Use of licap and ltap flaps for breast reconstruction.

Breast conserving surgery has been reserved for patients with favorable proportion between tumor dimensions and breast size. Introduction of local flaps from the lateral thoracic region has widened the indications for breast conserving surgery, by allowing surgeons to perform wider excisions, thus yet be able to ensure tumor-free surgical margins and a good aesthetic result. We have used lateral intercostal perforator flaps and flaps harvested on the lateral thoracic artery and lateral thoracic artery axial flap in patients with small breasts and an unfavorable tumor to breast size proportion. From May 2015 to October 2016, 19 patients with breast tumors have been treated with BCS and immediate volume replacement reconstruction by pedicle perforator flaps from the lateral thoracic region. In 15 patients lateral intercostal artery perforator flaps or lateral thoracic artery perforator flaps were used after quadrantectomy or wide local excision, in 3 patients as volume replacement after mastectomy and in 1 patient after mastectomy following previous augmentation mammoplasty. In all patients, good breast symmetry was achieved, with no major complications. Fibrosis of the flap and residual breast parenchyma, with volume reduction were noticed after postoperative radiotherapy in thin patients or flaps with little subcutaneous fat. Perforator flaps from the lateral thoracic region should become the gold standard for reconstructions after breast conserving surgery involving less than 20% of the breast volume or after mastectomy in patients with small breasts. The operating procedure is safe, quick and allows sparing of the latissimus dorsi muscle and thus minimal donor site morbidity, as well as an excellent aesthetic result.

Evaluation of the mobility of the shoulder and quality of life after perforator flaps for recalcitrant axillary hidradenitis.

BACKGROUND: Hidradenitis suppurativa is a very debilitating disease, treated by antibiotics and excision. The reconstruction is usually done by secondary wound healing and/or split-thichness skin graft. The aim of this study was to evaluate the reconstruction of the axilla with local perforator flaps as a single stage surgical treatment. METHODS: This was a monocentric retrospective study conducted between November 2013 and June 2015. We included the patients with a severe axillary localization of the disease. Between 6 months and 1 year postoperatively, we noted length of complete healing, complications, patients satisfaction score about the surgery, DASH functional score, maximum abduction angle of the arm, and recurrence of the disease. RESULTS: Thirteen patients were included, for a total of seventeen affected axillae. We performed seven thoracodorsal artery perforator flaps, seven lateral intercostal artery perforator flaps and three serratus anterior artery perforator flaps. The mean duration of follow-up was 279.1±84.1 days (180-365). The average complete healing time was 20.5±13.5 days (10-60). Six axillae were compounded (35%). The average recurrence rate of HS was 0%. The average score in the DASH questionnaire was 68.6±35.3 points (39-152) and the average maximum abduction angle of the arm was 160.6±18.5 degrees. The average score on the satisfaction questionnaire was 36.5±5.6 points (25-43). CONCLUSION: This is a single stage, reliable and effective surgical procedure. The results are very encouraging, with a good quality of life, a low functional disability and a shorter healing time.

Autologous breast augmentation combining the harvesting of the Anterior Intercostal Artery Perforator (AICAP) and Lateral Intercostal Artery Perforator (LICAP) flaps in massive weight loss patient: A case report.

Patients undergoing bariatric surgical procedures usually exhibit breast ptosis due to the quick weight loss. In this type of patients, the mastopexy represents a challenge for plastic surgeons considering the abundance of dystrophic cutaneous tissue, the loss of subcutaneous tissue and the impossibility to employ heterologous devices in the setting of Italian public healthcare. In addition, it is necessary to consider that patients undergoing post-bariatric surgery have increasingly high expectations. We describe a new reconstructive technique which combines and utilizes both the AICAP and LICAP flaps as "autoprosthesis". It could be considered a valid option for patients exhibiting a deficiency in the upper poles with hypotrophic and hypoelastic skin texture, associated with poor glandular representation. This procedure proves to be an excellent alternative to breast implants both in the reconstructive surgery and aesthetic surgery settings.

