Pedicled perforator flaps for partial breast reconstruction: a narrative review

Introduction

Background

Breast cancer is the most common type of cancer diagnosed in women, with more than two million new cases in 2022 (1). Surgery plays a central role in management and local disease control (2,3). However, our understanding of the role of surgery has evolved over time. The Halstedian view of breast cancer as a locoregional disease has given way to the recognition that it is a systemic disease with diverse biological processes that require multimodal therapy (4,5). Randomised trials combining surgery with radiotherapy established the evidence that breast conservation achieves comparative oncological outcomes to mastectomy (6,7). Breast conservation naturally evolved into oncoplastic breast surgery as an approach that combines oncological excisions while maintaining, or improving, aesthetics (8).

Rationale and knowledge gap

Oncoplastic surgical techniques of volume displacement and replacement have been developed, each with distinct indications and challenges (8,9). Pedicled chest wall perforator flaps (CWPFs) are an excellent volume replacement option to correct defects after breast conservation in relatively smaller volume breasts, all while preserving muscle function with minimal donor site morbidity (10). Early years’ experience suggests heterogeneity in the application of CWPF in partial breast reconstructions, with a lack of a concise outline that links elements such as patient complexity, tumour characteristics, perforator anatomy, technical execution and post-operative care into a synthesised pathway. Therefore, surgeons adopting these techniques in practice may face clinical uncertainty (11). A practical guide based on available evidence and clinical experience can help promote and standardise best clinical practices.

Objective

This article summarises available evidence to assist CWPF perioperative care. We discuss key concepts in patient and procedure selection, followed by a list of critical anatomical features that form the basis of reliable and reproducible pre-operative planning. We then present technical tips to help surgeons overcome technical challenges. Finally, we delineate a pragmatic pathway for postoperative recovery, centred on expedited early recognition and management of complications. We present this article in accordance with the Narrative Review reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-2026-1-0011/rc).

Methods

Clinical databases, PubMed and Embase, were searched for relevant literature. Findings were synthesised with the clinical practice and prior publications by the senior author to present a narrative review of CWPF utilisation in partial breast reconstruction. The search was limited to English-language publications published prior to August 2025. The search strategy is outlined in Table 1.

Indications

Patients with a large tumour-to-breast ratio (exceeding 20% of breast volume), multifocal disease, medial tumours, and skin involvement are more likely to require an oncoplastic approach beyond a standard wide local excision (8,12,13).

Several factors influence the choice of the procedure. In general, CWPFs are particularly useful for patients with small-to-moderate breasts and minimal ptosis (11,14). In patients with larger, more ptotic breasts, therapeutic reduction mammoplasties can achieve adequate tumour excision while improving breast shape, cosmetic outcomes and quality of life (14-16). Tumour location is another important factor. CWPFs were initially described for partial breast reconstruction after lateral excisions (10). The proximity of lateral tumours to the versatile short-pedicle lateral flaps makes planning and surgery easier, while for medially located tumours, complex longer-pedicle flaps [lateral thoracic artery perforator (LTAP), thoracodorsal artery perforator (TDAP)] are usually necessary (17).

Patient selection

Risk stratification can help streamline the decision-making process. A practical framework based on history and clinical examination (Table 2) categorises patients into three levels of complexity (Table 3): low, average, and high. Patients with lower complexity are offered the full range of oncoplastic options with minimal risk (tables reproduced under open-access permission) (14).

Contraindications

CWPFs have relative rather than absolute contraindications (17). Careful consideration of patient-specific, oncological, and technical factors is vital. Patients with a history of diabetes, cardiorespiratory diseases, smoking, and obesity are considered complex and consequently at risk of perioperative morbidity (14). From an oncological perspective, inflammatory breast cancer is a contraindication to breast conservation and would therefore preclude partial reconstruction with CWPFs. Furthermore, previous surgery or radiotherapy may damage perforator vessels and jeopardise flap viability (18). Finally, technical considerations, including the location and volume of the planned excision in relation to the donor site, as well as pre-existing chest wall deformities, may render CWPFs impractical (14).

Preoperative planning and intraoperative tips

Despite the seemingly complex anatomy, CWP vessels are reasonably consistent. Early on in the learning curve, surgeons are advised to map these vessels in the clinic. Experienced surgeons should also map perforators preoperatively in delayed cases, reoperations, or cases with suspected vascular compromise due to prior surgery or scarring.

