Local Perforator Flaps in Oncoplastic Breast Surgery: Clinical Applications of ICAP and TDAP Flaps in Reconstruction and Complication Management

Abstract

Introduction

Local perforator flaps have become an increasingly important option in oncoplastic breast surgery. Despite their long-standing use, their application in clinical practice remains limited. This study evaluates the use of thoracic wall perforator flaps, specifically the intercostal artery perforator (ICAP) and thoracodorsal artery perforator (TDAP) flaps, for volume and skin replacement after breast-conserving therapy and in the management of complications following reconstructive procedures.

Materials and Methods

We performed a retrospective analysis of 50 patients treated with local perforator flaps between March 2022 and March 2025 at the Interdisciplinary Breast Center, Klinikum rechts der Isar. Follow-up examinations were conducted in a standardized manner by the primary surgeon and included clinical and ultrasound assessments of the flap, as well as documentation of complications, perfusion, and patient-reported outcomes.

Results

ICAP flaps were used in 39 cases and TDAP flaps in 11 cases. The majority of reconstructions (72%) were immediate. ICAP flaps were mainly used for lower and central defects, whereas TDAP flaps were used for upper outer quadrant and complex cases. The mean operative time was 109 minutes, longer for TDAP flaps (153 minutes). There was no total flap loss and complications were rare (one partial necrosis, three seromas). Radiotherapy was administered in 72% of cases without flap compromise. Flaps were also effective in the management of implant-related or autologous reconstruction complications.

Discussion

Perforator flaps offer reliable, low morbidity reconstruction options with good aesthetic outcomes and low complication rates, even after radiotherapy. They are also suitable for secondary reconstruction and management of complications.

Conclusion

Local perforator flaps, particularly ICAP and TDAP, are safe, versatile tools in oncoplastic breast surgery and should be more widely considered in clinical practice.

 

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Zusammenfassung

Einleitung

Lokale Perforatorlappen haben in der onkoplastischen Brustchirurgie zunehmend an Bedeutung gewonnen. Obwohl diese Techniken seit vielen Jahren etabliert sind, werden sie in der klinischen Praxis bislang nur eingeschränkt eingesetzt. Ziel dieser Studie war es, den Einsatz thorakaler Perforatorlappen – insbesondere des Intercostal Artery Perforator (ICAP) und des Thoracodorsal Artery Perforator (TDAP) Flaps – sowohl zur Volumen- und Hautrekonstruktion nach brusterhaltender Therapie als auch im Management von Komplikationen nach rekonstruktiven Eingriffen zu evaluieren.

Material und Methoden

Es erfolgte eine retrospektive Analyse von 50 Patientinnen, die zwischen März 2022 und März 2025 am Interdisziplinären Brustzentrum des Klinikums rechts der Isar mit lokalen Perforatorlappen behandelt wurden. Die Nachsorge erfolgte standardisiert und umfasste klinische und sonografische Untersuchungen des Lappens sowie die Dokumentation von Komplikationen, Lappenperfusion und Zufriedenheit der Patientinnen.

Ergebnisse

ICAP-Lappen wurden in 39, TDAP-Lappen in 11 Fällen eingesetzt. Der Großteil der Rekonstruktionen (72%) erfolgte primär. ICAP-Lappen wurden überwiegend für Defekte in den unteren Quadranten und zentral verwendet, während TDAP-Lappen vor allem bei Defekten im oberen äußeren Quadranten und bei komplexen Fällen genutzt wurden. Die mittlere Operationszeit betrug 109 Minuten und war bei TDAP-Lappen länger (153 Minuten). Es traten weder vollständige Lappenverluste auf, noch kam es zu schwerwiegenden Komplikationen; dokumentiert wurden lediglich 1 partielle Nekrose und 3 Serome. Eine adjuvante Radiotherapie wurde in 72% der Fälle durchgeführt, ohne dass die Rekonstruktion hierdurch beeinträchtigt wurde. Darüber hinaus erwiesen sich die Lappen als wirksame Option im Management von Komplikationen nach implantatbasierter oder autologer Rekonstruktion.

Diskussion

Perforatorlappen stellen eine verlässliche und komplikationsarme Rekonstruktionsmethode mit guten ästhetischen Ergebnissen dar – auch nach Radiotherapie. Darüber hinaus sind sie für sekundäre Rekonstruktionen sowie für das Management von Komplikationen geeignet.

