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

Abstract

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

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

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

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

Fig. 1.

Chest wall perforator flap relevant anatomy. A, Image of the modified LICAP flap design described by Meybodi et al. The position of chest wall perforators are marked in red. B, Image of LICAP flap designs described by Hamdi et al. C, Image of the LTA and perforators, with the large LTA perforator marked by *. D, Image of our extended LICAP flap design suitable for larger and multiple defects. Flap design (green) and potential extent of subcutaneous dissection (blue).

Fig. 2.

Chest wall perforator flap relevant anatomy. A, Photograph of the preoperative marking of expected excision (blue), extended LICAP flap (black), LTAP, and intercostal perforating vessels (red). B, Photograph of the excision cavity of the same patient after WLE. C, Photograph showing the extent of flap dissection, based on the LTAP. D, Photograph of the flap rolled and positioned to fill large defect.

Fig. 3.

Figure of the immediate postoperative appearance (same patient as in Fig. 2).

Fig. 4.

Figure of the cosmetic result at 2 years (same patient as in Fig. 2).

Fig. 5.

Patient with lower outer quadrant tumor. A, Image of a patient with a 23-mm lower outer quadrant tumor preoperative appearance. B, Image of the extent of flap design with two perforating vessels marked. C, Image of the size of defects after WLE and axillary clearance. Flap is based on central perforating vessels. D, Image of the inferior part of the flap rolled to fill tumor cavity, superior part flipped in to fill axilla.

Fig. 6.

Image of the cosmetic result at 1 year.