The use of intercostal artery perforator to supply a musculocutaneous flap has been described since the 1970s [6]. LICAP was introduced by Hamdi et al. as a fasciocutaneous flap in reconstruction of lateral breast defects after partial mastectomy with the advantage of sparing the LD, preserving its function and its use as a flap in cases of local recurrence [7]. Several authors reported successful outcomes and advantages of the LICAP flap in challenging lateral breast defects [1, 8, 9]. Meybodi et al. published their modifications to the traditional LICAP flap, reporting a safer and faster technique with a better scar cosmetically [5].
We describe in this cohort the first series of this technique at our institute. The consultant surgeons involved in this study were exposed to such technique in different overseas centers which allowed them to transfer the experience to the junior surgeons locally.
Hamdi et al. described the classic technique for LICAP flap [4]. In our study, we started by performing the classic technique in the first three patients (11.5%), then we introduced few modifications as our learning curve progressed in the subsequent patients (88.5%). We found that this technique particularly time-saving mainly by eliminating the need to reposition the patient. The other noted advantage was the superior cosmetic outcome associated with a vertical lateral scar that allows better access to the axilla at the same time.
Our mean operative time was 129.6 ± 13.2 min compared to 249.3 ± 40.1 min as reported by Kim et al. [8].
The majority of authors reported using handled Doppler to locate and mark the perforator pre-operatively [3, 4, 8], and sometimes intra-operatively [9]. In our study, we used the handheld doppler to mark the perforator pre-operatively. As we progressed with the learning curve, the intra-operative confirmation of their constant anatomical position depended less on the use of Doppler. This study highlighted the almost constant anatomical location of lateral intercostal artery perforators. We observed that perforators in all cases located in a triangle between the lateral mammary fold, the inframammary fold, and the anterior axillary line. The confirmation of the perforators’ position depended less on the intra-operative Doppler as the team built more experience.
Some series reported repeat surgery for wider excision to clear the margins [10] or for axillary clearance due to positive SLNB [5]. In our institute, the availability of intraoperative frozen section eliminated the need for re-operation allowing a safe immediate reconstruction.
The reported complications in the literature include flap venous congestion [3, 8], partial flap necrosis [11, 10], wound infection [5, 11], fat necrosis [8, 10], hematoma [10], and seroma [10]; in our cohort, there were no reported immediate postoperative complications. Two patients (7.7%) developed late complications, in the form of keloid and fat necrosis and were managed conservatively without surgical intervention.
One patient was referred to our tertiary center with a scar extending to the UIQ following a lumpectomy with infiltrated margins in a small- to medium-sized breast. She underwent a wider excision, leaving a defect that extended to the UIQ. It was possible to extend the flap to cover this defect safely. This could be a promising option for reconstruction of defects in the UIQ in selected cases. Further studies are needed to evaluate this possible expansion of the technique.
LTAP flap is reported in the literature for the reconstruction of lateral breast defects either alone or combined with LICAP to maximize the flap perfusion [3]. In our study, we used LTAP flap in one case in which the defect was in the UOQ, where the lateral thoracic artery perforator was dominant and reliable. In another patient, we performed it combined with the LICAP in which both perforators were prominent.
We used a modification of the questionnaire of the Royal College of Surgeons of England as a simple tool to assess patients' satisfaction which was (88.5%) as excellent and good, and the photographic assessment by surgeons which was (96.2 %) as excellent and good. The results were matching with those reported by Kim et al, they use Kyungpook National University Hospital Breast Satisfaction Survey (93.1% and 93%) by patients and surgeons respectively [8].
Lateral chest wall perforator flaps initially described for small-sized breasts [9]. This indication expanded to medium- and large-sized breasts in further series [5, 10]. In our cohort, all patients were medium to large-sized breasts.
Regarding modifications to the flap design, we used the lazy S shaped incision toward the axilla described by Meybodi et al. Recently, Juliëtte et al. described the anterior LICAP flap with a different flap design toward the inframammary fold [12].
We recognize many limitations to our study. One main limitation is the small number of patients in the cohort and the relatively short time of follow-up. This reflects the reality of a newly adopted technique at our institute, the follow-up period extended up to at least 6 months after completion of radiotherapy and the patients continue to be followed-up further. We used a simple tool for assessment of cosmetic outcomes, as we felt it was more suitable for our patient population. Follow-up will be continued to assess long term cosmetic outcomes in patients with medium- to large-sized breasts by using other cosmetic results assessment tools.
