Article

The Versatility of the Inter-costal Artery Perforator (ICAP) flaps

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Abstract

Anatomy and classification of intercostal perforator flaps in addition to our experience with will be demonstrated for different indications. The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They are classified as following: dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery perforator (LICAP); and anterior intercostal artery perforator (AICAP) flap. Between 2001 and 2004, 20 pedicled (ICAP) flaps were harvested in 16 patients. The indications were: immediate partial breast reconstruction in eight patients who had a quadrantectomy for breast cancer; midline back and sternal defects in three patients who had radical excisions for a dermatofibrosarcoma or malignant melanoma; and autologous breast augmentation (four bilateral and one unilateral flap) in five post-bariatric-surgery patients. The average flap dimension was 18 x 8 cm(2) (range 8 x 5-24 x 12 cm(2)). There were two DICAP flaps, two (AICAP) flaps and 16 (LICAP) flaps. All but two flaps were based on one perforator. Mean harvesting time was 45min for a single flap. Bilateral breast augmentation with LICAP flap necessitated longer operative time (range 2-3h) depending whether it was combined or not with mastopoexy. Complete flaps survival was obtained. All donor sites were closed primarily. The (ICAP) flaps provide valuable options in breast surgery; and for challenging defects on the trunk without sacrifice of the underlying muscle.

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... McCulley et al. described the vascular anatomy and usage of LTAP flap in partial breast reconstruction [3]. The classic LICAP flap technique and the anatomy of lateral intercostal artery perforators were well described by Hamdi et al. [4]. Meybodi et al. added few modifications to overcome the limitations of the classic LICAP flap, avoiding the need to reposition the patient from the supine to the lateral position to harvest the flap. ...
... Hamdi et al. described the classic technique for LICAP flap [4]. In our study, we started by performing the classic technique in the first three patients (11.5%), then we introduced few modifications as our learning curve progressed in the subsequent patients (88.5%). ...
... The majority of authors reported using handled Doppler to locate and mark the perforator pre-operatively [3,4,8], and sometimes intra-operatively [9]. In our study, we used the handheld doppler to mark the perforator pre-operatively. ...
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Background Breast conserving surgery (BCS) has been a standard procedure for the treatment of breast cancer instead of mastectomy whenever possible. Lateral chest wall perforator flaps are one of the volume replacement techniques that participate in increasing the rate of BCS especially in small- to moderate-sized breasts with good cosmetic outcome. In this study, we tried to evaluate the outcome of those flaps as an oncoplastic procedure instead of the conventional flaps. Methods This study included 26 patients who underwent partial mastectomy with immediate reconstruction using lateral chest wall perforator flaps in the period from October 2019 to November 2020. The operative time, techniques, and complications were recorded. The cosmetic outcome was assessed 3 months post-radiation therapy through a questionnaire and photographic assessment. Results Lateral intercostal artery perforator (LICAP), lateral thoracic artery perforator (LTAP) and combined flaps were performed in 24, 1, and 1 patients, respectively. The mean operative time was 129.6 ± 13.2 min. The flap length ranged from 10 to 20 cm and its width from 5 to 9 cm. Overall patients’ satisfaction was observed to be 88.5% as either excellent or good and the photographic assessment was 96.2% as either excellent or good. Conclusions Lateral chest wall perforator flaps are reliable and safe option for partial breast reconstruction with an acceptable aesthetic outcome. In the era of oncoplastic breast surgery, they deserve to gain attention especially with the advantages of some modifications added to the classic technique.
... This study showed that CWPFs offer an excellent option for partial breast reconstruction in women with small and medium-sized breasts, with good patient-reported aesthetic outcomes and minimal morbidity. Various CWPFs used in partial breast reconstruction are reported in the literature, including TDAP, LTAP, LICAP and AICAP [6][7][8][9]. Apart from TDAP, all of these flaps were used in our series. We found that CWPFs could be used for tumours located in any quadrant of the breast although they were most frequently used laterally, and rarely in the upper inner quadrant. ...
... Hamdi [7,9] reported the first use of LICAP and AICAP flaps in partial breast reconstruction. The LICAP flap is based on perforators originating from the intercostal segment of the intercostal vessels, which are commonly found in the 5th to 7th intercostal spaces between 2.5 and 3.5 cm medial to the anterior border of the LD muscle [10]. ...
... In our series too, the LICAP flap was used most frequently, in 23 patients, all of whom had tumours located in the lateral quadrant of the breast (Figure 1-superolateral quadrant tumour excision with LICAP flap). The AICAP flap is based on perforators originating from the muscular or rectal segment of the intercostal vessels, which are located within 1-3 cm lateral to the sternal border [9]. The flap is suitable for defects in the medial aspect of the breast. ...
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Partial breast reconstruction using chest wall perforator flaps (CWPF) is a recent option used by breast surgeons, mainly for lateral quadrant defects with a relatively large volume of excision. We report a single-centre experience of CWPF with surgery details, complications, re-excision, aesthetic and oncological outcomes. This was a prospective observational cohort study of patients who had undergone breast conservation surgery (BCS) plus CWPF reconstruction. All variables were recorded prospectively in the institutional database. A survey was done to analyse patient satisfaction at about 6 months after completion of radiotherapy. Forty patients had CWPF based reconstruction in 3 years. 57.5 % of patients had lateral intercostal artery perforator (LICAP) flap, 5% had lateral thoracic artery perforator (LTAP) flap, 27.5% had combined LICAP plus LTAP and 10% patients had anterior intercostal artery perforator (AICAP) flap. Tumour excision cavity defect was of the lateral quadrant in 82.5%, central quadrant in 10% and medial quadrant in 7.5% of patients. The margin was positive for five patients, out of which four required cavity shave and one had a mastectomy. One patient had complete flap loss, and two patients developed surgical site infection. 96% of patients were satisfied with the scar, and 88% were happy with the treated breast in comparison to the opposite breast. 92% were comfortable going out in public and felt that in retrospect their decision not to have a mastectomy was correct. With a median follow up of 18 (10, 22) months, one patient died, and four had recurrences. CWPF may be used for partial breast reconstruction in the small non-ptotic breast with excellent outcome and high patient satisfaction scores.
... The PICA is divided into four segments, vertebral, costal, intermuscular, and rectus, based on the neurovascular branching pattern [4]. PICAPs arise from the vertebral segment while PLs and LICAPs originate from the costal segment [5]. ...
... Hamdi et al. [4] used PICAPs to cover back defects from the lower neck to the lumbosacral area and LICAPs Page 2 of 9 Elzawawy and Kelada World Journal of Surgical Oncology (2022) 20:244 for breast reconstruction with great success. They stated that the flap has a great versatility and can be used to cover large defects without sacrifice of the underlying muscles. ...
... Many studies [4,[6][7][8][9] focused on LICAPs for their importance in breast reconstruction. Few studies [4,10] described PICAPs and PLs. ...
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Background Posterior intercostal arteries perforators (PICAPs) and lateral intercostal arteries perforators (LICAPs) are great vascular pedicles. Between the 4th and 11th spaces, they arise from the thoracic aorta. These are large perforators that can be the basis of many flaps. Yet, these perforators are underrated as they are poorly studied and scarcely utilized in plastic reconstructions. Methods Twenty (ten males and ten females) adult cadaveric dissections were done on both sides to study the types, locations, and sizes of posterior intercostal perforators to help design flaps based on them in the best possible way. Perforators were assigned into one of 3 topographical zones of the back (medial, intermediate, and lateral). Results The skin of the back was divided into 3 vertical zones: medial, intermediate, and lateral. Posterior intercostal arteries perforators (PICAPs) were found in the medial and intermediate zones. Medial zone PICAPs were large and appeared at the medial border of erector spinae (Es). Intermediate zone PICAPs appeared at the lateral border of Es and passed through latissimus dorsi (Ld) before reaching the skin. Lateral zone perforators were branches of lateral intercostal arteries and were divided into 2 types: (1) posterior branches of lateral intercostal perforators: simply named posterior lateral perforators (PLs); they were small and present in most of the spaces, and (2) anterior branches of lateral intercostal perforators (LICAPs): they were large, dominant pedicles and were found mainly in the 4th to the 7th spaces. Conclusion PICAPs and LICAPs are constant and of enormous size and run for a great distance in the skin. They can be utilized as any type of flap.
... 9 Volume replacement techniques using perforator flaps for partial breast reconstruction are increasing in popularity. [10][11][12] Local perforator flaps are fasciocutaneous flaps based on the cutaneous perforators which arise from the underlying anatomically identifiable vessels. An important advantage of these flaps is that any underlying muscle is preserved which improves donor site morbidity. ...
... In recent times, there has been detailed description of the surgical anatomy and clinical application of these flaps. 10 The advantages of a local flap are the ability to fill defects in all quadrants, when the tumour to breast volume ratio is large (e.g. over 20%) thereby reducing mastectomy rates, and avoiding the need for contralateral symmetry surgery. ...
... The lateral chest wall perforator flaps are most commonly based on the LICAP vessels, which lie about 3cm anterior to the lateral edge of the LD muscle. 10 Multiple perforators can be located between the 5 th and 8 th intercostal spaces. The LTAP is also identified, anterior to the LD muscleapproximately at the anterior axillary line. ...
