Introduction

Breast reconstruction surgery restores the shape and volume to the affected tissues. The use of flaps is an important tool of its armamentarium. The description of different flaps based on chest wall artery perforators has enabled the use of donor sites with the same texture and color as the breast, while also concealing the scar in the inframammary line.

Choosing the most appropriate flap for each reconstruction is crucial to achieve optimal results. Several factors determine which perforator flap to choose and include the defect generated after tumor resection, location of the perforator that vascularizes the possible flap and its diameter, which is a reliable indicator of the perfusion capacity and therefore of the possible flap size to be achieved with this pedicle, and finally the evaluation of the donor site in terms of the final resulting scar.

The use of an algorithm to select flaps based on these factors has proven useful for their indication.

The aim of this study was to describe the clinical results of an algorithm for using chest wall perforator flaps for breast reconstruction after breast-conserving surgery for breast cancer.

Material and methods

We conducted a retrospective and descriptive study. The information was retrieved from the medical records of patients diagnosed with breast cancer who underwent oncoplastic surgery: tumor resection with immediate conservative breast surgery reconstruction using chest wall perforator flaps, between January 2020 and March 2022.

Post-resection defects were evaluated in the following locations: upper outer, lower outer, central, upper inner and lower inner quadrants.

Before surgery, the presence and thickness of the vascular pedicle was identified in all the cases using Doppler ultrasound (EDAN True Sonotrax Vascular Doppler, USA) to evaluate the vascular pedicles (cutaneous perforators) of the possible flaps to be used according to the region of the affected breast (Figures 1 and 2). The necessary flaps were then designed and made in each case, according to the algorithm described in Figure 3.

FIGURE 1 Evaluation and image of LICAP using Doppler ultrasound 

FIGURE 2 Mapping of chest wall perforators and different options for designing the different flaps, based on the origin of each perforator 

FIGURE 3. Algorithm for selecting chest wall perforator flaps according to the location of the postoperative tissue defect and the presence of perforators confirmed by color Doppler ultrasound. AICAP: Anterior Intercostal Artery Perforator. LICAP: Lateral Intercostal Artery Perforator. MICAP: Medial Intercostal Artery Perforator. LTAP: Lateral Thoracic Artery Perforator. TDAP: Thoraco Dorsal Artery Perforator 

The inclusion criterion was the identification of the pedicle corresponding to the chest wall flap by preoperative Doppler ultrasound. Current smokers were excluded from the analysis.

The information recorded included demographic data, type of flaps chosen and intraoperative and postoperative results.

The aesthetic results were evaluated by the patients using a satisfaction questionnaire, which rated the results as poor, fair, good, or excellent.

The study was approved by the institutional review board.

Results

During the study period 19 patients met the inclusion criteria. Mean age was 52 ± 11 years (range, 30-76). Mean body mass index was 22.4 kg/m² (range: 20-35). Two patients had type 2 diabetes and one had hypertension.

The histologic types were invasive carcinoma (n = 13), ductal carcinoma in situ (n = 4), Paget’s disease (n = 2) and phyllodes tumor (n = 1). One patient presented bilateral invasive carcinoma.

Sentinel-node biopsy was made via a separate axillary incision and was positive in 3 cases.

Twenty perforator flaps were used in 19 conservative surgeries: 7 AICAP (Anterior Intercostal Artery Perforator) flaps, 3 LICAP (Lateral Intercostal Artery Perforator) flaps, 4 MICAP (Medial Intercostal Artery Perforator) flaps, 4 TDAP (Thoraco Dorsal Artery Perforator) flaps and 2 LTAP (Lateral Thoracic Artery Perforator) flaps.

Of the flaps used, 19 (95%) survived well and only one (5%) presented superficial epidermolysis that did not affect flap vitality.

LICAP and TDAP flaps had the largest size.

TDAP flaps were used in 4 cases for coverage and volume replacement of upper inner and outer inner quadrants. LICAP flaps were used in 3 cases for volume reconstruction (2 cases) and coverage (1 case). AICAP flaps were used to replace volume and for coverage of the lower inner and central quadrants in 7 cases. MICAP flaps were used for lower inner and central quadrants in 4 cases (Figures 4 and 5).

FIGURE 4 Patient with a defect in the lower inner and central quadrants: flap design, transposition and immediate result with MICAP flap 

FIGURE 5 Long-term postoperative outcome at 6 months with AICAP flap 

The proposed algorithm for flap selection successfully identified the appropriate flap for reconstruction in all 20 patients.

There were no intraoperative complications during surgery. One patient developed a compressive hematoma that required surgical revision at 24 hours. The patients were discharge on postoperative day 1 or 2.

All the patients underwent postoperative radiation therapy without loss of volume or retractions.

Mean follow-up period was 15 months. None of the patients received aesthetic corrections on longterm follow-up and there were no local recurrences.

The patients rated the aesthetic results of the reconstructions at 6 months. Seven cases were rated as excellent, 11 cases as good, and two cases as fair.

Discussion

The results of this study indicate that the use of a Doppler-based algorithm to evaluate breast perfusion and perforator deficit was a useful tool for selecting the appropriate flap for reconstructive breast surgery.

The vascularization of the breast has been extensively and thoroughly studied and published by

many authors^1,2. It is based on the main vascular pedicles (internal mammary artery, external mammary artery,

intercostal arteries and lateral thoracic artery)^3,4. Many of these pedicles are usually sectioned or necessarily coagulated during the surgical procedure.

The remaining pedicles are of utmost importance not only to ensure vascular supply to the mastectomy skin flaps, but they can also be used to provide vascularization to adjacent skin flaps useful for immediate breast reconstruction^5,6. The use of color Doppler ultrasound is necessary and results superior to conventional Doppler to evaluate perforators and compare their diameters which are directly related to their blood flow and therefore to the amount of tissue they can vascularize^7,8.

The perforator vessels to the breast are branches of either the internal mammary artery (3^rd and 4^th intercostal perforators) and of other arteries as MICAP, AICAP, or LICAP^9,10. These branches are used as perforator flaps for the reconstructions described in these series. The lateral intercostal artery perforator (LIAP), branch of the axillary artery, and the thoracodorsal artery perforator (TDAP) are also used as flaps for breast reconstruction.

It is important to understand the origins of the anatomy of the intercostal vessels¹¹ which form an arcade between the aorta posteriorly and the internal mammary vessels anteriorly. The arcade is divided into vertebral, costal and muscular segments giving the dorsal, lateral, medial and anterior perforators. For descriptive purposes, the area of the chest wall beneath the inframammary fold can be equally divided into three regions⁷. The medial intercostal artery perforator (MICAP) is present medially and the anterior intercostal artery perforator (AICAP) is present in the central region.

The lateral intercostal artery perforator (LICAP) is present in the outer third.

Preoperative localization of the deep inferior epigastric artery perforator provides optimal surgical planning for autologous breast reconstruction with deep inferior epigastric artery perforator flaps. This information is useful to identify the location and diameter of these perforating vessels to improve the probability of reconstruction success. The use of preoperative breast vascular imaging is still an underutilized strategy despite the theoretical benefits including the identification of the intercostal breast vascularization. We highlight the versatility of local perforator flaps to correct breast defects for both immediate and delayed reconstruction.

The results of the present study should be confirmed in a larger sample before recommending the use of this algorithm as a standard tool for flap selection for breast reconstruction surgery.

In conclusion, the selection of perforator flaps can be performed using the algorithm described, based on the location of the defect. Understanding the vascular anatomy and mapping of the perforator branches can aid in dissection and preserve vascularization of the selected flap.