Oncoplastic breast volume replacement with the use of lateral intercostal artery perforator flap

Introduction

Breast malignancy has a high incidence and is on the rise all over the world, particularly among women, yet survival rates in underdeveloped countries are lower than in industrialized countries.^1,2 The advancement of diagnostic and therapeutic technology has also contributed to the rise in prevalence.^3,4 The treatment options for people with breast cancer are extremely varied and tailored to the patient's preferences, particularly for patients with early-stage cancer who are candidates for breast surgery with breast conserving surgery. Both breast conserving surgery (BCS) and mastectomy have an equal chance of survival.⁵ When surgery is combined with other therapy, BCS is often performed first since it has a better prognosis than mastectomy and one of the methods used is wide excision.⁶

The major goal of a wide excision in the breast is to remove the tumor completely while leaving clear surgical margins. When a tumor is minor, a wide excision is used to preserve the breast's natural contour. However, getting a proper excision margin around the tumor and not removing too much tissue, which may result in breast deformity, are at odds. In fact, up to 40% of all patients experience cosmetic failure after a comprehensive breast resection.⁷ Several studies have demonstrated that once 20% of the breast volume is removed, there is a significant risk of deformity and that the cosmetic consequences of extensive breast excision can be worse than mastectomy in some patients.⁸ Oncoplastic surgery has evolved as a new surgical method to address this issue, and it is now regarded as the gold standard in breast reconstruction in chosen patients.⁸ Oncoplastic breast surgery was attempted by Audretsch et al. in 1998. It is the expanded concept of BCS and includes consideration of breast cancer and aesthetics. Two techniques are currently used in oncoplastic surgery according to the excised volume of the breast: the volume displacement technique, which includes using the remaining tissue of the breast to fill the defect, and the volume replacement technique, which includes reconstruction of the breast with the transposition of tissue from elsewhere.^9,10

In oncoplastic surgery, breast size and excised volume are essential factors to consider. The remaining tissue in patients with moderately large breasts is adequate to achieve satisfactory cosmetic results utilizing the volume displacement procedure. After the excision of a small-sized defect, the volume displacement procedure can be used on patients with relatively tiny breasts. If the deformity is moderate or big, however, volume replacement techniques are the only way to provide satisfactory cosmetic results. The tumor's location should also be considered when choosing an oncoplastic volume replacement approach. A perforator flap, such as a lateral intercostal artery perforator (LICAP) flap, a thoracodorsal artery perforator (TDAP) flap, a latissimus dorsi (LD) myocutaneous flap, a lateral thoracodorsal flap, and a thoracoepigastric flap, are examples of volume replacement techniques that use autologous tissue.⁹

The LICAP flap has recently acquired popularity, particularly for partial breast reconstruction following lumpectomy or partial mastectomy for tumors in the lateral quadrant. At three points along the intercostal artery, perforators are released. The posterior perforator, located in the lumbar area, the lateral perforator, located in the midaxillary line, and the anterior perforator, located in the anterior chest line, are the three perforators. The anterior border of the latissimus dorsi muscle generally corresponds to the place where the LICAP emerges at the midaxillary line. The perforator continues anteriorly and superficially from here.¹¹ The LICAP flap uses a pedicled perforator flap to fill the defect created by the lumpectomy.¹⁰ In this paper, we describe a case series of partial breast reconstruction using lateral intercostal artery perforator in a patient with borderline phyllodes tumor and a patient with invasive breast carcinoma non-specific type grade II, DCIS.

Case report

Case 1

Due to a lump in the right breast in the upper lateral quadrant, a 19-year-old Javenese woman was examined for further assessment. She is an undergraduate student with unremarkable medical and psycho-social history, including her family’s. According to local inspection, the tumor was 35 mm in diameter, a well-circumscribed oval tumor, movable with respect to the skin and chest wall, and frequently uncomfortable. She had breast ultrasonography, which revealed a well-defined hypoechoic lesion in the right breast in the upper lateral quadrant, 4 cm from the papilla. There was no evidence of increased vascularity or intralesional calcification. The mass on ultrasonography appeared to be benign. The patient underwent excisional biopsy of the right breast in a private hospital. A borderline phyllodes tumor was discovered during the biopsy.

