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

Abstract

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

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

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

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

Keywords: Breast Cancer; Oncoplastic breast surgery; Perforator Flaps; Volume replacement.

Fig. 1

Preoperative markings indicating the extent of breast tumor excision, flap harvest area, and the location of perforator vessels

Fig. 2

CTA shows the location of the lateral thoracic artery perforator

Fig. 3

A 41-year-old female patient with breast cancer, strongly desiring breast conservation, underwent oncoplastic surgery using a lateral thoracic artery perforator flap; A: Tumor extent and excised glandular tissue weight of 80 g; B: Extent of the breast defect; C: Intraoperative view showing multiple perforator vessels originating from the lateral thoracic artery; D: After flap harvest, the flap was de-epithelialized to assess good blood supply

Fig. 4

The patient underwent breast-conserving surgery using a lateral thoracic artery perforator (LTAP) flap. (A) Preoperative lateral view showing markings for tumor excision and flap harvest areas. (B) Postoperative lateral view at 3 months showing near symmetry of both breasts with an aesthetically pleasing outcome. The incision is located on the lateral chest and is well-concealed

Fig. 5

The patient underwent breast-conserving surgery using an anterior intercostal artery perforator (AICAP) flap. (A) Intraoperative view after tumor excision, showing markings for the breast defect and flap replacement area. (B) Postoperative frontal view at 1 month showing near symmetry of both breasts with an aesthetically pleasing outcome. The incision is located in the inframammary fold and is well-concealed