Use of lateral intercostal artery perforator flaps in breast-conserving surgery for breast cancer: a single-center experience

Introduction

Breast cancer remains the most common malignancy among women worldwide. Although radical mastectomy was historically considered the standard treatment, landmark randomized trials have demonstrated equivalent long-term survival between mastectomy and breast-conserving surgery (BCS) combined with radiotherapy. Oncoplastic techniques have therefore gained increasing relevance, expanding the indications for breast conservation while improving cosmetic results and patient satisfaction. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0128/rc).

Methods

A retrospective observational study was conducted at Hospital Alemán between April 2024 and April 2025. Patients who underwent BCS followed by immediate reconstruction using lateral or anterior intercostal artery perforator (LICAP or AICAP) flaps were included.

Collected variables included patient demographics, comorbidities, tumor characteristics, imaging findings, presence of multifocal disease, surgical technique, flap type, resection volume, margin status, postoperative complications, and timing of adjuvant therapy.

Preoperative planning included clinical evaluation and Doppler-based perforator mapping. The choice between LICAP and AICAP flap reconstruction was based on tumor location, breast size, and availability of perforators. LICAP flaps were primarily used for lateral defects, while AICAP flaps were reserved for selected anterior defects.

Flap design and elevation were performed according to standard oncoplastic techniques. In LICAP flap reconstruction, perforators arising from the lateral intercostal vessels were identified preoperatively using handheld Doppler and confirmed intraoperatively. A skin paddle was designed along the lateral chest wall, and the flap was elevated in a suprafascial plane, preserving the perforator vessels. The flap was then rotated into the breast defect and secured without tension. In the single case requiring AICAP reconstruction, an AICAP flap was designed, following similar principles of dissection and inset. In all cases, volume replacement was achieved using de-epithelialized flaps, preserving the native breast skin envelope.

Postoperative complications were classified according to the Clavien-Dindo system. Fat necrosis was defined as the presence of palpable firmness and/or imaging findings suggestive of fat necrosis on ultrasound or mammography. Aesthetic outcomes and patient satisfaction were assessed at 3 months postoperatively through non-validated institutional questionnaires.

Statistical analysis

Descriptive statistics were used to summarize demographic, clinicopathological, and surgical variables. Continuous variables are presented as means and ranges, while categorical variables are expressed as frequencies and percentages. Due to the small sample size and descriptive nature of the study, no comparative inferential statistical analyses were performed. Statistical analyses were conducted using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA).

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective observational study used anonymized clinical data collected during routine clinical practice. According to institutional policy, formal ethics committee approval was not required for retrospective studies using fully anonymized data, and individual informed consent was waived. All clinical images were anonymized to ensure patient confidentiality.

Results

Fifteen patients met the inclusion criteria. Clinicopathological characteristics are summarized in Table 1, and surgical outcomes are presented in Table 2. The mean patient age was 66.3 years, with a mean body mass index (BMI) of 25.7 kg/m². One patient was an active smoker, and three patients had a history of type 2 diabetes mellitus.

Invasive carcinoma accounted for 73.3% of tumors, while ductal carcinoma in situ represented 26.7%. All tumors were located in the outer quadrants of the breast, and multifocal disease was identified in 53.3% of cases.

Reconstruction was performed using a LICAP flap in 14 patients (93.3%) and an AICAP flap in one patient (6.7%). The mean tumor size was 41.7 mm, and the mean resection volume was 60.2 cm³.

Clear surgical margins were achieved in 93.3% of cases, with one patient requiring re-excision. All flaps remained viable, with no cases of partial or total flap necrosis. Two minor postoperative complications were recorded: one surgical site infection and one hematoma. No major complications were observed.

Preoperative planning and surgical steps are illustrated in Figures 1-3. Figure 1 demonstrates flap marking in a patient with multifocal disease. Figure 2 shows elevation of a LICAP flap, and Figure 3 depicts intraoperative flap mobilization and inset. Postoperative scar evolution and early aesthetic outcomes are presented in Figures 4,5.

Figure 1 Preoperative marking of the flap in a case of multifocal disease.

Figure 2 LICAP flap. LICAP, lateral intercostal artery perforator.

Figure 3 Intraoperative flap mobilization.

Figure 4 Postoperative scar appearance.

Figure 5 Two-week postoperative outcome.

Adjuvant radiotherapy was administered to 13 patients (86.7%), and all patients initiated adjuvant treatment within 12 weeks following surgery. The 2 remaining patients did not receive radiotherapy for personal decision.