She was then referred to Dr. Cipto Mangunkusumo Hospital. She had a wide excision and volume replacement with a LICAP flap. During physical examination one month after the first surgery, on inspection there were surgery scar, no lump was found during palpation. However, in a case of phyllodes tumor, a wide excision up to 1 cm outside the margin of the tumor mass was still needed hence, further evaluation was done. Prior to the second operation, she had an ultrasound examination, which revealed an inhomogeneous hypoechoic lesion in the right breast that was irregular in shape and borders, with no enhanced intralesional vascularity, and was 0.6 x 0.5 x 0.5 cm in size. To get a clear margin, the lumpectomy and skin containing the prior scar were excised down to the plane of the pectoralis major muscle, with resection margins greater than 1.0 cm in relation to the neighboring tissues (Figure 1b). The excised tissues were frozen intraoperatively, resulting in a distinct boundary and the discovery of a fibroepithelial lesion.

Figure 1. (a) Design incision 6-to 8-cm flap pedicle is drawn at the level of the inframammary crease between the midaxillary line and anterior border of the latissimus dorsi muscle; (b) Specimen from wide excision; (c) Breast defect; (d) Flap perforators from the lateral intercostal artery of the 5^th and 6^th intercostal space; (e) Flap after tunneling to the defect; (f) Post-operative breast reconstruction.

The skin substance loss was 10x8 cm in size. After the wide excision, we continued with breast reconstruction to replace the volume that had been lost. At 6th and 7th intercostal region, the LICAP vessels were marked. In a “lazy S” toward the lower axilla, a line was drawn along the inferior and lateral mammary folds. The flap was finished with a second “lazy S”, drawn inferolaterally (Figure 1a). As with a typical adipocutaneous perforator flap, the flap is lifted over the fascia. The lateral perforators of the intercostal artery were concentrated on the flap that was excised. The LICAP was centered on the perforators found intraoperatively. The first perforator was found to come from the lateral intercostal artery of the 6th intercostal space, while the second perforator was discovered to originate from the lateral intercostal artery of the 5th intercostal space. After tunneling, the LICAP flap raised on both perforators was shifted to the level of substance loss. The drain was introduced once the donor sites were closed. To close the skin defect, the flap was sutured to the defect location (Figure 1c). The defect is slightly symmetrical with the contralateral breast after surgery. During follow-up, five weeks after the surgery, the defect looked naturally symmetrical with a contralateral breast (Figure 2a and 2b).

Figure 2. (a) Post-operative lateral intercostal artery perforator (LICAP) flap; (b) Lateral view.

Case 2

A 49-year-old woman came to the hospital with complaints of a lump in her left breast in the last 3 months, which was detected during a breast examination screening at the Dr. Cipto Mangunkusumo Hospital. Her ethnicity is Batak and working as a nurse. She had no history of diabetes mellitus type 2, hypertension, genetic abnormalities, or other associated medical conditions. The patient acknowledge that she had no history of smoking and no family members had history of breast lump. She had no prior history of medication or medical interventions regarding her symptoms. Mammography and biopsy were done at the polyclinic, where on the examination it was found to be a marble-size lump. The lump was stable; there was no pain, no orange peel-like appearance, no wounds, or retractions. The mammography showed focal asymmetrical fibroglandula in the left superolateral quadrant of the breast. Ultrasound showed solid lesions at 2-3 o'clock, 2 cm from the left mammary papilla, heterogeneous echogenicity, irregular shape, lobulated borders, parallel orientation, and heterogeneous posterior appearance, with an echogenic rim, measuring about 2.54 x 1.7 x 1.8 cm. On color Doppler, perilesional vascularization was seen.

There was a hypoechoic lesion at 9 o'clock; 1 cm in the direction of 6 o'clock; and 2 cm from the left mammary papilla; oval shape, well-defined, parallel orientation, without posterior features; size of about 0.5 x 0.3 cm. Color Doppler showed no intralesional or perilesional vasculature. The conclusion of the ultrasound results stated that the left breast mass was categorized as BIRADS 4. The biopsy results found an invasive carcinoma of no special type (NST) oncocytic pattern in breast grade 2, and ductal carcinoma in situ (DCIS) comedo necrosis type core grade 1 was also found in 5% of the tumor area.