Schlussfolgerung

Lokale Perforatorlappen, insbesondere ICAP- und TDAP-Lappen, stellen sichere, vielseitige und effektive Instrumente in der onkoplastischen Brustchirurgie dar und sollten in der klinischen Praxis breitere Anwendung finden.

 

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Keywords

breast cancer - oncoplastic breast surgery - perforator flap surgery - breast conserving surgery

Schlüsselwörter

Mammakarzinom - onkoplastische Brustchirurgie - Perforatorlappen - brusterhaltende Operation

Introduction

Breast cancer is the most prevalent form of cancer among the female population. In Germany, approximately 70000 new cases of breast cancer are diagnosed annually, with about 18000 resulting in mortality [1]. While the incidence of the disease has been rising over the last decades, the mortality rate has been declining continuously since the 1980s in the United States [2]. In addition to the continuous improvement of systemic therapy in early and advanced breast cancer, the further development of surgical therapy has also contributed to the increasing survival rates of breast cancer patients [3] [4] [5] [6]. For almost a century, radical mastectomy, first published by Halsted in 1894, served as the prevailing surgical intervention for patients diagnosed with breast cancer [7]. The seminal work of Veronesi et al. provided the foundational evidence for the oncological safety of breast-conserving surgery combined with adjuvant radiotherapy in early-stage breast cancer, thereby leading to a paradigm shift in surgical strategy for locoregional breast cancer treatment [8] [9]. In addition to the importance of oncological safety, the role of breast reconstruction following breast conservation and the aesthetic outcomes of the procedure have become progressively more significant within the field of breast surgery. During the 1980s and 1990s, a plethora of techniques for addressing volume defects were developed, leading to the conceptualization of oncoplastic surgery. Clough et al. advanced the definition of oncoplastic surgery and developed a quadrant per quadrant atlas for volume displacement after breast-conserving surgery [10]. These techniques have the potential to further reduce the rate of mastectomies, thereby providing enhanced cosmetic outcomes and a reduction in breast deformities. Two oncoplastic levels were defined depending on the resection volume and the need for skin excision.

In addition to Clough’s contributions, the field has witnessed the publication of over 30 definitions of oncoplastic surgery over the years. This has prompted the American Society of Breast Surgeons (ASBrS) to issue a consensus paper in 2019 [11]. This definition once more differentiates between two oncoplastic levels, dependent on the volume of the resected breast tissue. In contrast to Clough’s classification, this definition incorporates techniques for volume replacement in cases where more than 50% of the breast volume must be removed. Techniques for volume replacement include implant-based reconstruction, free flap surgery and local flap surgery such as the Thoracodorsal Artery Perforator (TDAP) flap. Perforator flaps, akin to the TDAP Flap, are fasciocutaneous flaps characterized by a solitary vascular supply, originating from the deep vascular system and traversing the muscular or intermuscular septa.

In contrast to perforator flaps, myocutaneous flaps such as the latissimus dorsi flap also include the musculature, which can result in significantly higher morbidity and movement limitations. Angrigiani et al. were the first to introduce a free skin and fat flap similar to the skin paddle of the latissimus dorsi flap without muscle involvement for defect coverage of the lower extremity [12]. In 2004, Hamdi et al. published the Intercostal Artery Perforator Flap (ICAP) in addition to the TDAP flap as an option in breast reconstruction [13]. Despite the fact that locoregional perforator flaps have been established in breast surgery for more than 25 years, their clinical use appears to be underrepresented in the field of oncoplasty. A meta-analysis from 2022 identified 30 articles with 829 patients included describing the use of perforator flaps after breast-conserving therapy [14].

Complication management after breast surgery is another possible implementation of the perforator flaps. The objective of the present study is to provide a comprehensive description of local perforator flaps, both as a volume and as a skin replacement following breast conservation. Furthermore, the utilization of this technique for the management of complications following implant-based or autologous reconstruction is illuminated. The target parameters of the analysis were flap size, resection volume, perioperative metrics, and especially the presentation of postoperative complications such as flap loss or liponecrosis. It is hypothesized that the present study will result in a greater number of breast surgeons becoming acquainted with the use of local perforator flaps as a versatile tool for oncoplastic surgery.