Article
Local perforator flaps may be utilised to correct volume defects after breast conserving surgery, improving the cosmetic outcome and avoiding the need for contralateral symmetrising surgery. The aims of this study were to assess longer term oncological outcomes following local perforator flap reconstruction and to demonstrate the learning curve associated with incorporating such techniques within routine clinical practice. We report a consecutive case series of 116 local perforator flaps performed between January 2014-May 2020. Data collected included patient demographics, tumour characteristics, surgical procedure data, complications and follow-up outcomes. All breast cancer patients are followed with annual mammographic surveillance for a minimum of five years. Of 116 procedures, 101 were performed as immediate partial breast reconstruction and 15 as delayed reconstructive procedures for patients who had prior breast surgery. Overall complication rate was 15%; the majority were minor surgical site infections, 1.7% required haematoma evacuation. At a median follow-up of 37 months, there were no local cancer recurrences. Three patients who underwent delayed reconstruction required revision procedures and one required a contralateral symmetrisation procedure. One patient in the immediate reconstruction group required additional lipofilling. Over time, the mean lesion size selected for immediate local flap reconstruction increased, operative times decreased and proportion of day-case procedures increased. Our data confirms that local perforator flaps are associated with low morbidity, excellent oncological outcomes and long-term durability. Use of local flaps can increase the range of indications for breast conserving surgery, reducing mastectomy rates and the associated revision and symmetrising procedures associated with them.
... In Total, 4 studies described partial breast reconstruction using LTAP flap 25,26,29,32 (combined with LICAP flap in some patients in 3 studies 25,26,32 ), 3 studies described partial breast reconstruction using LTD flap, 20,23,24 and 6 studies described partial breast reconstruction using LICAP flap. 21,22,27,28,30,31 A total of 432 patients were included, and the sample size of each study ranged from 8 to 87 patients. From the 432 included patients, 176 patients underwent an LTAP flap reconstruction (a combined LTAP + LICAP flap reconstruction in 103 cases), 76 patients underwent an LTD flap reconstruction, and 180 patients underwent an LICAP flap reconstruction. ...
... Preoperative identification of perforator vessels using a Doppler probe was described in all cases. Hamdi 21 and Roy 26 suggested performing Doppler evaluation, with the patient lying down simulating the intraoperative position. In addition, 2 studies 27,31 described that all patients underwent a 3-dimensional chest computed tomography angiography preoperatively to identify the dominant perforator vessel by its relationship with the LD muscle. ...
... Margin incision was carried down to the underlying anterior serratus and LD muscles, performing a suprafascial or a subfascial dissection. Hamdi 21 reported that pedicle's length of 3-5 cm is generally adequate to reach a defect over the lateral or superior part of the breast, and that if a longer pedicle is required, the dissection should be carried on within the costal groove. In addition, Hamdi 21 underlined that the lateral cutaneous nerve can eventually be stripped from the intercostal nerve to harvest a sensate LICAP flap. ...
Article
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Breast-conserving surgery followed by radiotherapy represents the standard of care for early-stage breast cancer. The aim of this article was to provide a review of the literature about the use of the lateral thoracic artery perforator (LTAP) flap, the lateral thoracodorsal (LTD) flap, and the lateral intercostal artery perforator (LICAP) flap in lateral partial breast defect. Methods: A literature search was performed via PubMed, Medline, and Cochrane. Patient's characteristics, topography and size of breast defect, flap size and design, number of perforators, and operative time were analyzed. Aesthetic and patient-reported outcomes, postoperative complications, and donor site morbidity were also registered. Results: Thirteen articles fulfilled inclusion criteria, and 432 patients were included. Different flap designs and flap combinations were described. Satisfactory outcomes were reported for between 78% and 100% of cases. Patient satisfaction ranged from 75.8% to 92.5% of cases. The overall complication rate was 9.25%, and donor site morbidity was very low (3.7%). Conclusions: A distinct advantage of LTAP, LTD, and LICAP flap reconstruction is that the thoracodorsal pedicle is not sacrificed, not compromising eventual delayed breast reconstruction with TDAP or latissimus dorsi flaps. This staged approach to partial breast reconstruction is especially useful in cases where the oncological margins are uncertain and wider resections (or mastectomies) are secondly required.
... 8,16 This group of flaps include the lateral thoracic artery perforator flap, the lateral thoracodorsal flap, the lateral intercostal artery perforator (LICAP) flap, or the thoracodorsal perforator flap. [17][18][19][20][21][22] These flaps are available in most patients and can be used to fill most defects of the superior, lateral, and inferior breast. Importantly, they are described with minimal donor site morbidity and the ability to maintain the blood supply to the latissimus dorsi for future reconstruction if needed. ...
... A number of studies have reported, through small and medium series of patients, on the safety of tissue replacement techniques during oncoplastic lumpectomy. 3,5,6,8,15,[17][18][19][20][23][24][25][26] With regards to the oncological safety of these flaps, authors 27 In our study, we had one positive margin that occurred in a patient treated with mastectomy. After thorough multidisciplinary review, it was thought that maximal resection was already achieved and the decision was made to complete her treatment with radiation alone. ...
... In some cases, these are performed by oncoplastic surgeons that perform both the resection and reconstruction. [15][16][17] One such study reports a positive margin rate of 13.4% with this approach. 16 At our center, we feel strongly that these cases should be managed as a multidisciplinary team with the oncologic breast surgeon working together with the plastic surgeon; each focused on their primary goal -oncologic clearance versus reconstruction of an aesthetically pleasing breast mound. ...
Article
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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.
... Growing experimental evidence shows that fasciocutaneous flaps are just as effective as muscle flaps in treating osteomyelitis and they also reduce donor-site morbidity 4 . Internal mammary artery perforator (IMAP) flap and lateral intercostal artery perforator flap (LICAP) are fasciocutaneous flaps supplied, respectively, by one muscle perforator arising from the internal mammary vessels and by one perforator arising from lateral intercostal artery [5][6][7][8][9] . We report the case of a patient affected by chronic cutaneous fistulas in sternum and ribs osteomyelitis, successfully treated with accurate debridement combined with reconstruction with IMAP flap and LICAP flap in the same procedure. ...
... IMAP flap has a good arc of rotation and considerable dimensions of its related perforasome, and can repair most defects of the anterior chest wall because of the wide angiosome of the internal mammary artery which spans from the clavicle to the 9 th rib and from the midsternal line to the anterior axillar line. LICAP flap has been described for defect coverage of different anatomical regions such as the back and sternal regions, or partial breast reconstruction or augmentation 8 . The aim of the reconstructive procedure is to provide a defect repair with no recurrence with minimal donor site morbidity and a good aesthetic outcome. ...
... 10 Over the past years, variable reconstructive techniques for soft tissue coverage of MMC defect have been described. [11][12][13] Such techniques, based on understanding the anatomy of the vascular perforators and the concept of angiosomes, were utilized to avoid the high failure rate of traditional closure in the past with extensive undermining and closure under tension. [11][12][13] Therefore, flap reconstructive procedures are preferred to minimize the risk of high complications associated with primary closure in large defects. ...
... [11][12][13] Such techniques, based on understanding the anatomy of the vascular perforators and the concept of angiosomes, were utilized to avoid the high failure rate of traditional closure in the past with extensive undermining and closure under tension. [11][12][13] Therefore, flap reconstructive procedures are preferred to minimize the risk of high complications associated with primary closure in large defects. Local flaps have been commonly described 14,15 ; however, one of the main issues that may arise is inadequate blood circulation associated with these random pattern flaps. ...
Article
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Background: Myelomeningocele is the most common phenotype of congenital neural tube defects. Various reconstructive techniques have been described for soft tissue coverage following myelomeningocele repair, one of which is the use of dorsal intercostal artery perforator based flaps. The aim of this study was to describe our experience with the use of a transverse-oblique back flap that can be reliably extended to the anterior axillary line for closure of myelomeningocele defect. This pedicle transposition flap is based on thoracic or lumbar paraspinal perforators that originate from the dorsal intercostal arteries. Methods: This is a retrospective two center case-series where all patients who underwent myelomeningocele defect closure with extended transverse-oblique flap over three years period were included. Patients' clinical data, surgical variables, and outcomes were documented and analyzed using descriptive measures. Flap harvest technique is also delineated in the present study. Result: Ten newborns (7 baby girls and 3 baby boys) who underwent a surgical closure of the myelomeningocele defect with an extended transverse-oblique back flap during the first week of life were included in the analysis. The defect was most commonly located in the lumbosacral area (50%) followed by the lumbar area (40%), with an overall average surface area of 22 ± 8.32 cm2. Common encountered complications include venous congestion to the distal part of the flap and minor wound dehiscence of less than 0.5 cm, all were managed conservatively. There were no incidences of flap loss or full necrosis. Primary closure of the donor site was possible in all cases. Conclusions: In the current series, the extended transverse-oblique back flap provided a safe and reliable coverage for myelomeningocele defect. Such a flap does not jeopardize other regional fasciocutanous or musclocutaneous flaps that might be needed for soft tissue coverage later in life for this population. It also obviates the placement of skin suture line over the repaired neural tube, thus yielding a durable coverage with no major complications or functional disability.
... INTRODUCTION morbidity and without including muscle tissue [6]. Intercostal artery perforator flaps have been used widely to cover the diverse trunk defects, based on an understanding of the anatomy of intercostal vessels [7][8][9][10][11][12]. Among them, dorsal intercostal artery perforator (DICAP) flaps have recently been described in posterior trunk reconstruction [13][14][15][16][17]. ...
... The DICAPs arise from the posterior intercostal artery at the vertebral segment. Consistent with the angiosome theory and recently published studies [20], the DICAP flap can be extended safely to capture adjacent perforasomes because of the extensive true anastomotic connections with the multiple surrounding perforators [10]. To date, the biggest DICAP flap elevated on a single perforator reported thus far was a 40 × 15 cm 2 propeller flap by Prasad and Morris [17]. ...
Article
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Posterior trunk defects have been a challenging anatomical area to cover in reconstructive surgery. The use of local myocutaneous flaps has been described extensively in the literature to cover these defects, but these techniques are associated with significant donor-site morbidity, including functional loss of muscle units. Freestyle perforator flaps enable local tissue recruitment with skin of a similar color and texture in diverse anatomic areas, but there is a shortage of case series on posterior trunk defects using propeller dorsal intercostal artery perforator (DICAP) flaps, particularly when the defects are extensive. In this report, the authors present a successful case of a DICAP propeller flap for an extensive defect on the upper back following a malignant peripheral nerve sheath tumor resection.