It was decided to have breast conserving surgery (BCS) with wide local excisions and volume replacement using LICAP to restore the defect. Due to the presence of DCIS an intraoperative sentinel lymphnode biopsy (SLNB) with methylene blue and frozen section was done. A lazy S incision was made following the left mammary fold towards craniolateral, a flap was formed towards the tumor, and continued excision of the tumor by encompassing the surrounding normal tissue after injecting methylene blue sub areola at 12 o'clock. The mass was taken and frozen, measuring 8 x 6 x 6 cm. The frozen section revealed a negative superior border at 1.5 cm, a negative lateral border at 2 cm, a negative inferior border at 2.5 cm, a negative medial distance of 2 cm, and a negative tumor base at 1.5 cm distance.

When SLNB was done, we extract one lymph node in the intercostobronchial with a negative node from frozen section. Following that, oncoplastic breast reconstruction volume replacement was performed, and the skin paddle was created with LICAP using inframammary and lateral skin. Three perforator arteries have been retained. A drain was implanted after the flap was epithelialized and sutured to fill the defect. The skin paddle was sutured to the skin defect subcuticularly (Figure 3).

Figure 3. (a) Design insicion; (b) Wide excision defect; (c) The specimen; (d) Perforator artery was found; (e) Post-operative LICAP flap; (f) Lateral view.

Discussion

In the first case, treatment for phyllodes borderline or malignant is wide excision with a surgical margin of ≤1 cm.¹² In our situation, an excisional biopsy was performed during the first surgery at the prior facility, with an unclear margin. We presume that the tumor was removed with a tight margin. As a result, some tumor cells are still present. We performed a large excision in the second procedure to obtain a free margin. The tumor was found in the upper lateral quadrant with a defect size of 10x8 cm. In the second case, the patient was confirmed to have invasive breast carcinoma, NST grade II, and DCIS. Surgery was done on the patient using wide excision to confirm lymph node involvement prior to adjuvant therapies. Sentinel lymph node biopsy was done intraoperatively guided with methylene blue. A volume replacement approach in both cases were required due to a substantial decrease in breast volume. The tumor's location should also be considered when choosing an oncoplastic volume replacement approach. To approach the fault, each flap has a favorable arc of rotation. The LICAP flap can be used to restore a lateral breast deformity. This flap has various advantages, including less donor site morbidity, improved flap shaping, improved cosmetic results, and increased patient satisfaction.⁹

For breast volume replacement, LICAP flap has many advantages and considered as a good option. However, it also has limitations, such as to harvest the flap and do the breast cancer resection, patient has to be repositioned from lateral to supine position during the surgery. In the other side, the harvesting will leave more apparent breast scar from the lateral mammary fold extends to 5 cm posterior from the posterior axillary line.^13,14

To ensure that the lateral cutaneous branch of the posterior intercostal arteries is included in the flap, the flap's posterior border should be at least 5 cm behind the posterior axillary line. Because perforators from the intercostal arteries emerge at intervals in the lateral chest fold, lateral displacement of the pedicle is feasible. It is preferable to use unidirectional Doppler to find the perforator prior to surgery. The perforator, on the other hand, is found without the use of doppler and is simply marked visually. To examine the perforators and allow easy elevation of the flap, a posterior incision is made first, with an anterior extension at the lower end of the flap. To expose the latissimus dorsi muscle, the incision is made deeper. Between the midaxillary line and the anterior border of the latissimus dorsi muscle, the flap pedicle is located at the level of the inframammary fold. The smaller posterior branch of the lateral cutaneous branch is detected after seeing the anterior border of the latissimus dorsi muscle. The larger anterior branch is found by following this branch.

Using a volume replacement procedure, individuals with lateral extra tissue who want to keep their present breast form and size may be able to have a wider excision. In our situation, for the first patient, we were able to keep the patient's breast volume and degree of ptosis is similar to the contralateral breast following second surgery. In the first case, however, the flap looked to be larger and darker than the surrounding skin. In the second case, the left breast, which underwent a volume replacement procedure, appeared bigger compared to the contra side because it had a smaller defect than the first patient. Despite such a difference, the aesthetic outcome was not compromised. In some cases, such as partial mastectomy, when the breast volume has been replaced but the ptosis is different from the contralateral side breast, the surgery is commonly paired with mammoplasty procedures to correct the ptosis; nevertheless, this would have required a bilateral procedure for symmetry.¹³ Two weeks after surgery, the breast appeared more symmetrical, and the conspicuous flap had vanished. The donor site appeared to be in line with the inframammary fold, but with a 5 cm posterior extension incision. The outcomes of this case reveal that abnormalities in all quadrants of the breast can be filled, with the upper lateral quadrant accounting for 95% of the malignancies. The anterior LICAP flap is a safe and effective flap with few problems. Complications were successfully addressed according to national recommendations.