These flaps offer the advantage of avoiding distant donor sites or implants while preserving muscle integrity. However, their routine use still raises important clinical questions: How effective and reliable are ICAP and TDAP flaps in restoring breast contour after tumor resection? Can these flaps be safely applied in immediate reconstruction, even in patients who require postoperative radiotherapy? Furthermore, what role can they play in secondary reconstructions following complications of primary surgery? To address these questions, we present our institutional experience and clinical outcomes with local perforator flaps, and place them in context through a comparison with current evidence from the literature.

 

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Material and Methods

Patient characteristics

Patients who received a local perforator flap for immediate reconstruction of volume and skin defects or who underwent surgical correction of breast reconstruction after complications at the Interdisciplinary Breast Center of the Department of Gynecology and Obstetrics, Klinikum rechts der Isar, were included in the analysis. Patients who underwent surgery between March 2022 and March 2025 were included in the study.

 

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Methods

The project was reviewed by the Ethics Committee of the Technical University of Munich. The approval number is 2023–113-S-SR. Photographic documentation was obtained in accordance with the relevant institutional ethical standards. Written and verbal informed consent was obtained from the patient prior to image acquisition. All images were anonymized to ensure that no personally identifiable information is visible. Data on surgery, follow-up and breast cancer therapy were obtained from the SAP hospital information system. The analysis was anonymized. IBM SPSS Statistics Version 26 and Microsoft Excel 2019 were used for the descriptive statistical analysis.

 

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Follow-up

Follow-up data were retrieved from the hospital information system. All follow-up examinations were conducted in a standardized manner by the primary surgeon. The initial postoperative assessment was performed 7–10 days after surgery, followed by a evaluation after 6 and after 12 weeks. In cases where adjuvant radiotherapy was administered, an additional follow-up was scheduled approximately 6 weeks after completion of treatment. Furthermore, all unscheduled visits were reviewed and included in the analysis.

Each follow-up visit comprised a standardized clinical examination, including palpation and ultrasound assessment of the operated breast, with particular attention to the visualization of the flap. Duplex ultrasonography was routinely used to evaluate flap perfusion. Additionally, patient-reported outcomes, including general well-being, symptoms, and satisfaction, were documented by the primary surgeon. Patient-reported outcomes were not assessed via standardized questionnaires but were gathered through direct evaluation by the operating surgeon.

 

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Surgical technique

All operations were performed in a gynecological breast cancer center by the first author. The surgeon is a specialist in gynecology and a certified breast surgeon with experience in autologous breast reconstruction.

The intercostal artery perforator flap

The intercostal spaces are supplied by the posterior intercostal artery, which arises from the arteria suprema intercostal artery, which in turn originates from the truncus costocervicalis in the first two intercostal spaces. The following nine intercostal arteries originate from the thoracic aorta. The anterior intercostal artery originates from the internal mammary artery. The internal mammary artery also supplies the rami mammarii mediales, which are used for the internal mammary artery perforator flap [15]. The publication of Badran et al. from 1984 provides a comprehensive account of the anatomy and vascularization of intercostal flaps in cadavers [16].

The course of the intercostal artery is divided into different segments. The classification of the ICAP flaps according to the Gent consensus is also based on this division [17]. In accordance with the established classification system, the supply of Anterior Intercostal Artery Perforator (AICAP) flaps is maintained by perforators, which are positioned in close proximity to the sternal border, approximately 2 centimetres away. In the extant literature, these flaps are referred to as the medial intercostal perforator flap (Medial Intercostal Artery Perforator Flap, MICAP) [18]. In order to maintain uniformity in terminology, the present study is grounded in the Gent consensus. There are different ways to design the ICAP Flap. In addition to the localization and dimensions of defects subsequent to breast conserving surgery, the patient’s condition constitutes a pivotal factor in the selection of the optimal flap. For central defects and defects in the lower quadrants, both the AICAP and the LICAP flap are suitable. The flaps are planned as a horizontal skin and fat island below the inframammary fold. The length of the flap can extend across the entire width of the breast. The width of the flap can reach up to 6–7 cm, depending on the fat tissue present in the upper abdomen. A pinch test can be used to estimate the width of the flap. The formation of a new inframammary fold is essential for the closure of the wound.

