What is the role of advancement flaps in breast wide local excision?

Advancement Flaps in Breast Wide Local Excision

Advancement flaps are valuable oncoplastic techniques that allow breast surgeons to fill tissue defects after wide local excision by mobilizing adjacent breast tissue, thereby extending breast conservation options to patients who would otherwise require mastectomy while maintaining acceptable cosmetic outcomes.

Role and Purpose

Advancement flaps serve as tissue displacement techniques designed to reduce the local volume deficit created after tumor excision in breast-conserving surgery 1, 2. These oncoplastic approaches have become standard training for breast surgeons to achieve both oncologic adequacy and acceptable cosmesis 1.

The primary goals remain unchanged from traditional breast conservation: complete removal of malignant tissue with minimal cosmetic deformity 1, 3. Advancement flaps help achieve these dual objectives by:

• Mobilizing adjacent breast parenchyma and subcutaneous tissue to fill the excision cavity 2, 4
• Preventing saucer-like deformities that occur when tissue defects are left unfilled 1
• Allowing wider excision margins without compromising breast shape 4, 5

Technical Considerations

Flap Design and Execution

The advancement flap technique involves elevating adjacent skin and subcutaneous tissue with or without glandular breast tissue, then advancing it into the defect created by tumor excision 4. Key technical principles include:

• Incision placement: Curvilinear incisions following Langer's lines generally achieve the best cosmetic results, though radial incisions may be preferable at the 3 and 9 o'clock positions and in the lower breast 1
• Tissue preservation: The subcutaneous tissue should be preserved with separate closure to improve cosmetic outcomes 1
• Hemostasis: Meticulous hemostasis is crucial to avoid hematoma formation, which complicates postoperative evaluation 3

Specific Advancement Flap Variations

Abdominal advancement flaps (AAF) can be particularly useful for lower breast defects in small- to medium-sized breasts 6. This technique pulls elevated abdominal skin upward to create the shape of the inferior breast portion by forming a neo-inframammary fold 6. However, outcomes are significantly better for lateral and central lower quadrant tumors compared to inner quadrant locations (92% vs 50% acceptable results, p<0.01) 6.

Combined local flaps using both rotational and thoraco-epigastric components can address larger defects, with mean excised volumes of 134 mm³ (20.4% of breast volume) achieving excellent or good cosmetic outcomes in 90% of cases 7.

Clinical Outcomes and Limitations

Oncologic Safety

Advancement flaps do not compromise oncologic outcomes when proper surgical principles are followed 4, 5. Critical requirements include:

• Adequate margins: No tumor at the inked margin, with minimum 1mm margin preferred for invasive disease and >2mm for in situ disease 1
• Specimen orientation: Using sutures, clips, or multicolored ink for accurate margin assessment 3, 2
• Tumor bed marking: Clips should mark the excision cavity to facilitate radiation boost field planning 1, 2

Cosmetic Results and Complications

In a series of 25 patients treated with local advancement flaps for upper outer or upper central tumors (mean size 3.1 cm), 84% reported satisfaction with cosmetic outcomes 4. Complications included one hematoma and one case of fat necrosis during radiotherapy 4.

Common pitfalls to avoid:

• Inner quadrant tumors: Advancement flaps for inner lower quadrant locations have significantly worse cosmetic outcomes (50% unacceptable) 6
• Larger breast size: Unacceptable cosmetic results occur more frequently in larger breasts when using abdominal advancement techniques (p<0.05) 6
• Excessive tissue sacrifice: Avoid removing skin segments unnecessarily, as this may alter nipple position or the inframammary crease 1

When to Consider Alternative Techniques

For defects requiring more substantial volume replacement, particularly after excision of >20% breast volume or in unfavorable anatomic locations, latissimus dorsi mini-flaps may provide superior outcomes compared to local advancement flaps alone 5. The LD mini-flap technique allows excision of significantly larger tumor volumes while achieving cosmetic results comparable to standard wide local excision and better patient satisfaction than mastectomy with immediate reconstruction 5.

Integration with Adjuvant Therapy

Postoperative radiotherapy remains strongly recommended after breast-conserving surgery with advancement flaps 1. The quality assurance target is local recurrence rates <1% per year, not exceeding 10% overall 1, 2.

Advancement flaps generally do not delay adjuvant therapy when performed properly, though flap necrosis complications can postpone radiation (mean delay 41 days for thoracoepigastric flaps with necrosis vs 28-30 days for uncomplicated cases, p=0.02) 8.