Discussion

BCS provides oncologic outcomes comparable to mastectomy in appropriately selected patients (1,2); however, achieving optimal aesthetic results remains challenging, particularly after large-volume resections (3-5). Oncoplastic breast surgery has emerged as an effective strategy to address this limitation by integrating oncologic principles with reconstructive techniques, thereby expanding the indications for breast conservation. In this context, perforator flaps such as the LICAP and AICAP flaps have gained increasing attention as volume replacement techniques that avoid muscle sacrifice and minimize donor-site morbidity (6-8).

In the present single-center experience, LICAP flap reconstruction was the predominant technique, with only a single case performed using an AICAP flap. Patient selection plays a critical role in achieving optimal outcomes with LICAP flaps. These techniques are particularly well suited for patients with moderate breast volume and tumors located in the lateral quadrants, where local tissue rearrangement alone may be insufficient to restore breast contour (9).

Our findings suggest that LICAP flaps are technically feasible and can be successfully integrated into BCS, with a low rate of postoperative complications and satisfactory early aesthetic outcomes. All flaps in this series remained viable, and only minor complications were observed, which is consistent with previously published data reporting low morbidity associated with perforator-based reconstruction.

These results are in line with prior studies, including the work by Lipman et al. (10), who first described the application of LICAP flaps in partial breast reconstruction and demonstrated their reliability and versatility in managing lateral breast defects. Subsequent series have confirmed these findings, supporting the role of LICAP flaps as a valuable option in oncoplastic surgery, particularly in patients requiring volume replacement following wide local excision (11,12).

An essential oncologic benchmark is the timely initiation of adjuvant therapy. In this cohort, adjuvant radiotherapy was initiated within the recommended timeframe for all patients, indicating that immediate reconstruction using perforator flaps does not delay postoperative oncologic treatment. However, this observation should be interpreted cautiously given the limited sample size.

With regard to oncologic outcomes, no local recurrences were observed during the follow-up period. Nevertheless, the mean follow-up of 20 months is insufficient to draw definitive conclusions regarding long-term oncologic safety. Therefore, these findings should be considered preliminary, and longer follow-up is required to validate the oncologic adequacy of this approach.

Aesthetic outcomes and patient satisfaction are key endpoints in oncoplastic surgery. In this series, favorable aesthetic results were observed based on institutional assessment tools. However, it is important to note that validated instruments such as the BREAST-Q were not formally applied, which limits the strength and comparability of these findings. Future studies incorporating standardized patient-reported outcome measures are warranted.

This study has several important limitations that must be acknowledged. First, the small sample size significantly limits the statistical power and generalizability of the results. Second, the absence of a control group precludes any comparative analysis with other reconstructive techniques or with standard BCS alone. Third, the retrospective design introduces potential sources of selection and reporting bias. Additionally, the relatively short follow-up limits the assessment of long-term oncologic and reconstructive outcomes.

Another important limitation is the imbalance between LICAP and AICAP flap utilization. Given that only one patient underwent AICAP reconstruction, no meaningful conclusions can be drawn regarding the role or performance of this technique in our cohort. Future studies with a larger and more balanced sample are necessary to better define the indications and outcomes of different intercostal artery perforator flaps.

Despite these limitations, this study provides preliminary evidence supporting the feasibility of LICAP flap reconstruction in the setting of BCS. The consistent flap viability, low complication rates, and acceptable early aesthetic outcomes observed in this series suggest that this technique may be a useful option in selected patients requiring volume replacement.

Further prospective studies with larger cohorts, standardized outcome measures, and longer follow-up are required to better define the role of perforator flaps in oncoplastic breast surgery and to assess their comparative effectiveness against alternative reconstructive techniques.

Conclusions

LICAP flap reconstruction may represent a feasible and promising option for volume replacement following BCS in selected patients. These techniques allow for larger oncologic resections while preserving breast contour, achieving favorable aesthetic outcomes, and maintaining timely access to adjuvant therapy.

However, these findings should be interpreted with caution given the retrospective design, small sample size, lack of a control group, and limited follow-up. Further studies with larger cohorts and longer follow-up are required to confirm these preliminary results.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0128/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0128/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0128/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0128/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This retrospective observational study used anonymized clinical data collected during routine clinical practice. According to institutional policy, formal ethics committee approval was not required for retrospective studies using fully anonymized data, and individual informed consent was waived. All clinical images were anonymized to ensure patient confidentiality.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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