In the case of defects in the upper outer quadrant and larger central defects, a LICAP flap is indicated. This flap is designed from its base dorsocranially along the lateral breast border. It has been demonstrated that flap lengths of up to 25 cm can be achieved. The presence of fatty tissue in the lateral thoracic wall facilitates the creation of thicker flaps that exhibit greater volume in comparison to the designs previously referenced. [Fig. 1] illustrates the possible designs of the ICAP flap.

Fig. 1 Schematic description of the ICAP flap design. Possible designs of the ICAP Flap. The blue crescent shows the shape of the anterior ICAP flap. Medial, anterior and lateral perforators can be used for this. The pink drawing shows a possible design for the LICAP flap on the lateral chest wall. The typical positions of the dominant perforators are highlighted in red.

 

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The thoracodorsal artery perforator flap

The thoracodorsal artery perforator flap is considered to be particularly suitable for larger volumes and skin defects in all quadrants of the breast, due to the possibility of larger flap dimensions. The origin of the artery is from the subscapular artery, and it supplies the latissimus dorsi, the serratus anterior and the teres major muscles. Typically, two to three skin perforators are observed arising from the vertical branch of the thoracodorsal artery [19]. The vertical branch may be traced approximately 2 centimetres lateral to the musculus latissimus dorsi margin. The proximal perforator can be visualized at a point approximately 8 centimetres below the axillary fold, using ultrasound Doppler imaging. Hamdi et al. propose an operative algorithm for selecting the appropriate perforators and surgical technique, dependent on the present Doppler signal and the intraoperative quality of the dissected perforators. In instances where the quality of the perforators is deemed to be inadequate, alternative muscle-sparing techniques may be employed or the use of an LD plastic may be considered intraoperatively [13]. In the present collective, a sufficient Doppler signal could consistently be observed, and intraoperatively sufficient vessels could be visualized. The flaps can be planned vertically with a slight overlap of the latissimus dorsi edge or as horizontal skin islands. A bra can easily cover the scar resulting from a horizontal flap design. The volume of the defect, the presence of skin defects, the fatty tissue on the donor side, and the patient’s wishes are all crucial factors in the planning of flap dimensions and design. In the context of flap harvesting, the patient is positioned in a lateral decubitus position, analogous to the LD plastic position with shoulder abduction and elbow flexion of 90 degrees. The patient may need to be repositioned during the operation. This may increase the length of the operation. [Fig. 2] illustrates the different designs of the TDAP flap.

Fig. 2 Schematic description of the TDAP flap design. Possible designs of the TDAP Flap. The flap can be planned as a horizontal island or vertically along the edge of the latissimus dorsi muscle. The horizontal scar is located in the bra line and can therefore be covered up well. The red star marks the typical location of the dominant vascular branch approximately 8 cm below the axilla.

 

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Results

Between March 2022 and March 2025, 50 patients underwent oncoplastic breast surgery with local perforator flaps. An ICAP flap was used in 39 cases and a TDAP flap in 11 cases. Among the 39 ICAP flaps, eight were anterior ICAP and 31 were lateral ICAP flaps. The median follow-up of the patients was 18 weeks (6–58). Primary reconstruction with a local flap was performed in more than two-thirds of the cases (72%). In cases of primary breast cancer surgery, immediate reconstruction was preferred. The high rate of primary reconstructions in our cohort reflects the intent to avoid additional surgical interventions. In our series, no re-excisions were required due to positive resection margins. Nevertheless, in the event of an R1 resection, the tumor cavity can be reliably localized, allowing for a secondary resection without technical difficulty. Adverse effects of flap integration following secondary resection are not anticipated. In contrast, the identification of the resection cavity following an extensive mammoplasty can sometimes be challenging, which may justify a two-stage approach in such cases. The ICAP flap was mainly used for primary volume and skin reconstruction in breast-conserving surgery (82.1%). The mean duration of surgery was 109 minutes (51–230 minutes), with a significantly longer duration for the TDAP flap (153 minutes). The duration of surgery was evaluated as the total time from incision to suture, including tumor excision and lymph node dissection, not just flap elevation. The longer duration for the TDAP flap can be explained by the more demanding preparation of the vascular pedicle through the muscle and the possible intraoperative repositioning of the patient. In 9 of the 11 cases, repositioning from the lateral decubitus to the supine position was required.

