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.

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.

Keywords

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

Schlüsselwörter

Mammakarzinom - onkoplastische Brustchirurgie - Perforatorlappen - brusterhaltende Operation

Publication History

Received: 14 June 2025

Accepted after revision: 14 September 2025

Article published online:
16 October 2025

• References

• 1 Robert Koch-Institut. Krebs in Deutschland für 2017/2018. Accessed September 29, 2025 at: https://www.krebsdaten.de/Krebs/DE/Content/Publikationen/Krebs_in_Deutschland/kid_2021/krebs_in_deutschland_2021.pdf?__blob=publicationFile
• 2 Giaquinto AN, Sung H, Miller KD. et al. Breast Cancer Statistics, 2022. CA Cancer J Clin 2022; 72: 524-541
• 3 Lüftner D, Kolberg HC, Hartkopf AD. et al. Update Breast Cancer 2024 Part 3 – Patients with Advanced Stage Breast Cancer. Geburtshilfe Frauenheilkd 2025; 85: 507-519
• 4 Würstlein R, Kolberg HC, Hartkopf AD. et al. Update Breast Cancer 2024 Part 1 – Expert Opinion on Advanced Breast Cancer. Geburtshilfe Frauenheilkd 2024; 84: 529-540
• 5 Janni W, Kolberg HC, Hartkopf AD. et al. Update Breast Cancer 2024 Part 2 – Patients with Early Stage Breast Cancer. Geburtshilfe Frauenheilkd 2025; 85: 493-506
• 6 Untch M, Banys-Paluchowski M, Brucker SY. et al. Treatment of Patients with Early Breast Cancer: 19th St. Gallen International Breast Cancer Consensus Discussed against the Background of German Treatment Recommendations. Geburtshilfe Frauenheilkd 2025; 85: 677-693
• 7 Halsted WS. I. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894. Ann Surg 1894; 20: 497-555
• 8 Veronesi U, Saccozzi R, Del Vecchio M. et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981; 305: 6-11
• 9 Veronesi U, Cascinelli N, Mariani L. et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347: 1227-1232
• 10 Clough KB, Kaufman GJ, Nos C. et al. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010; 17: 1375-1391
• 11 Chatterjee A, Gass J, Patel K. et al. A Consensus Definition and Classification System of Oncoplastic Surgery Developed by the American Society of Breast Surgeons. Ann Surg Oncol 2019; 26: 3436-3444
• 12 Angrigiani C, Grilli D, Siebert J. Latissimus Dorsi Musculocutaneous Flap Without Muscle. Plast Reconstr Surg 1995; 96: 1608-1614
• 13 Hamdi M, van Landuyt K, Monstrey S. et al. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg 2004; 57: 531-539
• 14 Chartier C, Safran T, Alhalabi B. et al. “Locoregional perforator flaps in breast reconstruction: An anatomic review & quadrant algorithm”. J Plast Reconstr Aesthet Surg 2022; 75: 1328-1341
• 15 van Huizum MA, Hage JJ, Oldenburg HA. et al. Internal Mammary Artery Perforator Flap for Immediate Volume Replacement Following Wide Local Excision of Breast Cancer. Arch Plast Surg 2017; 44: 502-508
• 16 Badran HA, El-Helaly MS, Safe I. The lateral intercostal neurovascular free flap. Plast Reconstr Surg 1984; 73: 17-26
• 17 Blondeel PN, van Landuyt KHI, Monstrey SJM. et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003; 112: 1378-1383 quiz 1383, 1516; discussion 1384–1387
• 18 Soumian S, Parmeshwar R, Chandarana M. et al. Chest wall perforator flaps for partial breast reconstruction: Surgical outcomes from a multicenter study. Arch Plast Surg 2020; 47: 153-159
• 19 Spinelli HM, Fink JA, Muzaffar AR. The latissimus dorsi perforator-based fasciocutaneous flap. Ann Plast Surg 1996; 37: 500-506
• 20 Hamdi M, van Landuyt K, de Frene B. et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 2006; 59: 644-652
• 21 Manchot C. The cutaneous Arteries of the human Body. New York: Springer; 1983
• 22 Salmon M, Taylor GI, Tempest MN. Arteries of the Skin. London: Churchill Livingstone; 1988
• 23 Kim JT, Ng SW, Naidu S. et al. Lateral thoracic perforator flap: additional perforator flap option from the lateral thoracic region. J Plast Reconstr Aesthet Surg 2011; 64: 1596-1602