Anatomy

Understanding the anatomy of perforator vessels is essential for accurate planning. The thoracodorsal artery (TDA) originates from the axillary artery, as the subscapular artery, and continues vertically through the axilla to form the lateral extent of a standard axillary lymph node dissection. It then bifurcates into horizontal and vertical branches (19-21). Each branch typically gives rise to 1 or 2 perforators, with an additional perforator running around the free edge of the Latissimus Dorsi (LD) muscle present in 55% of patients (21).

The lateral thoracic artery (LTA) runs vertically along the axilla, often uncomfortably close to the sentinel lymph node (17). It originates from the axillary artery, but other variations have been reported (22). The proximal 3–4 cm of the LTA runs behind the lateral edge of the pectoralis major, then continues on the serratus anterior fascia before giving off perforators superficially just above the level of the nipple (23).

The intercostal arteries encircle the thoracic wall, originating posteriorly from the aorta, and anteriorly from the internal mammary and musculophrenic arteries (17,24). Intercostal artery perforators are grouped according to the segment from which they originate. The lateral group is typically found between the 5th and 7th intercostal spaces, whereas the anterior and medial intercostal perforators are found between the xiphoid process and the anterior axillary line. The latter groups are short (<3 cm), delicate (<0.5 mm) and more abundant towards the lateral third of the anterior chest wall (25,26).

Marking the perforators and flap boundaries

Marking the tumour location with the intended macroscopic margin distance (in accordance with local policy), will allow a rough estimate of the volume needed to be replaced. The breast borders and the anterior and posterior axillary lines (the free edge of the LD muscle) are marked.

Chest wall perforators can be mapped with a unidirectional 8 Hz handheld Doppler (though more advanced instruments with colour Doppler have been used) (27). TDAPs are found around 8–11 cm below the axillary fold and 2 cm medial (towards the back) to the free edge of the LD muscle. The flap design is an ellipse that contains the mapped perforators (Figure 1). The upper margin should be below the level of the tip of the scapula. The anterior apex extends beyond the free edge of the LD muscle. This results in a flap that is typically 20 cm long and up to 8 cm wide, as determined by a pinch test (10,17,28).

Figure 1 Anatomical landmarks and design of the TDAP flap (perforator vessels marked as red dots). TDAP, thoracodorsal artery perforator.

The LTAP and lateral intercostal artery perforator (LICAP) flaps have similar flap designs. With the patient supine and the shoulder abducted to 90 degrees, the LTA is located 1–2 cm lateral to the anterior axillary line between the 3rd and 7th intercostal spaces. The ability to trace the course craniocaudally helps distinguish it from nearby LICAPs. The latter vessels are found in a triangle formed between the lateral edge of the breast, the mid-axillary line, and the level of the inframammary fold (IMF) inferiorly. This area is typically 2.5–3.5 cm anterior to the free edge of the LD. Both LTAPs and LICAPs can be incorporated in the same flap to enhance its vascularity. The flap outline is a modified ellipse. The lateral edge of the breast is used as the medial and superior aspects of the flap. The flap length can be up to 30 cm, and the width is determined by a pinch test and is typically 8–10 cm (23,29). The shape and position of the flap can be adjusted depending on the circumstances. For example, both can be oriented more vertically to facilitate access for the oncological part of the procedure, or have a “notched” lower incision to reduce tension during wound closure (Figure 2).

Figure 2 Modification of lateral chest wall perforator flaps (LTAP and LICAP). The traditional flap design (A) can be modified to a vertical (B) or notched (C) configuration to reduce tension. Perforators marked with red dots. LTAP, lateral thoracic artery perforator; LICAP, lateral intercostal artery perforator.

The anterior and medial perforators are found along the IMF and within 3 cm of it (17). While marking, it is useful to keep in mind the tumour location and the flap’s most convenient arc of rotation. The outline of the flap is crescent-shaped along the IMF’s curvature. The width of the flap is assessed by pinching the excess tissue; it is typically 3–5 cm (25).

Operative tips

The degree of mobilisation and method of inset are determined largely by intraoperative findings. Robust, pulsatile TDAPs intended for lateral breast reconstructions may require minimal intramuscular dissection, whereas small, non-pulsatile perforators may require intramuscular dissection of the TDA system towards its origin (28).

