What are the recommended local flaps (Local tissue transfer) for breast reconstruction after an inframmary (below the breast) incision?

Local Flaps for Breast Inframammary Incision Reconstruction

For breast reconstruction following inframammary incisions, lateral thoracic perforator flaps—specifically the lateral intercostal artery perforator (LICAP), thoracodorsal artery perforator (TDAP), and lateral thoracic artery perforator (LTAP) flaps—represent the primary local tissue transfer options, with LICAP flaps being most commonly selected when using ultrasound-guided preoperative planning. 1

Primary Local Flap Options

Lateral Intercostal Artery Perforator (LICAP) Flap

• LICAP flaps are the most frequently chosen local option when using ultrasound-guided preoperative planning, accounting for 57 of 65 propeller-design flaps (88%) in recent series 1
• These flaps are raised from the lateral thoracic region based on perforators from the intercostal vessels 2
• Particularly effective for lower-outer quadrant defects, which represent 61.5% of reconstruction cases 2
• Can be combined with LTAP flaps to augment perfusion and increase flap size 3

Thoracodorsal Artery Perforator (TDAP) Flap

• The TDAP flap utilizes perforators from the thoracodorsal artery without sacrificing the latissimus dorsi muscle 4, 5
• Propeller TDAP technique eliminates the need for intramuscular pedicle dissection, making harvest faster and safer 5
• Can be raised with 1-3 perforators depending on required tissue volume, with 93% used as propeller flaps 6
• Mean operative time of 200 minutes with 97% success rate in achieving reconstructive goals 6

Lateral Thoracic Artery Perforator (LTAP) Flap

• LTAP flaps were used in 44% of lateral chest wall reconstructions (either alone or combined with LICAP) 3
• Particularly reliable in immediate reconstruction settings 3
• Allows comparable flap size to LICAP flaps and can be raised independently for greater mobilization 3

Surgical Planning Algorithm

Preoperative Assessment

• Use Color-Coded Duplex Ultrasound for preoperative perforator mapping to identify optimal perforators and reduce operative time 1, 6
• Ultrasound planning reduced mean operative time from 156 minutes to 75 minutes (p < 0.0001) 1
• Assess breast size: local flaps are indicated for small to moderate volume breasts 2
• Evaluate tumor location: lower-outer quadrant defects are ideal candidates 2

Flap Selection Criteria

• For inframammary incisions with lateral defects: prioritize LICAP or LTAP flaps 1, 3
• For defects requiring more posterior tissue: select TDAP flap 5, 6
• Consider combined LTAP/LICAP flaps when larger tissue volume is needed 3

Surgical Technique: "Propuller" Concept

• The propeller advancement ("propuller") design eliminates the need for full perforator skeletonization, making harvest faster and safer 1
• This technique combines propeller rotation with advancement to transfer more tissue efficiently 1
• No flap losses reported with this approach across 65 cases 1

Outcomes and Complications

Success Rates

• Overall flap survival rate approaches 100% with proper technique 5, 1
• Major complications occur in approximately 10% of cases, including partial flap necrosis (7%), venous congestion (2%), and hematoma (1%) 6
• Minor complications include wound dehiscence (15%) and fat necrosis, all manageable conservatively 5, 2

Patient Satisfaction

• 90% of patients report being satisfied or very satisfied with results 2
• No donor site seromas or significant morbidity reported 5
• Minimal donor site complications compared to muscle-sacrificing techniques 2

Critical Contraindications

• Smoking and obesity are relative contraindications due to increased risk of wound healing complications and partial/complete flap failure 7, 4
• When postmastectomy radiation therapy is anticipated, consider that autologous tissue tolerates radiation better than implants, though local flaps may still be used 8, 4

Key Technical Advantages

• No muscle sacrifice required, preserving chest wall function 5, 2
• Adjacent tissue availability eliminates need for distant flap harvest 2
• Can be combined with tissue displacement techniques (glanduloplasty) for optimal cosmesis 8
• Does not interfere with detection of local recurrence 8, 7