... https://doi.org/10.4048/jbc.2021. 24.e11 ...
... To minimize the scarification of functional muscles, perforator flaps, such as the intercostal artery perforator flap or the thoracodorsal artery perforator (TDAP) flap, can also be applied. However, TDAP is a method that can be used selectively for a laterally located cancer in all areas, except the lower inner quadrant (LIQ) [24][25][26]. Compared with the classical preoperative design, all these surgical methods employ the concept of incision minimization, which incorporates the idea of scarless surgery. ...
Article
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Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has been accepted for decades, breast and plastic surgeons have been striving to develop more advanced surgical skills that ensure non-inferior oncologic outcomes with better cosmetic outcomes. Endoscopic or robotic devices, which are currently available only for chest or abdominal surgeries, could be used for breast surgery to ensure better cosmetic outcomes. The authors refer to this surgical concept as "aesthetic scar-less breast surgery and reconstruction," a term that encompasses the consequential concepts rather than naming it with simple technical words such as endoscopy-assisted or robot-assisted surgery. The "scar-less" term simply means leaving less of a scar, and better results can be expected by designing incisions on invisible areas. Herein, we summarize our experiences with various techniques of "aesthetic scar-less" surgery and review the existing literature on this topic.
... The anterior intercostal artery perforator (AICAP) flap was originally described for sternal wound repair by Hamdi et al. 6 This study aimed to present a clinical experience using this new flap in patients who underwent bilateral implant explantation. The results were analyzed in terms of flap survival rate, postoperative aesthetic appearance, patient-reported data using BREAST-Q, and brassiere size. ...
... From previous experience, and a preoperative evaluation of these patients, it would have been impossible to maintain similar volume using only reorientation of the intrinsic breast tissue13 . To the best of our knowledge, this is the first study to elucidate the utility of a laterally extended AICAP flap in patients who underwent explantation of breast implants.Previous reports of AICAP flaps utilized the submammary area as the donor site[6][7] and demonstrated that the lateral thoracic wall tissue could be safely mobilized to the breast mound using the same perforator vascular pedicle. A complementary volume can be added to the commonly used local breast tissue in explantation cases. ...
Article
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Explantation of breast implants has become increasingly common. This study aimed to analyze breast auto-augmentation following implant explantation (using a laterally designed anterior intercostal artery perforator [AICAP] flap) in patients who did not need new implants and required volume preservation. Twenty-four patients (48 breasts) aged 31-67 (mean, 52.4) years with body mass index between 24.43 and 29.34 (mean, 27.32) kg/m 2 underwent this procedure. All patients had implant-related problems such as recurrent capsular contracture (n=11), seroma (n=2), animation deformity (n=3), rupture-induced bleeding (n=5), and breast implant disease (n=3). Sizes of implants removed ranged from 215 to 355 ml. The mean flap size was 23.9 cm × 7.5 cm, and the average flap thickness was 2.3 cm (range, 2.0-3.2 cm). Flap survival was clinically examined postoperatively by ultrasonography. Preoperative and postoperative final breast volumes were compared by direct patient observation and independent photograph observation by three plastic surgeons according to a four-point scale (bad=1, regular=2, good=3, and excellent=4) and the brassiere size. All flaps were completely viable after harvesting. No postoperative signs of fat necrosis were observed, and independent plastic surgeon evaluation revealed good and excellent results in all cases. Patient satisfaction evaluated by Breast-Q data was >90%. This new design AICAP flap (with a lateral thoracic extension) can be safely used for breast volume restitution after breast implant explantation with high patient satisfaction. This flap exhibited reasonable potential of providing additional volume in patients who undergo implant explantation and require the preservation of similar volume.
... The evolution of OBS has seen various surgical techniques being employed for partial breast reconstruction in an attempt to improve the aesthetic outcomes and reduce mastectomy rates. Volume replacement using chest wall perforator flap (CWPF) is one such procedure, initially used by Holmström and Lossing et al [35], and later popularised by Hamdi et al [36][37][38]. These flaps are based on perforators supplying the lateral chest wall; namely lateral intercostal artery perforators (LICAP), lateral thoracic artery perforator (LTAP) and thoraco-dorsal artery perforators. ...
... They have been shown to be oncologically safe with low morbidity and good recovery of shoulder function and do not involve muscle morbidity [36,39,53]. When compared with mastectomy and reconstruction, CWPF offers quicker recovery, lower complication rates and better aesthetic results [38,39,41]. With increasing experience, longer flaps can be reliably raised based on LICAP and LTAP to reach central quadrants defects for breast cancer management. ...
Article
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Background: Breast cancers located centrally require excision of nipple-areola complex. A simple central wide excision is a safe option but results in suboptimal aesthetic outcome. An oncoplastic option involves therapeutic mammoplasty with or without areolar reconstruction, limited to moderate and large ptotic breasts. For small non-ptotic breasts, most surgeons would resort to mastectomy with/without reconstruction. Methods: Lateral chest wall perforator flap (CWPF) is an option for partial breast reconstruction in small to moderate sized, non-ptotic breasts for laterally located tumours. We have extended the application of CWPF for central tumours to avoid mastectomy in selected patients. Results: We here present a case series of four patients with small to medium-sized non-ptotic breasts, who had centrally located breast cancer or ductal carcinoma in-situ (DCIS). Three patients had single stage CWPF reconstruction, and one had central excision with immediate reconstruction following a failed attempt at therapeutic mammoplasty. All had the areola reconstructed using flap skin; one patient had simultaneous nipple reconstruction. Conclusions: CWPF is an option for treatment of centrally located breast cancers/DCIS needing nipple-areola complex excision for patients wishing to avoid mastectomy. Patients with small to medium-sized non-ptotic breasts are suitable, and need to be carefully selected.
... The intercostal perforator flaps have fewer of these problems but it often does not have sufficient volume for full reconstruction after mastectomy (7,8). Volume replacement techniques after breast-conserving surgery using perforator flaps commonly include the anterior intercostal artery perforator (AICAP) and lateral intercostal artery perforator (LICAP) flaps (9,10). LICAP flap originates from perforators arising from the costal segment while AICAP flap originates from perforators arising from the muscular segment (9). ...
... Volume replacement techniques after breast-conserving surgery using perforator flaps commonly include the anterior intercostal artery perforator (AICAP) and lateral intercostal artery perforator (LICAP) flaps (9,10). LICAP flap originates from perforators arising from the costal segment while AICAP flap originates from perforators arising from the muscular segment (9). These perforator flaps have not been used for full reconstruction Abstract: Surgery is the mainstay of curative treatment for breast cancer with mastectomy offering the lowest risk of local recurrence. ...
... In contrast, our incision design is simple and flexible and can be used to repair defects in the entire lower quadrant. In addition, unlike ICAP flaps, our flap is folded into the residual cavity and covered by the breast skin and subcutaneous fat, while a chromatic difference may exist between an ICAP flap and the surrounding skin, which can affect the visual appearance of the breast (11). ...
Article
Background Here, we describe an innovative oncoplastic technique for small to medium volume breasts with a tumor in the lower quadrant and this technique could provide sufficient tissue to avoid visible defects after tumor removal and help reshape the natural shape of the breast.MethodsA detailed procedure for the folding flap technique is described step by step. Then, the results of a retrospective analysis of patients treated using this technique, including complications and disease recurrence rate, between January 2017 and November 2021 are reported. Aesthetic outcomes were evaluated on a 5-point scale proposed by the Paris Breast Center.ResultsA total of 52 patients underwent surgery with the folding flap technique, The average operation time was 98.4 min (range, 75–120 min), and the mean bleeding volume was 56.5 mL (range, 20–100 mL). A margin-positive result was confirmed in 1 patient who underwent re-excision. Short-term postoperative complications were observed in 7 patients, including 4 with fat liquefaction, 2 with seroma, and 1 with skin redness and swelling. No flap necrosis was observed. The median follow-up time was 28.6 months (range, 9–58 months), and 2 patients experienced local recurrence. The mean aesthetic score was 4.7 points, with 36 patients scoring 5 points and 26 patients scoring 4 points, respectively.Conclusions The folding flap technique, as an innovative and favorable oncoplastic technique for treating small- to medium-volume breasts with a tumor in the lower quadrant, could retain sufficient tissue to fill the residual cavity after the operation while improving the aesthetic outcome of the breast.
... In the augmentation mammaplasty by reverse abdominoplasty (AMBRA) technique [11], the upper abdominal panicle juxtaposed inferiorly to the breasts is poised for easy repositioning as adipofascial flaps to allow augmentation mammaplasty. Other autologous techniques exist such as bilateral de-epithelialized transverse rectus abdominis musculocutaneous flaps, extended transverse rectus abdominis musculocutaneous flaps, pedicled perforator flaps, and autologous fat transplantation, which are considered to have the same level of performance as synthetic implants [16][17][18][19][20][21]. ...
Article
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Background The lateral chest wall is intimately associated with the esthetics of the breast. Patients with massive weight loss often have excess skin and fat in the lateral thoracic region causing functional, esthetic, and psychological discomfort. In addition, the breasts exhibit extreme ptosis after weight loss due to a reduction in volume and projection that is exacerbated by qualitative changes in the skin, with loss of its natural elasticity. This article describes a reliable new technique for simultaneous autologous breast augmentation and lateral thoracic dermolipectomy to provide autologous tissue for breast augmentation and simultaneous rejuvenation of the chest wall. Case presentation A 30-year-old Caucasian woman who had lost 58 kg after bariatric surgery had major skin excess sequelae combined with major breast ptosis. She wanted to correct her brachial and lateral thoracic skin and fat excess, as well as rejuvenate her breasts. The lateral thoracic panicle present was harvested and transposed in the retroglandular plane to perform autologous breast augmentation with lateral thoracic dermolipectomy. Results The patient was totally healed and complication-free at day 15. Both esthetic results and patient satisfaction were good at 6 months post-surgery. Conclusions Superolateral thoracic flap augmentation mammaplasty during thoracic dermolipectomy is a simple and safe procedure for selected patients. Durable and natural autologous breast augmentation may be achieved in a single step without the need for a breast implant, while rejuvenating the thoracic region.