Approximately half of the volume defects or primary tumors were located in the lower quadrants and central segment, and the other half in the upper/outer quadrant. While the ICAP was mainly used for caudal and central defects, the TDAP flap was used to cover defects in the upper outer quadrant. Patients with in situ carcinoma and all T stages underwent surgery. Patients presenting with a pT1 tumor often had associated in situ carcinoma, necessitating the resection of larger tissue volumes ([Table 1]).

Table 1 General patient and tumor characteristics.

	Overall (n = 50)	ICAP (n = 39)	TDAP (n = 11)
Median age (years)	57 (36–83)	58 (37–83)	55 (36–75)
Median follow-up (weeks)	18 (6–58)	18 (6–58)	18 (6–32)
Adjuvant radiotherapy	72% (n = 36)	82.1% (n = 32)	36.4% (n = 4)
Localization
Lower outer/inner quadrant	38% (n = 19)	46.2% (n = 18)	9.1% (n = 1)
Central breast	17% (n = 7)	15.4% (n = 6)	9.1% (n = 1)
Upper outer/inner quadrant	48% (n = 24)	38.5% (n = 15)	81.8% (n = 9)
Tumor stage (n = 28)
pTis (DCIS and Paget’s disease of the breast)	8.6% (n = 3)	9.7 (n = 3)	0%
pT1	28.6% (n = 10)	29% (n = 9)	25% (n = 1)
pT2	54.3% (n = 19)	58.1% (n = 18)	25% (n = 1)
pT3	5.7% (n = 2)	3.2% (n = 1)	25% (n = 1)
pT4	2.9% (n = 1)	0%	25% (n = 1)
Axillary intervention
pN0	57.1% (n = 20)	61.3% (n = 19)	25% (n = 1)
pN1	42.9% (n = 15)	38.7% (n = 12)	75% (n = 3)
Neoadjuvant chemotherapy	20% (n = 10)	17.9% (n = 7)	27.3% (n = 3)

The rate of adjuvant radiotherapy after perforator flap plasty was very high (72%, n = 36). No radiotherapy-related complications, such as liponecrosis, secondary volume reduction of the flaps or negative cosmetic outcome, were observed during follow-up.

Twenty percent of patients received neoadjuvant chemotherapy as part of their oncological treatment. No increased rate of complications was observed in this group, particularly wound healing problems. The overall complication rate was very low. In one case, partial flap necrosis occurred, necessitating secondary resection of approximately 3 cm of the distal flap segment. Wound healing problems (n = 2) and seroma formation (n = 3) were also rarely observed. Only one patient with a TDAP flap had a persistent seroma requiring puncture. The low seroma rate can be considered a clear advantage of TDAP over LD-Flap. In one case of impaired wound healing, a dehiscence occurred in the inframammary fold which was closed with a secondary suture ([Table 2]).

Table 2 Data on the flap surgery and complications.

	Overall (n = 50)	ICAP (n = 39)	TDAP (n = 11)
Primary reconstruction	72% (n = 36)	82.1% (n = 32)	36.4% (n = 4)
Secondary reconstruction	28% (n = 14)	17.9% (n = 7)	63.6% (n = 7)
Duration of surgery (min)	109 min (51–230)	97 min (51–160)	153 min (98–230)
(Minor) Complications	12% (n = 6)	12.8% (n = 5)	10% (n = 1)
Wound healing	4% (n = 2)	5.1% (n = 2)	0%
Seroma	6% (n = 3)	5.1% (n = 2)	9% (n = 1)
Flap failure	0%	0%	0%
Partial flap necrosis	2% (n = 1)	2.6% (n = 1)	0%
Median dimension of removed tissue (cm)	6.7 × 5.6 × 2.8 cm (n = 45)	6.6 × 5.5 × 2.7 cm (n = 37)	7.1 × 5.9 × 3.3 cm (n = 8)
Median flap length (cm)	17.3 cm (11–26 cm)	16.5 cm (12–24 cm)	20.4 cm (14–26 cm)
Median flap width (cm)	5.2 cm (3–8 cm)	4.7 cm (3–7 cm)	6.7 cm (6–8 cm)
Skin replacement	56% (n = 28)	46.2% (n = 18)	90.9% (n = 10)

In five cases, it was necessary to perform chest-wall perforator flap plasty due to complications arising from implant-based or autologous reconstruction. Two women suffered delayed wound healing after a reduction mastectomy with implant reconstruction. The damaged skin was replaced using a LICAP flap, thus avoiding more serious complications and implant loss. Two cases of partial necrosis were observed following transverse upper gracilis flap surgery. This resulted in a deficiency of volume in the caudal part of the reconstruction. In both cases, the defect was successfully corrected with a TDAP flap. In the fifth case, the authors combined a TDAP flap with an epipectoral implant reconstruction following autologous flap failure. These complex cases illustrate that perforator flaps can be utilized effectively in managing complications during breast surgery.