Adipose perforator flaps without skin donor site: "in between" single scar approach for reconstruction of small peripheral breast defects after lumpectomy.

In breast conserving surgery, the reconstruction of defects in small breasts where volume displacement techniques are not feasible can be challenging. In contrast, patients with bigger breasts may not wish to undergo major breast remodeling surgery or breast symmetrization procedures. In such cases, volume replacement techniques can be beneficial, but these leave additional scars and are time consuming. The authors propose an "in between" single scar approach to perform both lumpectomy and reconstruction of small peripheral breast tumors. This approach reduces morbidity and operating time compared with standard volume replacement techniques. The tumors are resected from below, guided by wire, using an incision in the lateral breast crease or inframammary fold, depending on their location. The same incision is used to raise an adipose or adipofascial flap based on perimammary perforators, lateral thoracic artery perforator flap (LTAP), lateral intercostal artery perforator flap (LICAP), or anterior intercostal artery perforator flaps (AICAP) flaps, without skin donor site. Between March and November 2022, eight patients underwent this procedure. In four cases LICAP flap was used; in three-AICAP flap was chosen; and in one-LTAP perforator flap was used. Clear surgical margins were achieved in all cases. The average follow-up time was 9.9 months, during which no local recurrences were detected. All flaps survived. Two patients experienced seromas at the donor site, and an organized hematoma was also reported. This approach represents a viable alternative to volume displacement techniques or no reconstruction for small peripheral lumpectomy defects.

LICAP Versus TDAP for the Reconstruction of Partial Breast Defects.

Perforator flaps are the latest development in reconstructive surgery. Pedicled chest wall perforator flaps can be utilized in many cases of partial breast reconstruction. This research compares the outcome and technique of thoracodorsal artery perforator flap (TDAP) and the lateral intercostal artery perforator flap (LICAP) in the reconstruction of partial breast defects. Patient records were reviewed for the time period between 2011 and 2019 at the Breast Unit of the National Cancer Institute of Cairo University. Eighty three patients were accessible for the study. (46 cases of TDAP flap and 37 cases of LICAP flap). Relevant clinical data were extracted from patients' records. A special visit was organized for all 83 patients, where a digital photograph was taken in an antroposterior view. The photographs were later processed via BCCT.core software to obtain an objective cosmetic outcome assessment. Complication rates and cosmetic outcome were comparable for both techniques. TDAP flap proved to require more tedious dissection and preoperative Doppler mapping to localize perforator vessels. On the other hand, LICAP was technically easier with more consistent perforators. Pedicled chest wall perforator flaps constitute an excellent reconstructive option in partial breast defects. TDAP flap and LICAP are two reliable perforator flaps which can reconstruct outer breast defects with acceptable outcome.

The reverse LICAP flap: A laterally based submammary perforator flap for breast reconstruction.

INTRODUCTION: The traditional donor sites for autologous breast reconstruction include the abdomen, thigh, buttock, and posterior thorax. Herein, we describe the use of the reverse lateral intercostal perforator (LICAP) flap originating from the submammary region as an option for breast reconstruction. METHODS: Fifteen patients (30 breasts) were included in this retrospective review. The procedure was performed for immediate reconstruction following a nipple sparing mastectomy utilizing an inframammary incision or an inverted T pattern with preservation of the fifth anterior intercostal perforator (n = 8), volume replacement after implant explantation (n = 5), and partial lower pole resurfacing with exteriorization of a portion of the LICAP skin paddle (n = 2). RESULTS: Flap survival was achieved in all patients. Three flaps (10%) had 1-2 cm of intraoperative distal tip ischemia, which was managed by excision prior to inset and closure. At the 12-month postoperative follow-up, stable results with good nipple position, breast shape, and projection were achieved in all patients. CONCLUSIONS: The reverse LICAP flap is a safe, effective, and reliable option for breast reconstruction following mastectomy.

