Pedicled Flaps in Partial Breast Reconstruction

Breast cancer is one of the most common cancer forms worldwide and has become the commonest cancer in women in most parts of the world. Surgery remains the single best treatment modality and globally, breast conservations are on the rise with increasing Oncoplastic techniques. Oncoplastic techniques have evolved over the last decade with the increasing use of pedicled flaps to enable partial breast reconstruction. This handy guide fills a gap in available publications to describe current trends, to help advance the knowledge and update skills of the reader. After an historical introduction, chapters on pre-operative mapping and imaging, as well as on patient selection for each approach, over eleven chapters are devoted to specific flaps and to their combination. The crucial management of complications and radiotherapy planning are also developed in dedicated parts. With contributions from world-renowned plastic and oncoplastic breast surgeons, step-by-step videos linked to the surgical chapters and a wealth of original photographs and illustrations, Pedicled Flaps in Partial Breast Reconstruction will be a valued reference for fellows, residents, practicing and highly experienced plastic surgeons, breast surgeons, and practitioners in related surgical sub-specialties, who will find this a useful tool in their day-to-day practice. Foreword Preface Acknowledgements Contents 1: History of Pedicled Perforator Flaps for Breast Reconstruction 1.1 Breast Reconstruction Historical Background 1.2 Perforator Flaps Historical Background 1.3 History of Surgical Planning of Perforator Flaps 1.4 Perforator Flap Era 1.5 Pedicled Perforator Flaps: Tissue Transfer Evolution 1.6 Conclusion References 2: Pre-operative Mapping and Imaging of Perforator Flaps 2.1 Introduction 2.2 Procedure for Angio-CT Examination for Mapping of Perforators 2.3 Perforators in the Abdominal Wall 2.3.1 Deep Inferior Epigastric Artery Perforator (DIEAP) Flap 2.3.2 Superficial Inferior Epigastric Artery Perforator (SIEAP) Flap 2.3.3 Superior Epigastric Artery Perforator (SEAP) Flap 2.4 Perforators of the Tight 2.4.1 Profunda Artery Perforator (PAP) Flap 2.5 Perforators of the Back 2.5.1 Lumbar Artery Perforator (LAP) Flap 2.5.2 Gluteal Artery Perforators References 3: Choosing the Right Patient and Right Approach in Partial Breast Reconstruction with Pedicled Chest Wall Perforator Flaps 3.1 Preoperative Perforator Mapping 3.2 Clinical Settings Where Pedicled Chest Wall Perforator Flaps Are Used in Partial Breast Reconstruction 3.3 Lateral Thoracic Artery Perforator Flap (LTAP) 3.4 Lateral Intercostal Artery Perforator Flap (LICAP) 3.5 Anterior Intercostal Artery Perforator Flap (AICAP), Medial Intercostal Artery Perforator Flap (MICAP) 3.6 Thoracodorsal Artery Perforator Flap (TDAP) References 4: The Thoracodorsal Artery Perforator (TDAP) Flap 4.1 Anatomy 4.2 Applications 4.3 Steps 4.3.1 Planning 4.3.2 Harvesting 4.3.3 Transference 4.4 Conclusions 4.5 Clinical Application References 5: Lateral Intercostal Artery Perforator (LICAP) Flap 5.1 Anatomy 5.2 Applications 5.3 Steps 5.3.1 Planning 5.3.2 Dissection 5.4 Conclusion 5.5 Clinical Application References 6: Serratus Anterior Artery Perforator (SAAP) Flap 6.1 Anatomy 6.2 Applications 6.3 Steps 6.3.1 Planning 6.3.2 Harvesting 6.3.3 Transference 6.4 Conclusions 6.5 Clinical Application References 7: Lateral Thoracic Artery Perforator (LTAP) Flap 7.1 Background 7.2 Anatomy 7.3 Patient Selection 7.4 Technique 7.5 Comparison with Other Perforators 7.5.1 LTAP Vs. LiCAP 7.5.2 LTAP Vs TDAP 7.6 Outcomes 7.7 Conclusions References 8: Extended Thoracodorsal Artery Perforator (TDAP) Flap 8.1 Anatomy 8.2 Applications 8.3 Steps 8.3.1 Planning 8.3.2 Harvesting 8.3.3 Transference 8.4 Conclusions 8.5 Clinical Application References 9: Anterior Intercostal Artery Flap: AICAP FLAP 9.1 Anatomy 9.2 Indications 9.3 Contraindications 9.4 Planning and Preoperative Marking 9.5 Intra Operative (Video 9.1) 9.6 Conclusions References 10: Superior Epigastric Artery Perforator (SEAP) FLAP 10.1 Anatomy 10.2 Applications 10.3 Steps 10.3.1 Planning 10.3.2 Harvesting 10.3.3 Transference 10.4 Conclusions 10.5 Clinical Application References 11: Subcostal Artery Perforator (SCAP) Flap: A New Application in Breast Reconstruction 11.1 Anatomy 11.1.1 General Information on the Anterolateral Abdominal Wall 11.1.2 General Information on the Vascularization of the Anterolateral Abdominal Wall 11.1.2.1 Arterial Vascularization 11.1.2.2 Venous Vascularization 11.1.3 Anatomy of the Subcostal Pedicle 11.1.3.1 The