[Fig. 3], [Fig. 4], [Fig. 5] illustrate a case of primary breast reconstruction utilizing a lateral intercostal artery perforator (LICAP) flap in a 58-year-old female patient diagnosed with breast cancer. Preoperative imaging and histopathological assessment revealed a multifocal carcinoma located in the upper outer quadrant of the right breast. The patient underwent a quadrantectomy in combination with a sentinel lymph node biopsy (SLNB).

Fig. 3 ICAP Case: preoperative documentation. a–c Preoperative marking of the LICAP flap, including the localization of the dominant perforators as identified by preoperative ultrasonography, d, e surgical specimen with skin paddle. Histopathological analysis revealed a bifocal carcinoma with two tumor foci measuring approximately 2.7 cm each, and tumor-free resection margins.

Fig. 4 ICAP Case: intraoperative documentation. a Incision of the flap and dissection of two dominant perforators were performed, followed by mobilization of the remaining flap tissue. b, c The flap was rotated into the resection cavity. The skin paddle was marked, and the remaining skin of the flap—demonstrating good perfusion—was de-epithelialized. d Final results after closure of the donor site and the skin paddle.

Fig. 5 ICAP Case: follow-up documentation. a–d Follow-up after adjuvant chemotherapy (25 weeks postop). e, f Follow-up after radiotherapy (42 weeks postop). Sonography showed no sign of liponecrosis and a good perfusion of the flap tissue.

Clinically, infiltration of the skin was evident, necessitating skin resection. The patient wanted to avoid a symmetrizing procedure on the left breast; therefore, the option of volume and skin reconstruction using an ICAP flap was discussed. [Fig. 3] shows the preoperative markings (hematoma following biopsy). A pre-existing volume asymmetry between the right and left breast was noted. The patient also wished to avoid further reduction of the right breast volume. [Fig. 4] illustrates the surgical steps of flap harvest and defect reconstruction. [Fig. 5] demonstrates that, even in the long-term follow-up and after radiotherapy, no volume loss occurred, and the breast shape could be preserved compared with the preoperative condition.

 

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Discussion

Local perforator flaps have been utilized since the early 2000s for reconstruction following breast-conserving therapy. The groundwork for the development of flaps such as the TDAP, ICAP, and LTAP was laid by foundational anatomical studies on cutaneous vasculature by Manchot and Salmon. These pioneering studies were followed by further research in this area by Angrigiani, Hamdi and Kim [12] [20] [21] [22] [23]. Despite being well established for over two decades, the widespread application of these techniques in oncoplastic surgery remains limited. Recent studies continue to report relatively small patient cohorts [24] [25] [26] [27] [28] [29].

In 2022, Chartier et al. published a review of 30 studies involving thoracic wall flaps for breast reconstruction, encompassing a total of 829 patients, or an average of 27 patients per study [14]. The most extensive retrospective analysis to date, the PartBreCon trial, evaluated 507 cases of locoregional flaps across 15 centers in the United Kingdom between 2011 and 2021 [30]. The number of cases per center ranged from 13 to 107. The study documented a low complication rate with only one total flap loss and two partial flap losses. Our findings support these observations and further demonstrate the applicability of local perforator flaps in managing postoperative complications and in combination with implant-based reconstruction—an area less explored in current literature. It is important to note that, in the British study, only 11 TDAP flaps were included in the 507 cases.

An important finding of the PartBreCon trial was the tumor stage distribution: 84.7% of patients had T1–T2 tumors, with a median T2 tumor size of 26 mm. This is contradictory to the American Society of Breast Surgeons’ guidelines, which recommend volume displacement techniques (e.g., mastopexy, reduction mammaplasty) for resections involving less than 50% of the breast volume. Especially in patients with a small breast volume, even the resection of a small tumor (T1–T2) can result in a significant cosmetic deficit. In such cases, a nipple-sparing mastectomy with subsequent implant reconstruction is frequently advised. This approach often results in asymmetry with the contralateral, healthy breast due to the available implant shapes and implant profiles. In such cases, a contralateral augmentation is commonly deemed necessary to restore symmetry. The clinical experience of the authors suggests that patients with small tumors and limited breast volume benefit significantly from perforator flaps, as volume and skin replacement can be achieved in a single-stage procedure. However, displacement techniques frequently necessitate contralateral symmetrization, a procedure which in Germany may not be covered by insurance. This has the potential to impose significant psychological and financial burdens on patients.

