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.
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.
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.
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.
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.
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.
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
38% (n = 19)
46.2% (n = 18)
9.1% (n = 1)
17% (n = 7)
15.4% (n = 6)
9.1% (n = 1)
48% (n = 24)
38.5% (n = 15)
81.8% (n = 9)
Tumor stage (n = 28)
8.6% (n = 3)
9.7 (n = 3)
0%
28.6% (n = 10)
29% (n = 9)
25% (n = 1)
54.3% (n = 19)
58.1% (n = 18)
25% (n = 1)
5.7% (n = 2)
3.2% (n = 1)
25% (n = 1)
2.9% (n = 1)
0%
25% (n = 1)
Axillary intervention
57.1% (n = 20)
61.3% (n = 19)
25% (n = 1)
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)
4% (n = 2)
5.1% (n = 2)
0%
6% (n = 3)
5.1% (n = 2)
9% (n = 1)
0%
0%
0%
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.
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.
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.
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.
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.
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.