... The regional flaps can be performed with a wide tissue base (mostly with skin) ( ) or similar to the island perforant flaps. Different types of perforant flaps are well described in the literature and became more popular in oncoplastic breast surgery (18)(19)(20)(21). In our techniques are part of our concept of "invisible surgery" (22). ...
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Background: Oncoplastic breast conserving surgery (BCS) becomes the standard of care in multidisciplinary breast cancer treatment. From our perspective, the aim of oncoplastic BCS is the best oncological, aesthetic and functional surgical treatment results. The study's objective is to present our approaches to the selection of surgical techniques and determine operative and oncological outcomes of oncoplastic surgery. Methods: This retrospective study presents a single institution experience with patients who underwent oncoplastic BCS for breast cancer between 2007 and December 2020. Demographic and clinicopathologic characteristics as well as postoperative complications were analyzed. The analysis was performed by taking into account the types of procedures. Surgeries were categorized into two types: 1. volume displacement (level 1; advanced parenchyma displacements; therapeutic mammaplasties) and 2. volume replacement techniques (regional flaps with wide base, regional island perforant flaps). We consider as oncoplastic all the operations that are planned and performed taking into account an optimal aesthetic result regardless of the specific technique. Results: There were 833 surgeries performed for 823 cancer patients. In 153 cases, patients had symmetrized procedures. The average weight of specimens was 112,9 g (2-1034 g); the average size of tumors was 2,8 cm (0,2-15,8 cm). 106 patients (12,7%) had multifocal/multicentric tumors. In (3,8%) 32 cases involved margins were found and re-excision was required. 793 (96,4%) patients were on follow up. The median follow-up period was 48 months (6 164 months). Local recurrence was found in 10 (1,2%) patients, regional axillary recurrence in 2 (0,3%), systemic progression in 87 (11,0%) patients and 50 (6,2%) of them have died. Complications were observed in 190 (23,1%) patients, mostly seromas and ischemic disorders. Conclusions: We present our approaches to oncoplastic breast conserving surgery with focusing on the aesthetic results of the procedures. Oncological outcomes demonstrate the safety of advanced oncoplastic BCS in the framework of multidisciplinary teamwork.
... Hamdi et al. originally described the fifth anterior intercostal artery perforator as a perforator flap and were the first to isolate the flap on a single perforator for reconstruction of sternal defects. 17 Hallock performed the same flap and used the island intercostal perforator flap for coverage of epigastric abdominal wounds. 18 Persichetti et al. have described the use of the anterior intercostal flap for breast volume enhancement in postbariatric patients that was perfused by the fifth and sixth anterior intercostal artery perforators. ...
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Background: The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola com- plex following nipple-sparing mastectomy. Methods: Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple- sparing mastectomy in a woman with mammary hypertrophy is provided to dem- onstrate the utility of preserving the fifth anterior intercostal artery perforator. Results: The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nip- ple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perfora- tors are independent of one another. Conclusion: The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue inde- pendent of the Würinger fascia. (Plast. Reconstr. Surg. 149: 00, 2022.)
... If needed, simultaneous use of an inverted-T-mastopexy and a SEAP flap is possible, combining the horizontal scar in the reversed abdominoplasty scar. Combined use of the ICAP and SEAP flap is also possible and may add volume to the breast while correcting contour of the lateral axillary region as described by M. Hamdi et al. [18] Dissection of the SEAP flap is fast and does not increase the morbidity risk to patients since they often require excision of the excess skin-fat tissue epigastrically. Nevertheless, massive weight loss patients may have comorbidities that can be contraindications for long surgery or may compromise wound healing. ...
Article
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We present a surgical technique of recuperating tissue from the upper abdominal wall, based on the superior epigastric artery perforators, thereby providing tissue for autologous augmentation of the breasts in combination with reversed abdominoplasty in patients after massive weight loss. A 20-year-old woman was seen in the outpatient clinic with a large residual skin laxity of the superior abdomen following circular abdominoplasty after weight loss of 55 kg. She was dissatisfied with the appearance of her breasts and superior abdomen. Bilaterally, pedicled SEAP flaps were harvested from the epigastric region. In addition, a reversed abdominoplasty was performed. The flaps were secured in a retroglandular pocket superiorly to the anterior chest wall in order to augment the breasts. The islanded pedicled SEAP flap in combination with reversed abdominoplasty is a useful and safe technique for autologous breast augmentation following massive weight loss. In addition, the potential risk of implant-related complications is eliminated as implants are replaced by autologous tissue. Level of evidence: Level V, therapeutic study.
... Perforator flap reconstruction is a relatively new procedure. Although Hamdi et al described its use in partial breast reconstruction in 2006, 9,10 its popularity has picked up pace only recently. The two groups in this study were comparable. ...
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Background: Chest wall perforator flaps (CPF) and therapeutic mammoplasty (TM) are often done in patients with anticipated poor cosmetic outcome with level 1 breast conservation surgery. The aim of this study was to assess the complications and oncological outcomes between CPF and TM. Methods: Prospectively collected data of breast conservation surgery between September 2016 and January 2021 by a single surgeon were reviewed. Specific outcomes included complications needing intervention, re-excision and mastectomy rate, locoregional recurrence, and distant metastasis. Patients were followed up at 3 months and then every 12 months. Statistical analysis included chi-squared test and independent t test, and a P value of less than 0.05 was considered significant. Results: There was no statistically significant difference between CPF and TM with regard to patient characteristics except for BMI and bra cup size, which was significantly higher in the TM group. One patient who had TM returned to the operating room for a hematoma evacuation, and one patient who had CPF had fat grafting, for unsatisfactory cosmetic outcome. Five of the 30 patients having CPF had further re-excision surgery for inadequate margins, but none needed mastectomy, and four of the 43 patients having TM had further surgery (one had re-excision of margins and three had mastectomy) and this was not statistically significant (P = 0.346). There was no locoregional recurrence in CPF and TM groups after a median follow-up of 22 months and 25 months, respectively. Conclusion: There is no significant difference in early complications and oncological outcomes between CPF and TM.
... The lateral intercostal artery perforator flap is another alternative for lateral and inferior breast defects. 25 The anterior intercostal artery perforator flap is based on perforators originating from the intercostal vessels through the rectus abdominis or the external oblique muscles. Because it has a short pedicle, the anterior intercostal artery perforator flap is suitable to cover close defects that extend over the inferior or medial quadrants of the breast. ...
Article
Aesthetic concern is one of the main driving forces behind the popularity of the oncoplastic approach to breast conservation therapy. Oncoplastic options at the time of lumpectomy include volume replacement techniques such as flaps and volume displacement techniques such as the oncoplastic reduction. These techniques can be employed to ensure preservation of breast shape and contour, size and symmetry, inframammary fold position, and position of the nipple-areola complex. The importance of aesthetic outcomes is not only to improve overall patient satisfaction but also to minimize the need for revisional surgeries for shape and symmetry. The purpose of this review is to discuss ways to optimize the aesthetic result and to review the evidence behind aesthetic outcomes.
... This fasciocutaneous flap has also been used by others for post-mastectomy implant-based breast reconstruction with reliable results.17 Various authors18,19,20 have described partial breast reconstruction using pedicled perforator flaps from the intercostal perforators (AICAP, LICAP), lateral thoracic artery perforator (LTAP) and thoracodorsal artery perforators (TDAP). The LICAL/LTAP flaps are similarly harvested from the lateral chest wall with careful perforator dissection and pre-operative doppler is routinely done to identify the dominant perforator. ...
Article
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Plastic surgical principles are incorporated with breast conservation surgery (BCS) for cancer to improve aesthetic outcomes. In developing countries, average tumour size is larger at presentation resulting in larger resections often including overlying skin. LD flap has been the workhorse of partial breast reconstruction. We present an easy and effective alternative to LD flap for carefully selected cases of outer quadrant breast tumours. We report 41 cases of local transposition flap from lateral chest wall for oncoplastic restoration post BCS, performed between January 2016 and February 2020, at our institution. The median age was 49 years (28-63). Twenty-six patients underwent upfront surgery and 15 after neoadjuvant chemotherapy (NACT). The average pathological tumour size was 2.9 cm (median 2.7, 1.1-6) and 1.5 cm (median 1.8, range 0-3.5) for upfront and post-NACT groups, respectively. The median volume of resected specimen was 277.8 ml and 253.2 ml for upfront and post-NACT groups, respectively. Three patients (7.5%) had a microscopic positive margin requiring margin revision. Three (7.5%) patients had post-operative minor wound complications and were managed conservatively. At a median follow-up of 14 months (1-36), only 2/19 (10.5%) patients had clinical fat necrosis. Local transposition flap from the lateral chest wall based on dermal & subdermal plexus, carefully designed in selected patients, can be used effectively for reconstruction of outer quadrant breast defects. It is easy to learn, offers good cosmetic outcome, avoids the morbidity and time of LD flap, and saves LD flap for future use.
... [5][6][7][8] In the same manner, the intercostal perforator artery flap was mainly used to achieve partial breast reconstruction and was limited to lateral defects. 9 Based on the advances of vascular anatomy of the region and with the aim to simplify breast reconstruction while sparing the latissimus dorsi muscle, the senior author describes a new technique of breast reconstruction that is based on a thoracodorsal paddle turned in a flip-over pattern without perforator dissection and is associated with lipofilling and internal loops to achieve a total breast reconstruction. ...