The present study demonstrates the versatility of local perforator flaps. In addition to the established indications for primary and secondary volume replacement, the utilization of TDAP and ICAP flaps in the management of complications, including in implant-based reconstructions, was found to be efficacious. The existing literature on this combination is limited; Bambilla et al. reported 12 TDAP flaps combined with implants for treating post-radiation contractures, with lower complication rates compared to the latissimus dorsi flap [31]. However, in cases of implant failure following radiation therapy, free autologous reconstruction is widely regarded as the optimal approach. Consequently, the combination of local flaps with implants may be considered only for a select group of patients for whom free flap surgery is contraindicated.

The timing of reconstruction is crucial in planning flap-based surgery. After breast conservation surgery, adjuvant radiotherapy is usually indicated, according to national and international guidelines [32] [33]. While two-stage procedures reduce the risk of complications in free flap reconstruction, the evidence on radiation-associated complications is mixed. A number of studies have reported an increase in fat necrosis and fibrosis following radiation, while others have found no significant differences [34] [35] [36]. Considering patients who have received a pedicled TRAM-Flap for breast reconstruction, there are increased complication rates after adjuvant irradiation and a higher risk of fat necrosis, requiring surgical removal [37]. Based on these findings, our center recommends a two-stage approach—initial implant reconstruction followed by autologous reconstruction if radiation is indicated post-mastectomy.

Since most patients undergoing local perforator flap reconstruction also receive adjuvant radiotherapy, direct comparisons with non-radiated cohorts are limited. As demonstrated in extant studies, the complication rate in this setting is low. However, it has been hypothesized that there may be a higher incidence of fibrosis in patients with minimal subcutaneous fat [38] [39]. Low sample sizes and methodological quality clearly limit these findings. The patient satisfaction levels following local perforator flap reconstruction and radiotherapy appear to be high. A small-scale study employing ICAP flaps reported consistently positive patient-reported outcomes after radiation [25]. Although our study did not include standardized satisfaction surveys, patient feedback was consistently positive. Prospective studies with standardized patient-reported outcomes are planned.
Despite the limited follow-up period in our study, no complications associated with radiation therapy, such as liponecrosis or a reduction in flap volume, were observed in the collective. It is anticipated that further follow-up over a period of 5–10 years will provide significant insights in this regard.

Accurate tumor bed localization is essential for planning adjuvant radiotherapy, particularly boost or partial breast irradiation. After oncoplastic surgery, localization may be compromised due to tissue rearrangement. A study on mini-latissimus dorsi flaps demonstrated a 36% change in tumor bed location when comparing pre- and postoperative CT scans [40]. In accordance with the recommendations provided, it is advocated that the tumor bed be marked with a minimum of four clips when local perforator flaps are used or when oncoplastic procedures involving significant tissue displacement are performed. Clipping the tumor cavity before reconstruction enables precise planning of the adjuvant radiotherapy.

The need for adjuvant therapy should always be factored into surgical planning, as complications or revisions can delay radiotherapy or chemotherapy, potentially impacting oncologic outcomes. Multiple studies have shown that oncoplastic techniques do not lead to significant delays in adjuvant therapy [41]. Similarly, our cohort showed no delays in adjuvant treatment.

Since their introduction, the use of chest wall perforator flaps in partial breast reconstruction has been shown to be oncologically safe. A systemic review with 432 observed cases of chest wall perforator flaps reported a positive margin rate of 10.8% [42]. The data on recurrence rates remain inconclusive due to the short follow-up period of only 21 months in this review. Other studies showed low recurrence rates of maximum 0.9%, but with low follow-up times [18] [43]. Reliable long-term oncologic outcomes require extended observation periods of at least 5–10 years. A systemic review of 32 studies by Raufdeen et al. investigated the oncological safety of different oncoplastic techniques. A comparison was made between volume displacement techniques and volume replacement techniques with and without LD flap. The volume replacement group without LD flap showed lower local recurrence and mortality than the other groups [44]. To date, no evidence suggests that chest wall perforator flaps compromise oncologic outcomes. In our cohort, no reoperations were required due to positive margins, and no local or distant recurrences were observed during the follow-up period.