There are numerous volume replacement procedures reported. Flaps are chosen based on the size of the defect, its location, the surgeon's experience, and local customs. The TDAP flap and the LD flap are two alternative oncoplastic volume surgery options, in addition to the LICAP flap. A fasciocutaneous flap called the TDAP can be used as an alternative. The perforator of the thoracodorsal artery is based on the perforating vessel of the thoracodorsal artery's longitudinal (lateral) terminal branch. These vessels perforate the LD muscle to share in the blood supply of the skin over the back and lateral part of the chest wall.^7,12 The LD flap is a myocutaneous flap. It is a composite graft including variable amounts of muscle, skin, and subcutaneous tissue, with a perforator from the thoracodorsal artery. The disadvantage of the LD flap is that we sacrifice the LD muscle.

The advantage of LD flap is it has enough vascular supply from thoracodorsal artery thus it has less risk of ischemic complication.^10,15,16 The disadvantages of harvesting LD muscle were more observed on the donor-site. Regarding the cosmetic and oncological outcome, both TDAP and LICAP flaps have good results. The location and size of the defect, together with the surgeon’s experience may be considered to decide the use of these two flaps.¹⁷

Despite the fact that the perforator was short and narrow in our case, LICAP was an excellent choice for the lateral breast defect since the flap could reach the defect without strain and there was no necrosis. The aesthetic result was also satisfactory. The TDAP flap, on the other hand, is more adaptable and can be used in all quadrants. The perforators of TDAP are also short, and they were dissected from the muscle until they contacted the thoracodorsal artery and vein. When a lengthy pedicle and angle rotation are necessary, the perforators should be dissected superiorly until the axillary area. Between the anterior border of the LD muscle and the defect, a subcutaneous tunnel was formed through which the flap was passed before being translated into the breast defect. Extreme caution was exercised at each stage to avoid harming the perforators.¹⁷

The volume displacement procedure can be used following the removal of a small-sized defect in patients with relatively tiny breasts, notably in the Asian population. On the other hand, the volume displacement technique makes it difficult to obtain excellent cosmetic outcomes in patients with moderate or substantial abnormalities after tumor excision. In our scenario, the only way to achieve satisfactory cosmetic results is to use a volume replacement approach with autologous tissue in various types of flaps. Finally, the patient's happiness with the cosmetic outcome was dependent on the right volume replacement approach being chosen in these circumstances, taking into account the removed volume and tumor location.⁹ To the best of our knowledge, this is the first case report from Indonesia which is reporting the application of TDAP and LICAP flap in Indonesian patients. We are looking forward that TDAP and LICAP could be done more often in cancer centers, considering its satisfactory outcome for the patients. However, the patients were only followed-up for short period and post-operative complications were not observed in this case report.

Conclusion

Surgery is often an option for patients with breast cancer but getting a proper excision without removing too much tissue is rare. Oncoplastic surgery is now regarded as the gold standard in breast reconstruction in chosen patients. In oncoplastic surgery, breast size and excised volume are essential factors to consider. There are two well-known procedures: volume displacement and volume replacement. Volume displacement procedures can be used on patients with relatively tiny breasts, while volume replacement techniques are the only way to provide satisfactory cosmetic results when the deformity is moderate or large. LICAP, TDAP, and LD are examples of volume replacement techniques that use autologous tissue. TDAP and LICAP flaps showed good outcomes in terms of cosmetic and oncological aspects. Choosing between these two flaps, the decision is influenced not only by the location and size of the defect but may also depend on the experience of the surgeon. LICAP was an excellent choice for the lateral breast defect since the flap could reach the defect without strain and provide a satisfactory aesthetic result. The perforator flap was a suitable reconstructive option with limited donor site morbidity.

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patients.