Article
Introduction The use of the thoracodorsal musculocutaneous flap has been limited to donor site complications, whereas the thoracodorsal fasciocutaneous flap spares the muscle and limits morbidities. Our objective is to describe a new technique of breast reconstruction using an extended lateral thoracic (ELT) flip-over flap combined with loops and lipofilling (ELT FOLL) to achieve better breast remodeling. Methods Between 2013 and 2018, 64 patients underwent breast reconstruction using an ELT FOLL. The flap is designed in an elliptical transverse pattern and extends 2 cm lateral to the back midline up to the breast axis at the level of the inframammary fold. The surgical technique consists of an infiltration and tunnelization of the breast recipient site and surrounding area, deepithelialization of the skin paddle, and additional preparation of the flaps and loops. Liposuction is performed using the power-assisted liposuction and lipofilling technique, and lipofilling is achieved throughout the thoracic cutaneous surface of the reconstructed site, particularly into the lower quadrant of the breast. Results Among the reconstructions, 73.4% was delayed and 92.2% was unilateral. A fourth of the patients were smokers, and 39.1% received radiotherapy. The total complication rate was 8.7%, the patient's shoulder function was not affected at long term, with the DASH score rising from 6.53 preoperatively to 11.32 at 6 weeks and 7.52 at 6 months. The average operative time was 57 min, and drains were removed at day one after surgery. Conclusion The ELT FOLL should be considered a simple, safe, and reliable alternative for breast reconstruction.
... The introduction of chest wall perforator f lap (CWPF) to partially reconstruct breast [1,2] has revolutionized the way an Oncoplastic surgeon can approach breast conserving surgery. The consistent and robust nature of various chest wall perforators has led to its widespread acceptance amongst oncoplastic breast surgeons and plastic surgeons. ...
Article
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We describe the use of chest wall perforator flap (CWPF) to reconstruct the central mound of breast tissue in women presenting with central/retro areolar breast cancer. We describe the results of seven patients (median age, 59 years) with a median follow-up of 9 months. We were able to conserve the breast in all except one woman who was found to have extensive DCIS. Two patients were taken back to theatre, one for a washout of infected seroma and second for a wound debridement. There was no flap loss or donor site complications in our series. We were able to conserve the breast, maintain aesthetic contour of the central mound along with projection and achieve excellent cosmetic outcome for our patients. Partial breast reconstruction using CWPF provides an oncologically safe and cosmetically superior alternative in selected women with breast cancer needing central wide local excision.
... In the last decade the use of these flaps has been reduced in favor of more conservative flaps based on perforating arteries. The defects of the lower part of the breast can be replaced by using local flaps such as abdominal adipofascial flaps or thoraco-epigastric perforator flaps (TAP) (14)(15)(16)(17)(18). Lateral intercostal artery perforator flap (LICAP), lateral thoracic artery perforator flap (LTAP) and thoracodorsal artery perforator flap (TDAP) can be used to cover the defects of the lateral half of the breast (19)(20)(21)(22)(23). ...
Article
The role of plastic surgeon in breast reconstruction is mandatory in those cases of ductal carcinoma in situ (DCIS) requiring a wide surgical excision. The reconstructive treatment must be tailored on each patient with the aim to obtain a good cosmetic result in terms of form and symmetry, avoiding surgical complications.
... [11][12][13] The defects in the lateral half of the breast can be reconstituted with lateral chest wall perforator flaps including the lateral intercostal artery perforator flap (LICAP), lateral thoracic artery perforator flap (LTAP), and thoracodorsal artery perforator flap (TDAP). 7,[14][15][16][17] The distant flaps (LD, omental) 18,19 used for volume replacement after partial reconstruction are most commonly pedicled, though some small case series of free flap volume replacement after partial mastectomy have been published. 20,21 This article focuses on PBR with lateral CWPF, commonly used perforators being LICAP and LTAP ( Figure 1). ...
Article
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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.
... The nature of the perforator flap used varies, depending on tumor location, preoperative breast volume, and the ratio of the excised mass.. The use of thoracodorsal artery perforator (TDAP) flap, lateral intercostal anterior perforator (LICAP) flap, anterior intercostal artery perforator (AICAP) flap, omental flap, mini latissimus dorsi (LD) flap modified from the classical LD flap, or muscle-sparing LD flap has been previously reported [11][12][13][14][15][16]. The mini LD flap, which has a similar design and technique to an extended LD flap, is designed as small as necessary for post-partial mastectomy defects in the cutaneous flap and dissected lesser in the inferior pole of the LD muscle. ...
Article
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Background We conducted a prospective cohort study to evaluate effective techniques for breast reconstruction after partial mastectomy due to breast cancer. Determining the method of reconstruction is often difficult as it depends on the location of the cancer and the amount of tissue excised.. Here, we present a new technique, using the vertical latissimus dorsi (LD) flap, that can be used in all partial mastectomies and can almost conceal scarring. We also compared these results to those of the mini LD flap. Methods We analyzed the data of a total of 50 and 47 patients, who underwent breast reconstruction with the mini LD flap and the vertical LD flap, respectively. Immediately after tumor excision, breast reconstruction was initiated. The skin flap for vertical LD was designed in a planarian shape, such that it may be hidden as much as possible and minimize bulging during closure, and the LD muscle flap was designed with a sufficient distance in the inferior direction. Results Our finding showed that the vertical LD flap group required significantly less total operation time than the mini LD flap group. While the mini-LD flap resulted in a scar that was difficult to conceal, the donor site scar of the vertical LD flap could not be seen easily, and no scar was visible on the back. Conclusions The vertical LD flap is useful for partial breast reconstruction, in all breast regions requires a rather small volume of the flap. Moreover, recovery was relatively fast with high patient satisfaction.
Article
Introduction: Oncoplastic breast surgery following breast conservation surgery (BCS) utilizes aesthetic breast reduction techniques, and these reconstructions entail either volume displacement or volume replacement depending on the size and location of the excised tumor. The anterior Intercostal flap (AICAP) for immediate reconstruction after BCS is scarcely described in the literature. In this study, we present our experience with the Anterior Intercoastal Artery Perforator flap in 16 patients with small breast sizes. Patients and methods: Sixteen patients underwent lumpectomy followed by immediate reconstruction with Anterior ICAP flap between 2019 and 2021 at Hadassah University Hospital. Median age was 49 (range 28-67). Breast cup size, lumpectomy to breast size ration, defect measurements and location are provided. Flap design and flap in-setting was planned and executed according to the size and location of the defect determined at the time of surgery. Surgical technique is described. Diagram of proposed reconstruction according to defect location is proposed. Results: Flap dimensions clinically matched the defect size or were slightly larger due to anticipated shrinkage of tissue post radiation with mean of 5.4 × 3.9 × 3.75 cm (range of 2.5-13 × 2-13.2 × 0.8-4.5 cm). Complications, namely one seroma and one mild infection, were seen in two patients. Median follow up was 3 months after completion of radiation. All reconstructions were satisfactory by both surgeon and patient at last post-operative follow-up visit. Conclusion: The anterior ICAP flap is an important addition to the armamentarium of immediate reconstruction options after BCS, particularly in patients smaller size breast sizes.
Article
Purpose: The reconstruction of defects resulting from spinal surgery poses a challenge to plastic surgeons due to the curved contour and strong skin tension of the back. Implant and metal exposure can also increase the difficulty of covering such defects. This study presents our experiences of covering defects after spinal surgery using dorsal intercostal artery perforator (DICAP) flaps.Methods: From November 2018 to August 2021, 14 patients with spinal soft tissue defects underwent DICAP flap reconstructive surgery at our department. The mean age of the patients was 54.3 years (range, 35–70 years). Age, sex, etiology, the dimensions of the defect and the flap, the site of the defect, surgical technique, and postoperative complications were recorded.Results: All flaps survived, with no major complications such as total flap necrosis. Minor complications were observed in four cases. One patient developed an infection with erythematous changes and another developed partial flap necrosis. Two patients experienced wound dehiscence. These minor complications were all resolved with conservative treatment. No additional complications occurred during the follow-up period.Conclusion: The use of DICAP flaps was successful in all cases. DICAP flaps can adequately cover defects following spinal surgery and have a low complication rate. Thus, DICAP flaps are a good choice for covering defects resulting from spinal surgery.
Article
Local perforator flaps are used as immediate volume replacement techniques in breast conserving surgery. Here, we describe a case series of local perforator flaps used in the delayed setting to correct defects following previous breast surgery, including previous breast conservation surgery or mastectomy with reconstruction. All cases were performed in a tertiary referral breast unit between 2014 and 2020. Cases were identified using a prospectively maintained database. Indications, type of perforator flap used, immediate post-operative complications, and longer term outcomes were recorded. Fifteen cases were identified: 8 following previous breast conserving surgery and radiotherapy, 6 following mastectomy and reconstruction, and 1 for developmental breast asymmetry following childhood radiotherapy. Indications included volume deficit, contour defect, asymmetry, and capsular contracture. One patient a major complication requiring return to theater due to implant-related infection. There were no flap losses. Longer term, 2 patients underwent lipomodeling to further augment breast volume as part of a planned, staged revision. One patient subsequently elected to have bilateral breast implant exchange to increase volume. Our series shows the versatility of local perforator flaps in the correction of complex breast defects that can occur following previous breast surgery. Delayed local perforator flaps are associated with low morbidity, and further revision surgery is not commonly required.
Article
Oncoplastic breast reconstruction has improved esthetic results after breast‐conserving surgery with low complication rates and stable oncologic outcomes. Basic principles can be applied across different volume displacement and replacement techniques including restoration of breast shape and symmetry through esthetic incisions while eliminating dead space. Technique selection is guided by several factors including breast size, resection‐to‐breast ratio, and patient desires. A surgeon familiar with all techniques will allow individualization of treatment and optimization of outcomes.
