioning was 20 min (range 15-28 min). The median weight of resected breast specimens was 41 g (range 10-127 g). Total tumour size ranged from 7 to 35 mm (median 16 mm; three cases exhibited multifocal disease). Clear radial resection margins were achieved in 29 cases (96.7%). The median post-operative stay was two days (range 2-3 days). There were two postoperative complications comprising delayed wound healing/fat necrosis, which resolved with monitoring and inadine dressings. Based on the Breast-Q results, patients reported high levels of satisfaction with the physical appearance of their reconstructed breast, psychosocial and physical wellbeing.

CONCLUSION

AICAP flaps appear to be safe in restoring breast contour after wide excision of lower pole breast cancers, with high levels of patient satisfaction reported postoperatively.

Partial Breast Reconstruction with Lateral Chest Wall Perforator Flap to Facilitate Breast Conservation in Breast Cancer: First 100 Cases with Cancer Outcomes at 8 Years Follow-Up and the Lessons Learned

Background

This is a prospective cohort study of partial breast reconstruction (PBR) with a lateral chest wall perforator flap (LCWPF) to facilitate breast conservation surgery (BCS) for women undergoing surgery for breast cancer. The study was undertaken to study the clinical and cancer outcomes.

Methods

Patients diagnosed with ductal carcinoma in situ (DCIS) or breast cancer who consented to undergo BCS with PBR with LCWPF were included in the study. A prospective database has been maintained to collect information on clinico-pathological features, complications, and follow-up. Patients were asked to complete an anonymised PROM questionnaire over the years. The hospital electronic records were interrogated for women who have completed 5 years follow-up to assess for development of recurrence/events.

Results

A total of 105 patients underwent PBR with LCWPFs between 2011 and 2018. Of these, 74% underwent cancer resection and PBR as one operation whilst 26% underwent PBR as a two-stage approach. The median tumor size on pre-op imaging was 30 mm for the one-stage approach and 39.5 mm for the two-stage approach (p-value=0.003). The complication rates were low and the re-operation rate for close margins was 10%, with 4% eventually requiring mastectomy. Good-to-excellent esthetic outcomes were reported in more than 80% of cases by patients and clinicians. The local recurrence rate (LR) was 2%, distant recurrence rate 10.5%, disease free survival (DFS) 86%, distant disease-free survival (DDFS) 89% and overall survival (OS) 94.8% at 4.5 years median follow-up. This procedure provides an effective oncological approach, avoiding mastectomy with a good-to-excellent cosmetic outcome. The follow-up data establishes the safety of this approach.

Discussion

This is the first published series of recurrence and survival data in patients undergoing PBR. We intend to continue with data collection to assess long-term outcomes beyond 10 years. The authors would recommend consideration of this technique to facilitate BCS and avoid mastectomy.

Registration

Not applicable.