Modified chest wall lateral intercostal artery perforator (MCW-LICAP) flap: a versatile flap in the era of oncoplastic breast surgery.

BACKGROUND: Breast reconstruction following oncological resection is becoming more common in recent years. In some ladies, implant reconstruction is not ideal due to significant implant visibility or palpability. Autologous reconstruction addresses the limitations of implant reconstruction but results in potential donor site morbidities. To date, there is no clear advantage ascribed to any technique. With appropriate selection, patients with adequate lateral mammary fold have the option of reconstruction with MCW-LICAP flap. We present our techniques and outcomes from a series of 29 patients who underwent MCW-LICAP flap. METHODS: A retrospective review of consecutive patients who underwent curative resection for breast cancer with immediate MCW-LICAP flap reconstruction, between July 2018 to April 2022 was conducted. The techniques used with its variations along with video demonstrations are presented. RESULTS: A total of 29 patients underwent 34 procedures. Nineteen breast conserving surgeries and 15 mastectomies were completed, and immediate reconstruction performed in all cases. Twenty-three patients had MCW-LICAP, 1 with a Stacked intercostal artery perforator (STICAP) flap, and 5 had MCW-LICAP combined with a Goldilocks mastectomy. There were no cases of complications requiring re-operation. All patients had acceptable time to adjuvant therapy with a median of 36 days. Learning curve analysis showed a significant reduction in operative time after the 6th case. CONCLUSION: In our preliminary experience, MCW-LICAP flap is a safe, reliable, and versatile oncoplastic reconstruction option.

Lateral Intercostal Artery Perforator Flap to Treat Pure Cutaneous Recurrence After Breast-Conserving Surgery: A Case Report.

Pure cutaneous recurrence after breast-conserving surgery is rare and presents a unique challenge to clinicians. Some carefully selected patients may be amenable to further breast-conserving therapy. We present the case of a 45-year-old female with a cutaneous recurrence of previously treated right breast cancer along the operative scar in the upper outer quadrant. The patient underwent a further wide local excision with lateral intercostal artery perforator flap with a skin paddle reconstruction. We achieved volume replacement with this technique, disease control, and a pleasing cosmetic result.

A before and after evaluation of patient reported outcomes assessed by Breast Q following LICAP turnover flap in breast conservative therapy.

Chest-wall perforator-based techniques to replace volume for breast conservative therapy allow excision of large breast areas with minimal sequalae, such as the nipple-areolar complex displacement, parenchymal indentation or contour deformity. Furthermore, chest wall perforator flaps facilitate the maintenance of breast symmetry, hence decreasing the need for contralateral surgery. Lateral intercostal flap was described in numerous variants among which the most famous are the propeller flap and the turnover version. The turnover version is the easiest and fastest version that allows the replacement of large amount of volume. In this paper, we evaluate patients reported outcomes, before and after surgery, collected through the Breast Q. This study was conducted on 21 patients who were admitted to the plastic surgery department. A prospectively maintained database was used to identify the patients and their records were assessed retrospectively. The pre/post operative patients data were collected. The Breast-Q questionnaire was administered before the surgery and at least 1 year after. No major surgical complications were reported. Mean Breast-Q scores were evaluated at least 1 year after surgery and radiotherapy and compared with pre-surgical scores. Among all the modules, no significant differences between the pre-surgical and post-surgical Breast-Q scores were observed. Until now, the lateral intercostal artery perforator flap has not been widely used, due to a difficult dissection and a challenging preoperative planning. According to the reported surgical technique, the execution is easy. This technique provides the same breast-related quality of life compared to preoperative values, reduces the mastectomy rate and increases the overall survival.

Chest wall perforator flaps for partial breast reconstruction after conservative surgery: Prospective analysis of safety and reliability.