In addition to oncological outcomes, these reviews also examined surgical complications. A systemic review of Pujji et al. reported an overall complication rate of 12.3% among the 432 cases, with low rates of flap necrosis (2.1%), seroma (2.1%), and infection or wound dehiscence (2.4%) [42]. Complications specific to perforators, including fat necrosis (2.1%), venous congestion (0.8%), and total flap loss (1 case), were rare. Our findings align with these data, supporting the safety and reliability of local perforator flaps. Another advantage compared to other oncoplastic techniques is that symmetrization to the opposite breast can be achieved in a single-stage procedure. Up to the latest follow-up, no patient in our cohort required contralateral symmetrization or secondary volume augmentation. However, the relatively limited follow-up period must be acknowledged. Post-radiation skin contracture or flap volume loss could necessitate delayed revisions. Symmetrization operations on the contralateral breast, which may be necessary in the case of a reduction mammoplasty, impose further psychological and physical burden for the patient, require staff capacities and are not always covered by the health insurance funds in the German health care system. These factors must be considered as operation times are also longer when compared to breast conserving surgery with simple volume rearrangement. Breast surgeons with oncoplastic training can quickly learn the techniques of chest wall perforator flaps. The findings of this study may support broader adoption of local perforator flap techniques by breast surgeons without specialized microsurgical training, thereby expanding access to these oncoplastic options for a wider patient population.

 

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Limitations

Despite its strengths, our study is not without limitations. The single-surgeon, single-center nature of the analysis may limit generalizability, and the relatively short median follow-up (18 weeks) limits assessment of long-term outcomes, particularly with regard to late-onset radiotherapy-related complications or aesthetic changes. In addition, the cohort size, although larger than many comparable studies, still reflects a relatively modest sample size, particularly in subgroup analyses.

Future research should include multicenter, prospective studies with longer follow-up to confirm oncological safety, assess the durability of cosmetic results, and further investigate patient-reported outcomes such as quality of life and satisfaction. A formal cost-effectiveness analysis could also provide valuable insights, especially given the potential of these techniques to avoid more complex and expensive procedures such as free flap reconstruction.

 

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Conclusion

Local perforator flaps such as the ICAP and TDAP flaps offer a reliable and reproducible technique for soft tissue reconstruction in oncoplastic breast surgery. Their consistent vascular anatomy and low donor site morbidity make them suitable for a wide range of indications, including defect coverage following oncologic resection and revision of wound healing complications. Based on our clinical experience, these flaps can be incorporated into reconstructive algorithms as a valuable complement to microsurgical free flaps, implant-based reconstruction, or other oncoplastic techniques, thereby expanding the reconstructive armamentarium and enabling a higher proportion of patients to undergo breast-conserving surgery. Further studies are needed to validate long-term outcomes and refine patient selection criteria.

 

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Declarations

• Funding: Not applicable

• Availability of data and material: All data and material are available upon reasonable request.

• Ethics approval: An ethics approval was obtained in advance from the ethics committee of TU Munich (Ref: 2023–113-S-SR).

• Consent to participate: not applicable

• Consent for publication: All authors consent to the publication of this manuscript.

 

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Contributorsʼ Statement

Georg Schmidt was responsible for the conception and design of the study, performed all surgical procedures, conducted postoperative patient follow-up, carried out the data analysis, and led the writing of the manuscript. Theresa Mayo and Angela von Falkenhausen contributed to surgical assistance, patient follow-up and supported the editorial process, including language revision and manuscript refinement. Marion Kiechle was involved in the initial study design and provided substantial editorial input throughout the manuscript development. Daniel Müller assisted in surgical procedures, contributed to surgical planning and patient follow-up, and played a key role in conceptualizing and editing the manuscript.

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We extend our sincere gratitude to all patients who participated in this study. We are especially thankful to those who generously consented to the use of clinical photographs, thereby contributing to the scientific and educational value of this publication.

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Publication History

Received: 14 June 2025

Accepted after revision: 14 September 2025

Article published online:
16 October 2025