Article
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Background Perforator flaps account for a fraction of reconstructive procedures despite their growing popularity. Specific microsurgical skills are required for successful harvesting of perforator flaps, which are difficult to attain through direct operating room training. Cadaver and small animal dissection cannot simulate human perforator dissection, lacking either bleeding and vessel feedback or providing too small calibers. Thus, we have developed and refined over the last ten years five perforator flaps models in living pig, described their harvesting technique and provided evidence for their effectiveness as perforator flap training models. Method CT angiography data from ten living pigs was used for detailed examination of the integument’s vascular anatomy. Microsurgical techniques were used to standardize and harvest the perforator flaps in acute models. The same operator-assistant team, with no prior perforator flap harvesting experience, raised all flaps in a sequential manner, one animal per day, during a 7 weeks timespan. Porcine flaps were compared to human counterparts in terms of vessel caliber, dissection times. Immediate flap survival was measured as duration of perforator pulsation after completion of flap harvesting, measured every 10 minutes for up to two hours. Results Five perforator flaps were standardized, based on the deep cranial epigastric, thoracodorsal, lateral intercostal, cranial gluteal and dorsal cervical arteries and the operative technique was described in detail. Mean pig perforator size was 1.24±0.36 mm and mean pedicle diameter was 2.78±0.8 mm, which matched closely the human calibers for each flap. Total harvesting time increased 22.4% between the first two experiments due to a more cautious approach following the lack of perforator pulsation in all flaps in the first experimental animal. A total decrease of 44.4% harvesting time between second and last experiment was observed, as expected with all repetitive surgical procedures. Post-operative perforator pulsation time revealed a steep learning curve, with no or short-term pulsatile perforators in the first five pigs, followed by a 275% increase in total perforator pulsation time between 5 th and 6 th experimental animal. Based on these findings we provide a description of the most common mistakes, their consequences and gestures which can be trained using the pig perforator flaps, in order to overcome these mistakes. Conclusion These five pig perforator flap models provide a fast and efficient learning tool to develop perforator flap harvesting skills safely. Surgical training using these five experimental models offers a similar hands-on perforator flap dissection experience as with human tissue, based on the similar sized calibers of both perforators and pedicles with their human counterparts.
Article
When autologous breast reconstruction is planned but abdominal tissue is not available, the lumbar artery perforator flap provides an alternative choice with minimal donor site morbidity. The lumbar and posterior intercostal arteries supply adjacent perforasomes on the posterolateral flank. The purpose of this report is to highlight the salvage of an autologous breast reconstruction free flap using a dorsal perforator of the posterior intercostal artery, when the planned lumbar artery perforators were not suitable. The patient was a 74‐year‐old with recurrent left‐sided breast cancer requiring immediate breast reconstruction. A lumbar perforator flap was planned as an oblique ellipse 19 × 10 cm. Intraoperatively, the two identified perforators traveled superiorly up to the 12th rib and therefore originated from the intercostal rather than lumbar arteries. The internal mammary artery and the vena comitants were used as recipient vessels, anastomosed to an interposition graft. Postoperatively, the patient was discharged home after 7 days without complication. Six months later, the patient was pleased with the reconstruction and had negligible donor site morbidity. The dorsal intercostal artery perforator flap therefore provides a salvage option when presumed lumbar artery perforators are dissected and found to be intercostal in origin.
Article
Breast-conserving surgery (BCS) outcomes are comparable to mastectomy in breast cancer treatment. However, patients with large tumours were offered mastectomy due to the resulting poor cosmetic sequelae after standard BCS. With the introduction of chest wall perforator flaps (CWPF), BCS is an option in patients with large tumour:breast ratio. The objective of our study was to evaluate the surgical outcomes of CWPFs and their impact on mastectomy rates. In order to assess the impact of CWPF on mastectomy rates, patients who underwent breast cancer surgery from January 2016 to December 2019 were included in a cohort named group A. In group A, the type of surgery performed was collected for each year from January 2016 to December 2019. Patients who underwent BCS and CWPF from July 2016 to June 2021 were included in another cohort named group B. In group B, patient-related and disease-specific details including post-operative complications were collected and analysed. In group A, following the introduction of CWPF, the mastectomy rates dropped by 10.69% and the mastectomy with reconstruction rates dropped by 23.29%. In group B, a total of 152 patients underwent CWPF reconstructions. The median tumour size was 20 mm (range = 0–80). A majority of patients were discharged within 24-h hospital stay (98.2%). Seventeen patients (11.11%) had a re-operation for margin positivity. Sixteen patients (10.46%) developed early complications and 19 patients (12.42%) developed delayed complications. CWPFs expand indications for BCS thus reducing mastectomy rates. It also has less morbidity when compared to reported mastectomy and reconstruction rates, thus making it a safe option for suitable patients.
Article
Explantation of breast implants has become increasingly common. This study aimed to analyze breast auto-augmentation following implant explantation (using a laterally designed anterior intercostal artery perforator [AICAP] flap) in patients who did not need new implants and required volume preservation. Twenty-four patients (48 breasts) aged 31–67 years (mean, 52.4 years) with body mass index (BMI) between 24.43 and 29.34 (mean, 27.32) kg/m2 underwent this procedure. All patients had implant-related problems, such as recurrent capsular contracture (n=11), seroma (n=2), animation deformity (n=3), rupture-induced bleeding (n=5), and breast implant disease (n=3). Sizes of implants removed ranged from 215 to 355 ml. The mean flap size was 23.9 cm × 7.5 cm, and the average flap thickness was 2.3 cm (range, 2.0–3.2 cm). Flap survival was clinically examined postoperatively by ultrasonography. Pre- and postoperative final breast volumes were compared by direct patient observation and independent photograph observation by three plastic surgeons according to a 4-point scale (bad=1, regular=2, good=3, and excellent=4) and the brassiere size. All flaps were completely viable after harvesting. No postoperative signs of fat necrosis were observed, and independent plastic surgeon evaluation revealed good and excellent results in all cases. Patient satisfaction evaluated by BREAST-Q data was >90%. This new design, AICAP flap (with a lateral thoracic extension), can be safely used for breast volume restitution after breast implant explantation with high patient satisfaction. This flap exhibited reasonable potential of providing additional volume in patients who undergo implant explantation and require the preservation of similar volume.
Article
Postoperative tracheoesophageal or bronchoesophageal fistulas represent a major surgical challenge. The authors report the description of an original perforator-based intercostal artery muscle flap, aiming to cover all types of intrathoracic fistulas, from any location, in difficult cases such as postoperative fistulas after esophagectomy in an irradiated field. Between June of 2016 and January of 2019, eight male patients were treated with a perforator-based intercostal artery muscle flap. All had previous surgery for esophageal cancer and developed a tracheoesophageal or bronchoesophageal fistula during the perioperative course. The mean patient age was 55.9 ± 8.8 years. All patients received neoadjuvant chemotherapy and seven received neoadjuvant radiation therapy. A perforator-based intercostal artery muscle flap, with a mean skin paddle size of 9.86 × 5 cm, was harvested. The median operative time was 426.50 minutes. The tracheoesophageal or bronchoesophageal fistula was successfully and definitively occluded in three patients; two patients experienced recurrence; and one patient underwent reoperation. At 1 year, five patients were alive (62.5 percent), and among them, three (37.5 percent) were free from any intrathoracic complications. Three patients died, because of massive digestive bleeding, mesenteric ischemia, and multiorgan failure, respectively. The perforator-based intercostal artery muscle flap, like the Taylor flap in abdominoperineal reconstruction, could become a workhorse flap for all intrathoracic reconstructions, as it can always be harvested, even if a previous thoracotomy has ruined most of the options. This surgical technique, easily feasible, reliable, and reproducible, became our first option for all postoperative tracheoesophageal or bronchoesophageal fistula patients during the postoperative course following esophagectomy. Clinical question/level of evidence: Therapeutic, IV.
Article
The use of chest wall perforator flaps (CWPFs) following breast conservation surgery for breast cancer has become a useful tool in the armamentarium of the oncoplastic breast surgeon, however robust evidence for the technique is lacking. The aim of this study was to conduct a systematic review appraising the current evidence for the use of CWPFs, evaluating clinical, oncological and cosmetic outcomes. A PRISMA‐compliant systematic review, with PROSPERO published protocol a priori and search of all relevant database and trial registries between 1990 to July 2020. Eleven studies amounting to 432 cases were reviewed and considered to be at high risk of bias due to small sample size, selective outcome reporting and selection bias. Heterogeneity due to lack of consensus of outcome measures prevented meaningful analysis. Fifty-two (12.3%) clinical complications were recorded: seroma (n = 9; 2.1%), fat necrosis (n = 9; 2.4%), haematoma (n = 8; 1.9%), infection (n = 9; 2.1%), and flap necrosis (n = 9; 2.1%). Thirty-four (10.8%) patients had an involved positive margin, 29 patients underwent re-excision (9.3%) and four underwent completion mastectomy (1.3%). One local recurrence and six distant recurrences were observed during a mean follow up of 21 months (1–49). A pooled patient cosmetic satisfaction descriptor of good or excellent was described in 93% of cases. CWPFs are a safe method of partial breast reconstruction following BCS. They are associated with a low complication rate, acceptable short-term oncological outcomes and satisfactory cosmetic outcome. There is a relative paucity in quality of data in this field and larger prospective studies are needed to investigate outcomes further.