• 24 Adler N, Carmon E, Chapchay K. et al. Anterior intercostal artery perforator flap for immediate reconstruction following breast conservation surgery. Microsurgery 2023; 43: 20-26
• 25 Carrasco-López C, Julian Ibañez JF, Vilà J. et al. Anterior intercostal artery perforator flap in immediate breast reconstruction: Anatomical study and clinical application. Microsurgery 2017; 37: 603-610
• 26 Leach GA, Clark RC, Tong S. et al. The Intercostal Artery Perforator Flap: Expanding Breast-Conserving Therapy With a Modified Oncoplastic Approach. Ann Plast Surg 2023; 90 (Suppl. 3) S236-S241
• 27 Youssif S, Hassan Y, Tohamy A. et al. Pedicled local flaps: a reliable reconstructive tool for partial breast defects. Gland Surg 2019; 8: 527-536
• 28 Zeeshan S, Vohra LM, Shamsi US. et al. A single centre experience of local perforator flaps in oncoplastic breast surgery; a cross-sectional study. Ann Med Surg (Lond) 2022; 84: 104916
• 29 Hashem T, Taha SN, Orabi A. LICAP Versus TDAP for the Reconstruction of Partial Breast Defects. Indian J Surg Oncol 2023; 14: 181-185
• 30 Agrawal A, Romics L, Thekkinkattil D. PartBreCon Collaborators. et al. ‘PartBreCon’ study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps. Breast 2023; 71: 82-88
• 31 Brambilla L, Parisi P, Gatto A. et al. A Retrospective Comparative Analysis of Latissimus Dorsi (LD) Flap Versus Thoracodorsal Artery Perforator (TDAP) Flap in Total Breast Reconstruction with Implants: A Pilot Study. J Reconstr Microsurg 2022; 38: 451-459
• 32 Arbeitsgemeinschaft Gynäkologische Onkologie E.V.. Kommission Mamma. 2023 Accessed October 26, 2023 at: https://www.ago-online.de/leitlinien-empfehlungen/leitlinien-empfehlungen/kommission-mamma
• 33 Cardoso F, Kyriakides S, Ohno S. et al. Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol 2019; 30: 1194-1220
• 34 Cooke AL, Diaz-Abele J, Hayakawa T. et al. Radiation Therapy Versus No Radiation Therapy to the Neo-breast Following Skin-Sparing Mastectomy and Immediate Autologous Free Flap Reconstruction for Breast Cancer: Patient-Reported and Surgical Outcomes at 1 Year-A Mastectomy Reconstruction Outcomes Consortium (MROC) Substudy. Int J Radiat Oncol Biol Phys 2017; 99: 165-172
• 35 Myung Y, Son Y, Nam TH. et al. Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction. PloS one 2018; 13: e0197615
• 36 Pont LP, Marcelli S, Robustillo M. et al. Immediate Breast Reconstruction with Abdominal Free Flap and Adjuvant Radiotherapy: Evaluation of Quality of Life and Outcomes. Plast Reconstr Surg 2017; 140: 681-690
• 37 He S, Yin J, Robb GL. et al. Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?. Ann Plast Surg 2017; 78: 633-640
• 38 Martellani L, Manara M, Renzi N. et al. Use of licap and ltap flaps for breast reconstruction. Acta Chir Plast 2019; 60: 4-8
• 39 Almasad JK, Salah B. Breast reconstruction by local flaps after conserving surgery for breast cancer: an added asset to oncoplastic techniques. Breast J 2008; 14: 340-344
• 40 Alço G, Igdem S, Okkan S. et al. Replacement of the tumor bed following oncoplastic breast-conserving surgery with immediate latissimus dorsi mini-flap. Mol Clin Oncol 2016; 5: 365-371
• 41 Dogan L, Gulcelik MA, Karaman N. et al. Oncoplastic surgery in surgical treatment of breast cancer: is the timing of adjuvant treatment affected?. Clin Breast Cancer 2013; 13: 202-205
• 42 Pujji OJS, Blackhall V, Romics L. et al. Systematic review of partial breast reconstruction with pedicled perforator artery flaps: Clinical, oncological and cosmetic outcomes. Eur J Surg Oncol 2021; 47: 1883-1890
• 43 Quinn EM, Burrah R, O’Ceallaigh S. et al. Six-year experience of oncoplastic volume replacement using local perforator flaps. J Plast Reconstr Aesthet Surg 2021; 74: 2184-2193
• 44 Raufdeen F, Murphy J, Ahluwalia M. et al. Outcomes in volume replacement and volume displacement techniques in oncoplastic breast conserving surgery: A systematic review. J Plast Reconstr Aesthet Surg 2021; 74: 2846-2855