Subcostal Artery 11.1.3.2 The Subcutaneous Vein 11.1.3.3 The Nerves 11.1.4 Anatomical Study of the SCAP Flap 11.2 Applications 11.3 Steps 11.3.1 Regarding the Closure 11.4 Conclusion References 12: The Latisimus Dorsi Miniflap 12.1 Introduction 12.2 Indications 12.3 Deciding on the Suitability of a Miniflap 12.4 Operative Technique 12.4.1 Incisions 12.4.2 The ‘Classical’ Miniflap Operation 12.4.3 The Myocutaneous Miniflap Operation 12.4.4 Tips for a Successful Result 12.5 Outcomes 12.5.1 Complications 12.5.2 Oncological Outcomes 12.6 Cosmesis, Quality of Life and Well-Being 12.7 Summary References 13: Pedicle Perforator Flaps with “Invisible” Scar 13.1 Introduction 13.2 Anatomy 13.3 Application 13.4 Techniques 13.5 Conclusions Further Reading 14: Chest Wall Perforator Flaps in Breast-Conserving Surgery: Nottingham Approach 14.1 Lateral Intercostal Artery Perforator (LICAP) Flap 14.2 LICAP Steps 14.2.1 Assessing Available Perforators 14.2.2 Flap Markings and Planning 14.2.3 Patient Positioning 14.2.4 Dissection 14.2.5 Flap Inset and Skin Closure 14.3 LTAP Flap 14.4 LTAP Steps 14.4.1 Markings 14.4.2 Dissection of the LTAP Flap 14.5 Combined LTAP/LICAP Flaps 14.6 Choosing Between the LICAP, LTAP, and Combined Flap? 14.7 Decisions that Impact on Chest Wall Perforated Flaps 14.7.1 Nodal Status and Requirements for Axillary Clearance 14.7.2 Single-Stage or Two-Stage Surgery? 14.8 Anterior Intercostal Artery Perforator (AICAP) Flaps and Internal Mammary Artery Perforator (IMAP) Flaps 14.8.1 Planning and Dissection 14.8.2 Complications of Chest Wall Perforator Flaps 14.9 Conclusion References 15: Complications with Breast Volume Replacement Local Perforator Flaps: Avoidance, Recognition and Treatment 15.1 Introduction 15.2 Prevention of Complications 15.2.1 Patient Selection 15.2.2 Peri-operative Planning 15.2.3 Surgical Technique 15.2.4 Post-operative Care 15.3 Intra-Operative Complications 15.3.1 Ischaemia 15.4 Post-Operative Complications 15.4.1 Immediate 15.4.1.1 Haematoma 15.4.2 Early 15.4.2.1 Wound Dehiscence 15.4.2.2 Seroma 15.4.2.3 Infection 15.4.2.4 Flap Necrosis 15.4.2.5 Injury to Adjacent Structures 15.4.2.6 Fat Necrosis 15.4.2.7 Oncological Considerations Positive Margins Local Recurrence 15.4.3 Delayed Complications 15.4.3.1 Scarring 15.4.3.2 Cosmetic Complications “Trap-Door” Deformity Loss of Breast Volume and Contour Abnormalities 15.4.3.3 Pain 15.5 Conclusion References 16: Radiotherapy and Local Chest Wall Perforator Flaps in Partial Breast Reconstruction 16.1 Introduction 16.1.1 Indications for Radiotherapy After Breast Conserving Surgery 16.1.2 Postmastectomy Radiotherapy 16.2 Consideration 1: Postoperative Radiotherapy After Local Perforator Flap Reconstruction 16.2.1 Postoperative Radiotherapy and Complications 16.2.2 Postoperative Radiotherapy and Cosmetic Appearance 16.2.3 Postoperative Radiotherapy Effects on Flap Volume and Position 16.3 Consideration 2: The Effect of Flaps on Adjuvant Radiotherapy 16.3.1 Local Flaps and Timing of Adjuvant Radiotherapy 16.3.2 Local Flaps and Radiotherapy Planning 16.4 Consideration 3: Previous Radiotherapy and Local Perforator Flaps 16.4.1 Indications for Local Flaps in Patients Who Have Had Previous Radiotherapy 16.4.2 Previous Radiotherapy and Early Complication Rates 16.4.3 Timing of Surgery After Prior Radiotherapy 16.4.4 Effects of Previous Radiotherapy on Cosmetic Appearance and Patient Reported Outcomes After Delayed Flap-Based Reconstruction 16.5 Future Considerations 16.5.1 Partial Breast Radiotherapy and Local Flaps 16.6 Conclusions References 17: Tumour Bed Boost Radiotherapy and Planning Following Partial Breast Reconstruction with Chest Wall Perforator Flaps 17.1 Background 17.2 Discussion 17.2.1 The Rationale of Tumour Bed Boost 17.2.2 Comparison Between Different TB Techniques 17.2.3 Tumour Bed Boost After Volume Replacement Oncoplastic Breast Surgery with CWPF 17.2.4 Challenges to Tumour Bed Contouring and Boost Delivery Planning in Volume Replacement Oncoplastic Breast Surgery 17.2.4.1 Tumour Bed Displacement 17.2.4.2 Larger Target Volume 17.2.5 Is a Boost Necessary After Volume Replacement Surgery? 17.3 Conclusions References 18: Quality of Outcomes 18.1 Background 18.2 Breast Cancer Surgery 18.3 Outcomes 18.3.1 General Aspects 18.3.2 Oncological Safety 18.3.3 Surgical Complications 18.3.4 Physical Function 18.3.5 Cosmetic Outcomes 18.3.6 Patient Satisfaction and Quality of Life 18.4 Conclusions References 19: A Systematic Review of Partial Breast Reconstruction with Pedicled Perforator Artery Flaps: Clinical, Oncological and Cosmetic Outcomes References