Article
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Background: Oncoplastic breast surgery is well established in many parts of the world and is gaining popularity in the rest of the world. The cornerstone in oncoplastic breast surgery is to respect oncological principles during cancer resection maintaining good aesthetic and cosmetic outcome. With the advancement in local, regional, and systemic treatment for breast cancer, survival has improved, and patients live longer. It is utmost essential to help our patients to maintain a good quality of life. Aesthetic and cosmetic outcomes have a significant impact on patient's psychosocial, emotional, and sexual well-being.Oncoplastic techniques have evolved over the last decade with the increasing use of perforator flaps to enable partial breast reconstruction. We report the findings of a prospective cohort study using modified lateral intercostal artery perforator in partial breast reconstruction. This modified technique offers a less visible scar and good access to the axilla without any need for repositioning the patient during the operative procedure. Methods: A retrospective review of a prospectively maintained database of patients who underwent partial breast reconstruction with a modified lateral intercostal artery perforator flap was carried out between July 2016 and January 2020 in 2 oncoplastic breast units. The study had local approval from the respective audit departments. Patient demographics, operative data, surgical complications, and outcomes were collected and analyzed. Results: Forty-one patients underwent the procedure between July 2016 and January 2020. The median age of the population data was 58 years (interquartile range, 9 years). There were 10 active smokers (24.4%), and 3 patients had diabetes mellitus (7.3%). Overall, 3 patients (7.1%) developed seroma, 1 had a hematoma (2.4%), and 1 had a locoregional recurrence (2.4%). Two patients (4.9%) underwent margin re-excision for close margins. Most patients (92%) had the procedure carried out as day-case surgery. None of the patients developed wound infection, necrosis, or flap loss. The results were comparable across the 2 participating units. Conclusions: The data suggest that modified intercostal artery perforator flap is an excellent oncoplastic technique for volume replacement in partial breast reconstruction with a short learning curve and minimal perioperative morbidity.
Article
When performing breast reconstruction, reduction of the contralateral breast is often required to achieve symmetry. The tissue that would otherwise be discarded from the reduced breast has been utilized as a free flap. This has the benefit of minimizing donor site morbidity, and combining the principles of “spare-part-surgery” and replacing “like-with-like.” The purpose of this paper is to report the procedure, outcome, and potential controversies of using a free lateral thoracic artery perforator flap for contralateral breast reconstruction. We present a 32-year-old with congenital breast asymmetry previously corrected with an implant. The patient required tertiary breast reconstruction for capsular contracture, and a simultaneous left breast reduction. There was no history of breast cancer. The reconstruction proceeded as follows; the right sided breast implant was removed. On the left breast, a wise pattern reduction with a superomedial pedicle was instigated. Intraoperatively, four perforating arteriovenous pedicles perfusing the reduced tissue were identified; of which the lateral thoracic artery perforator was selected. The flap weight was 296 g. The lateral thoracic pedicle was anastomosed to the right internal mammary vessels. The flap survived completely. The post-operative course was uneventful and without complication. The patient was followed up for 1 year and was pleased with the final result. The application of the LTAP free flap may cautiously be extended to oncological breast reconstruction. For patients to be suitable, they would need a large remaining breast to provide adequate tissue for reconstruction, up-to-date breast screening and a low risk of developing breast cancer in the future.
Article
Introduction Volume Replacement (VR-OBCS) and Volume Displacement Oncoplastic Breast Conserving Surgery (VD-OBCS) are commonly used in the management of breast cancer. Many studies summarize the individual post-operative outcomes of these two procedures; however, there is a lack of research comparing outcomes of these approaches. This review summarizes the available VR and VD-OBCS literature in terms of oncological, cosmetic, and clinical outcomes. Methods An online literature search (MEDLINE, EMBASE, PubMed, CINAHL) was performed. Studies were included if they were written in English, had more than 10 adult (18+) female patients who underwent VR-OBCS or VD-OBCS and reported at least one well-described oncological, clinical or cosmetic outcome. Results Thirty-three studies (26 VR-OBCS and 7 VD-OBCS) were included in this review; VR-OBCS studies were separated based on the use of Latissimus Dorsi (LD) flaps. Studies utilizing VR-OBCS with LD flaps reported the highest rate of all oncological outcomes; VR-OBCS studies without LD flaps reported the lowest. Rates of hematoma, seroma and wound dehiscence were highest in VR-OBCS with LD flaps, partial flap loss and fat necrosis were highest in VR-OBCS without LD flaps and infection was highest in VD-OBCS studies. Inconsistencies in methodology (cosmetic outcome measures, outcome definitions and time horizons) were found in all procedural groups. Conclusion Differences in outcomes for both OBCS procedures may be due to the heterogeneity of patient populations. “Doers” and “Users” of breast oncoplastic research should consider tumor size, laterality of tumor, breast size, measurement scales and defensible time horizons before application of a study's conclusions.
Chapter
This chapter is dedicated to the volume replacement techniques for THE restoration of the gland in breast-conserving surgery. Different methods of how to use the locoregional tissue around the breast to fill the defects after tumor removal are presented and discussed. The techniques include skin-adipose-fascial flaps on the wide skin base—modifications of rotational, advanced and rhomboid flaps (lateral thoracic (subaxillary) flap, rotational advanced flap, and thoracoepigastrical advanced and rotational flaps). The use of pedicled perforator flaps (LTAP, LICAP, SEAP) are also presented and discussed.
Article
Background: Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques. Objectives: Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes. Search methods: We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions. Selection criteria: We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer. Data collection and analysis: Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures. Main results: We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation. Authors' conclusions: The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.
Article
Background: When autologous breast reconstruction is desired and deep inferior epigastric artery perforator (DIEP) flap is inadequate or unavailable, other perforator flaps in the truncal region should not be disregarded. This study aimed to review all truncal-based perforator flaps used for autologous breast reconstruction to identify clinical indications and outcomes of alternate perforator flaps. Methods: From 2013 to 2018, patients undergoing truncal-based perforator flap breast reconstruction were reviewed and data recorded for; indications, pre-operative and intra-operative treatment decisions, flap failures, take-backs, and revisions. Compared to the gold standard of the DIEP flap, alternate truncal-based flaps were evaluated for their reconstructive merit and application. Results: A total of 975 perforator flaps were harvested circumferentially around the lower trunk. As an alternative or adjunct to the DIEP flap (n = 633, 65%), perforator flaps were harvested based on the superficial inferior epigastric, the deep and superficial circumflex iliac arteries, the intercostal, and lumbar arteries (n = 342, 35%). Overlapping vascular territories facilitate the safe harvest of these alternate flaps with 0.8% of flaps requiring take back (n = 8) and 0.2% flap failure rate (n = 2). There was no difference in peri-operative outcomes between anterior abdominal and alternate truncal-based flaps (p > .05). Conclusions: Circumferential harvest of alternate truncal flaps is an appropriate option for autologous reconstruction with comparable peri-operative and long-term outcomes as compared to flaps from the anterior abdomen.
Article
The authors believe that oncoplastic breast surgery has to achieve the best possible aesthetic results. In this article, they propose the concept of “invisible surgery.” This is a combination of certain oncoplastic techniques that allows for restoration of the original appearance of the breast without obvious scars on the breast. Further, the authors classify the techniques as follows: the “level 1 technique,” with contour approach; the “from inside” technique; the lateral parenchymal flap; the axillary subcutaneous adipofascial flap; the rotational lateral thoracic flap; regional island perforator flaps (lateral intercostal artery perforator, lateral thoracic artery perforator, anterior intercostal artery perforator, and medial intercostal artery perforator flaps); and the nipple-sparing mastectomy with immediate expander reconstruction. These techniques were combined by internal logic—one can move from one to another according to the preoperative planning and margins status during the operation. They call their approach the “scenario strategy.” The authors have performed 138 operations in 137 patients using this approach. Most of them involved the “from inside” technique and perforator flaps. The average tumor size was 2.4 cm, and the average specimen weight was 43.2 g. The total rate of complications was 14.6 percent. According to this concept, the surgery should be performed in such way that breast appearance will not change. It should be planned as one would plan a staged procedure, taking into account possible changes in the scenario during the operation to achieve the best possible aesthetic result.
Article
Background: Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps. Patients and methods: From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap. Results: Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed. Conclusion: Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.
Article
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.
Article
Ductal carcinoma in situ (DCIS) is a heterogenous disease. The mainstay of its management is surgery, and lumpectomy with or without radiation therapy (RT) or mastectomy are standard options. Endocrine therapy may be given to maximize risk reduction. With standard treatment, the longterm breast cancer-specific survival is excellent and exceeds 95%. Currently, management strategies are based on standard clinicopathological features. Genomic tools to predict local recurrence have been developed, and prospective studies to evaluate their impact on RT recommendations and outcomes are ongoing. Because of concerns regarding overtreatment of DCIS, there has been much enthusiasm for de-escalating locoregional therapy. RT halves the risk of local recurrence but does not affect survival, and its omission can be considered in low-risk groups. Active surveillance for lowrisk DCIS is being evaluated in 4 prospective trials. The concern regarding these trials is whether the selected "low-risk" cases are truly at low risk, and what threshold of recurrence is considered acceptable. Additionally, it is unclear whether patients will be willing to trade short outpatient procedures for more biopsies, more imaging, and possibly increased concern about recurrence. The clinical relevance and the safety of this approach are yet to be determined.
Article
Background: Volume replacement oncoplastic breast-conserving surgery (VR-OBCS) uses islanded or pedicled chest wall fasciocutaneous perforator flaps from outside of the breast footprint to replace the volume that has been excised during lumpectomy, extending the options for breast conservation to patients who may otherwise require mastectomy. This study compares outcomes for VR-OBCS with both standard volume displacement oncoplastic breast-conserving surgery (VD-OBCS) and mastectomy with immediate total breast reconstruction (TBR). Methods: A retrospective cohort study was conducted; demographic data, clinicopathologic factors, surgical details, and postoperative events were collected until patients had completed their reconstructions. Variables were compared using the t test and analysis of variance test, or chi-square analysis and Fisher's exact test, as appropriate. Results: Ninety-seven consecutive patients (109 immediate breast reconstruction procedures) were included: 43 percent underwent standard VD-OBCS procedures, 35 percent underwent mastectomy with immediate TBR, and VR-OBCS techniques were used in 22 percent, of which only one patient required a delayed procedure for symmetry. Mean whole tumor size was similar in the VR-OBCS and TBR groups and was significantly higher than for the VD-OBCS group (p < 0.05). Overall rate of complications affecting the breast area (p < 0.001), need for additional surgery to either breast (p < 0.001), and time to reconstruction completion (p < 0.001) were significantly higher in the TBR group. Conclusions: VR-OBCS extends the options for breast conservation to many patients that would otherwise require mastectomy. The complication rate is lower, fewer procedures are necessary, and less time is required to complete the reconstruction when compared with mastectomy and immediate TBR. Clinical question/level of evidence: Therapeutic, III.