INTRODUCTION: Breast-conserving surgery associated with adjuvant radiotherapy is the state of the art in the surgical treatment of breast cancer. Oncoplastic surgery through dermo-adipose flaps based in perforating arteries (muscle sparing flaps) for partial reconstruction is increasingly used as a good option for avoiding musculocutaneous flaps. In this study we evaluate the outcomes of the use of chest wall perforator flaps in the replacement of partial breast volume. METHODS: A prospective cohort study of female patients that underwent a conservative oncoplastic surgery procedure with partial breast reconstruction using a dermo-adipose flap of perforating arteries of the chest wall was conducted between November 2020 and March 2022 at our centre. Primary outcomes were surgical morbidity, positive margins and reoperation rates. Characteristics associated with the occurrence of complications were further identified. RESULTS: Forty-five patients underwent the procedure of interest during the study period. The mean age was 55 years. The median larger dimension of the tumor was 23 mm. Lateral intercostal artery perforator (LICAP), lateral thoracic artery perforator (LTAP), a combined flap and Anterior Intercostal Artery Perforator/Medial Intercostal Artery Perforator (AICAP)/(MICAP) were performed in 22, 16, 2 and 5 patients, respectively. The mean operative time was 126 min. A total of 9 (20.0%) patients required a reoperation after definitive diagnosis, 4 due to positive margins and 5 due to immediate/early surgical morbidity. CONCLUSIONS: Local perforator flaps in oncoplastic breast-conserving surgery are a good option for immediate reconstruction after conservative surgery, showing low morbidity and favourable outcomes.

'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps.

BACKGROUND: Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes. METHODS: STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis. RESULTS: Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%). CONCLUSIONS: This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Exploration of chest wall perforator vascular anatomy on standard breast MRI: A potential aid to chest wall perforator flap planning.

Local chest wall perforator flaps (CWPFs) are a volume replacement technique permitting breast-conserving surgery in patients who otherwise may require a mastectomy. These flaps are based on one or more perforating arteries arising from the lateral chest wall that travel through the soft tissue and into the sub-dermal plexus to perfuse the flap. Examples include the lateral intercostal and lateral thoracic artery perforators (LICAP and LTAP, respectively). Cross-sectional imaging of perforating vessels is not routinely performed, and vessels are mapped pre- and peri-operatively using a hand-held acoustic doppler device. As many breast cancer patients undergo pre-operative MRI scanning for oncological purposes, we investigated the role of MRI in mapping the vascular anatomy to aid with the surgical planning of CWPFs. We collated data retrospectively on a cohort of breast cancer patients who underwent breast MRI as part of routine pre-operative imaging. Axial 3D high-resolution dynamic contrast-enhanced MRI sequences with multiplanar reconstructions were analysed by a consultant radiologist. The presence and calibre of lateral chest wall perforator vessels were assessed. Fifty patients were suitable for inclusion. A consistent pattern of lateral chest wall vasculature was observed. Forty-eight patients (96%) demonstrated a bilateral lateral thoracic artery (LTA) descending inferiorly along the chest wall with two-thirds of these communicating with perforating intercostal vessels. True independent LICAP vessels were identified in six patients. From our observations, lateral CWPFs are dependent on an intricate intercommunication between intercostal vessels and the LTA which in turn supply perforators to the lateral chest wall donor site.

Lateral chest wall perforator flaps in partial breast reconstruction.

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.

A single centre experience of local perforator flaps in oncoplastic breast surgery; a cross-sectional study.