Article
Full-text available
Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.
Article
A gluteal perforator-based flap employing the gluteus maximus muscle perforators located around the sacrum is described. A cadaveric study disclosed the existence of several significant perforators all around the gluteal region. Among these, the parasacral perforators originating from the internal pudendal artery and lateral sacral artery have proven useful for the repair of sacral pressure sores. A total of eight decubitus in seven patients were treated with gluteal perforator-based flaps. There were no postoperative complications, such as flap necrosis and wound infection, with the exception of fistula formation in one case. This flap requires no transection or sacrifice of the gluteus maximus muscle, and elevation time for the flap is short. However, the perforators are located at various sites and thus require some careful dissection. (C)1993American Society of Plastic Surgeons
Article
The intercostal island flap is a new omnipotential flap that is extremely valuable for torso reconstruction, provided one understands the intricacies of intercostal anatomy. Human cadaver dissections were done to determine the precise course and branching pattern of the lower (T7-T11) intercostal neurovascular bundles. On the basis of these dissections, the intercostal structures can be divided into four anatomical segments: vertebral, costal groove, intermuscular, and rectus. The anatomical segments can be safely combined in many ways to create versatile skin flaps. Three different clinical applications with requisite modifications in surgical technique are described in detail to exemplify important anatomical observations. The potential value of the intercostal island flap in reconstructive surgery is discussed.
Article
A new type of flap is described based on unnamed perforators located near the midline of the lower back region. Such flaps combine the superior blood supply of the myocutaneous flap with the lack of donor-site morbidity of a skin flap. Five clinical cases are presented, showing how such perforators can augment skin flaps or create custom-designed island flaps. The dissection of the flap is described, and further possibilities for its use are suggested. (C)1988American Society of Plastic Surgeons
Article
In man, the vascular supply to the skin is via a segmental perforator cutaneous system. The musculocutaneous arteries are the primary vessels, but they are augmented by a limited number of non essential direct cutaneous arteries. Skin flaps may be defined in terms of their supplying vessels and categorized as cutaneous, arterial, or island flaps. Most experimental animals do not have a vascular supply to the skin similar to that of man. The pig's cutaneous vascular supply has been demonstrated anatomically and surgically to be more comparable than most to that of man; thus, it may be an acceptable model for the experimental study of skin flaps. The two fundamental cutaneous arteries (musculocutaneous and direct cutaneous arteries) were utilized to design experimental cutaneous, arterial, and island flaps in the pig. A fixed surviving length, independent of increasing width, occurred for each type of flap. The surviving length of direct arterial flaps was comparable to that in island flaps and in delayed cutaneous flaps. The maximum surviving length occurred in delayed arterial flaps. The correlation of the experimental findings with clinical observations may provide a better understanding of the general principles governing the survival of skin flaps. The clinical limitations on the direct transfer of island flaps by microvascular anastomoses have been delineated. Two series of free island flap transfers with microvascular anastomoses were done in pigs, in a vascular model comparable to man, and the results are reported. The ideal island flap has been defined and clinical alternatives proposed. Expanded clinical trials appear to be justified.
Article
Young children with meningomyelocele and hydrocephalus frequently have a serious problem with decubitus ulcers. A new operation is described, whereby a neurovascular sensory island flap of abdominal skin, based on one of the lower intracostal neurovascular bundles, is passed subcutaneously to the insensitive area of the decubitus ulcer. This brings sensation and new blood supply to the decubitus area, plus a skin patch. (C)1974American Society of Plastic Surgeons
Article
The lateral intercostal flap is a new neurovascular flap that may be used as a free or island flap. It is based on the lateral cutaneous branch of a single posterior intercostal neurovascular bundle. The donor area of the flap is the anterolateral skin of the abdomen. The flap is large, thin, and has a long pedicle that contains the lateral cutaneous nerve. The donor pedicles of the flap are multiple, and its venous drainage is adequate. The detection and design of this flap were based on information gained from the dissection of 95 intercostal spaces in 40 fresh cadavers. The flap was then applied 12 times in 11 patients. Ten flaps were successful, one flap was partially lost, and one was completely lost. The flap was used as a noninnervated flap to resurface six defects in the neck and one facial defect, and it was used as an innervated flap to cover two hand defects and two heel defects.
Article
A "reverse," posteriorly based transposition of a latissimus dorsi musculocutaneous flap on its segmental blood supply is presented. This adds new possibilities to this versatile and reliable musculocutaneous unit. The variable modes of blood supply to the musculocutaneous units are discussed, and the question of the strategic vascular and neurosympathetic delays are raised.
Article
A narrow pedicled intercostal cutaneous perforator (np-ICP) flap is used for reconstruction of hand scar contractures after burns. This flap is designed with a narrow pedicle which includes some intercostal cutaneous perforators of 4-7th intercostal spaces, and with a wide distal area which lies over the costal cage and upper abdomen. Additionally the flap is thinned until only the subdermal vascular network is preserved in most of the wide distal area. It seems that this flap is more useful, not only functionally but also aesthetically, than conventional methods. This report describes the technique and concept, with a demonstration of some clinical examples.
Article
Ten cases suffering from facial contour deformities caused by loss of subcutaneous tissue are presented. Three cases had hemifacial microsomia, 3 had postmaxillectomy collapsed cheek, while the remaining 4 patients had Romberg's disease. All cases were treated by the insertion of a deepithelialized, revascularized lateral intercostal flap. The flaps used had dimensions ranging from 9 cm x 6 cm to 12 cm x 14 cm. The vascular pedicle of the flap is the lateral cutaneous branch of one of the lower four posterior intercostal bundles (usually the tenth or the eleventh). The flap is designed to have the pedicle in its center, thus allowing defattening of the edges at the primary surgery and minimizing the need for secondary debulking. Nine flaps were successful and one failed. All successful flaps gave a permanent and satisfactory correction of the deformity. The difficulties and advantages of the flap are presented.
Article
We report a two-part anatomical and clinical study whose aim was to map the dominant dorsal intercostal cutaneous perforators (DICPs), which are useful for microvascular augmentation of flaps raised from the skin of the back called subdermal vascular network (SVN) flaps, and to test their reliability in the clinical setting. In the anatomical arm of the study, using preserved cadavers, we macroscopically confirmed the location of DICPs, and performed micro-angiography of the dorsal skin to find each dominant DICP. In the clinical arm of the study, we confirmed the location of the dominant DICP during microvascular augmented SVN flap transfer. Postoperatively, posteroanterior radiographs of the chest were taken to locate vessel clips used to ligate the DICPs. The combined study results showed that the dominant DICP is the sixth or seventh in most instances, but there are some anatomical variations. If no dominant DICP is found in the sixth or seventh spaces, at least one DICP that is of sufficient calibre for microvascular augmentation can usually be found in the general vicinity, such as the fifth, eighth or ninth spaces. The clinical application of microvascular augmented SVN flaps, both pedicled and free, is presented.
Article
Due to its increasing popularity, more and more articles on the use of perforator flaps have been reported in the literature during the past few years. Because the area of perforator flaps is new and rapidly evolving, there are no definitions and standard rules on terminology and nomenclature, which creates confusion when surgeons try to communicate and compare surgical techniques. This article attempts to represent the opinion of a group of pioneers in the field of perforator flap surgery. This consensus was reached after a terminology consensus meeting held during the Fifth International Course on Perforator Flaps in Gent, Belgium, on September 29, 2001. It stipulates not only the definitions of perforator vessels and perforator flaps but also the correct nomenclature for different perforator flaps. The authors believe that this consensus is a foundation that will stimulate further discussion and encourage further refinements in the future.
Article
Treatment of patients with infected median sternotomy wounds includes debridement and closure using vascularized tissue, most often the pectoralis major muscle. However, occasionally, surgeons use other flaps to close sternotomy wounds. The purpose of this study is to review 1 center's experience with infected median sternotomy wounds utilizing a less common technique, the rectus abdominis musculocutaneous flap.
Article
The gluteal perforator-based flap is designed according to the localisation of sacral perforator vessels. These vessels penetrate the gluteus maximus muscle and reach the intrafascial and suprafascial planes, and the overlying skin forming a rich vascular plexus. The gluteal perforator-based flaps described in this paper are highly-vascularised, have minimal donor site morbidity, do not require the sacrifice of the gluteus maximus muscle and rarely lead to post-operative complications. We believe these easy-to-perform flaps might be considered as the first choice in the repair of gluteal pressure sores.
Article
Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.
Article
A technique is described for autologous breast augmentation based on perforator flaps of the lateral chest wall. Raising these flaps as perforator flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.
Article
Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.
Biological or artery flaps of the face. Monaco: Institut Esser de Chirurgie Structive
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Figure 9 (A) and (B) Results at 18 months postoperatively
  • M Hamdi
Figure 9 (A) and (B) Results at 18 months postoperatively. M. Hamdi et al.
Intercostal neurovascular island skin flap. 2nd ed Grabb's encyclopedia of flaps
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An anatomical and clinical study of the dorsal intercostal cutaneous perforators, and application to free microvascular augmented subdermal vascular network (ma-SVN) flaps
  • R Ogawa
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Ogawa R, Hyakusoku H, Murakami M, Apki R, Tanuma K. An anatomical and clinical study of the dorsal intercostal cutaneous perforators, and application to free microvascular augmented subdermal vascular network (ma-SVN) flaps.
An anatomical and clinical study of the dorsal intercostal cutaneous perforators, and application to free microvascular augmented subdermal vascular network (ma-SVN) flaps
  • Ogawa