Background & objectives: Various oncoplastic techniques have emerged over the years to preserve breast cosmesis and symmetry without compromising the principles of tumor excision. One of the newer techniques for breast volume replacement to achieve symmetry and cosmesis is the use of fasciocutaneous pedicled chest wall perforator flaps or local perforator flaps (LPF). The objectives of this study were to document the details of the surgical procedure as well as patient-reported satisfaction and well-being following the procedure using a validated BREAST-Q tool among Pakistani women. Materials & methods: This cross-sectional study was conducted from March 2019 to February 2021 enrolling 25 female patients who underwent breast conservative surgery using LPF for breast tumors at The Aga Khan University Hospital, Karachi. Data related to the procedure was collected on a pre-designed proforma. Cosmetic outcomes and patient satisfaction were evaluated using 2 scales from BREAST-Q BCT domain version 2.0. The questionnaire was self-administered by the patients during their routine follow-up in the clinic. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Mean (SD)/median (IQR) were computed for quantitative variables and frequency and percentages were calculated for qualitative variables. 2 sample t-test was applied. P-value ≤0.05 was considered significant. Results: 25 patients underwent LPF with a mean age of 47 ± 13.1 years. 8 LICAP, 7 AICAP, and 10 LTAP flaps were performed. Two postoperative complications of wound site erythema were encountered. 23 women were eligible for the BREAST-Q survey. Median (IQR) postoperative satisfaction with breasts and physical well-being chest (equivalent Rasch transformed score) was 100 (41) and 76 [18] respectively. We found high satisfaction with breasts and comparable physical well-being among Pakistani women after LPF surgeries. Conclusion: Local perforator flaps in oncoplastic breast-conserving surgery are a good option showing high satisfaction with breasts and physical well-being in Pakistani women.

The anterior LICAP flap: a design option for oncoplastic breast reconstruction.

The purpose was to describe the operation technique of an anterior lateral intercostal artery perforator (LICAP) flap and analyse outcomes and complications. An anterior LICAP flap is a good and safe alternative for direct oncoplastic breast reconstruction. It is a reliable flap that provides sufficient volume and good esthetic outcomes.

Staged approach to partial breast reconstruction to avoid mastectomy in women with breast cancer.

BACKGROUND: The lateral chest wall perforator flaps (CWPF) offer an excellent option for partial breast reconstruction (PBR) in women undergoing breast conservation surgery (BCS) for laterally placed tumours in small to moderate non-ptotic breasts. METHODS: A total of 20 patients underwent PBR with lateral CWPF over the last 4 years, as two-stage approach. This approach was undertaken for patients with high tumour to breast ratio (>30% predicted resection) in an attempt to avoid mastectomy. The reconstruction was carried out 2-4 weeks after wide local excision in order to ensure clear margins prior to undertaking PBR. RESULTS: Twenty-three women were selected for attempt at BCS with 2-stage approach. Three patients had extensive disease so they were then counseled for mastectomy after the first surgery and 20 patients had successful BCS. Out of 20 patients, 13 were symptomatic and 7 were screen-detected with mean age of 49 years. The median tumour size on pre-op imaging was 43 mm (23-75 mm). A percentage of 50% women with unifocal cancers undergoing primary surgery had disease overestimated on pre-op imaging. The complication rate was low. Good to excellent aesthetic outcomes were reported in 90% cases. Patients reported high satisfaction scores. CONCLUSIONS: We recommend considering two-stage approach in selected women with high tumour-breast ratio to ensure successful BCS prior to PBR. This approach facilitates BCS and avoids mastectomy in borderline cases, particularly lobular cancers, DCIS, bifocal cancers and post neoadjuvant chemotherapy where pre-operative disease estimation could be challenging. Our small series has shown that this approach results in safe oncological surgery with good aesthetic outcomes in the selected group of women.

Oncoplastic Breast Surgery: What, When and for Whom?

Oncoplastic surgery is integral to all breast cancer surgeries. The use of an aesthetic approach to breast conservation or mastectomy greatly enhances the range of options that can be offered to women with breast cancer and facilitates better outomes from it. It should be the standard of care. However, a structured approach to selecting appropriate techniques is essential, and although many operative procedures are reported, this article sets out to describe a set of principles and an algorithm by which the what, when and for whom for oncoplastic surgery can be defined.