The LTA dissection starts at the superior aspect of the flap. Once the clavipectoral fascia is reached, dissection is slowed down. Blunt and sharp dissection and cautious use of bipolar diathermy are then used to narrow the field of dissection around the vessel. If axillary surgery is performed as part of the procedure, then it is worth investing the time to identify and preserve the vessel before the oncological part of the procedure is completed.

As the LTAP and LICAP vessels often align vertically, preservation of both sets of perforators is possible by starting flap dissection laterally and progressing medially. Once the free edge of the LD is reached, slow and deliberate bipolar cautery dissection reduces perforator injury. These flaps can be kept attached to a fascial “mesentery” and easily slid or flipped into the defect.

Anterior intercostal artery perforator (AICAP) and medial intercostal artery perforator (MICAP) flaps are very useful for reconstruction of inferior and medial defects. The IMF can be repositioned or redefined with delayed absorbable sutures to reduce inferior migration of the scar (17). Dissection in a medial-to-lateral direction preserves the option to recruit the LICAPs, especially if the intended AICAP is inadvertently injured or does not provide sufficient length to reach the breast defect. AICAP/MICAP flaps are versatile and especially helpful when skin replacement is required in the lower quadrants. Therefore, it is advisable to keep the skin intact and de-epithelialize later on if in doubt. The lateral and medial “wings” of the flap can be folded into the cavity to replace the excised breast volume.

Post-operative phase

The majority of CWPF reconstructions can be performed as day-case or short-stay (23-hour) procedures. Negative suction dressings are not used routinely but may be considered in higher-risk wounds (e.g., high BMI, tension, prior surgery). Drains are not mandated either (30); their use is usually dictated by the oncological part of the procedure, such as those associated with axillary dissection. Supportive non-wired bras are permitted, provided no direct pressure is applied on the vascular pedicle or tunnelled part of the flap.

Early mobilisation is encouraged. The senior author’s practice is to limit abduction beyond 90 degrees and external rotation for 2 weeks. Thereafter, shoulder movement is gradually extended. Routine formal flap monitoring is not necessary or possible since most are buried unless skin replacement. After discharge, easy access to specialist nursing is advisable. Early in-person review with the surgeon (e.g., at 1 week) is reserved for higher-complexity cases.

Outcomes

These flaps are associated with low rates of surgical complications and high patient satisfaction, all while allowing breast conservation in patients who might have otherwise required mastectomy (11,31-35).

The largest cohort study in the United Kingdom, published in 2023, reported low rates of re-admission, re-operation (<3%), and 30-day surgical complication rate (<5%) (11). Oncological outcomes were within expected limits for breast-conserving surgery; locoregional (1.6%) and systemic (3.2%) recurrence rates were low, but with limited median follow-up of 2 years. The positive margin rate was 17.7%, determined by local policies in this multiregional study. These were variable but typically recommended 2–5 mm margins, which, in the absence of a national guideline on margins before 2015, may have overestimated positive margins compared with today’s no-tumour-on-ink (to 2 mm) standard.

Patient-reported outcomes are increasingly desirable for many oncoplastic procedures. However, staffing and time limits affect the adoption and execution of complex validated tools. Early reports on the use of one psychometrically validated tool, albeit a combination of two Breast-Q modules (with permission from the Breast-Q team), suggest that CWPFs are acceptable to the vast majority of patients (36,37).

Complications

The complication profile is comparable to that of other oncoplastic procedures (30,38-40), though more commonly associated with larger excisions/flaps (11). The primary aim is prevention through patient selection, optimisation and meticulous surgical technique.

The rate of haematomas is around 4%; half of these will require surgical intervention (11,31). Prevention starts with meticulous surgical technique and haemostasis. Intravenous tranexamic acid at the time of induction and oral tranexamic acid for 3–5 days after surgery is advisable. When they occur, small, non-tense haematomas can be managed conservatively, whereas tense, rapidly expanding haematomas can jeopardise the flap’s viability and require prompt exploration. Attention to preservation of the perforators is obviously vital during surgical exploration.

Surgical site infection rates are around 4%, but they account for half of hospital readmissions (11,17). As these tend to present after 5–7 days, patient education is important for early reporting, especially for patients with relatively high-risk conditions (41). At our institution, we administer intravenous antibiotics pre-operatively but do not routinely prescribe them after surgery. When diagnosed, infections are treated with empiric broad-spectrum therapy, which is adjusted by tissue/fluid culture results according to local protocols.

Uncomplicated seromas occur in approximately 3–4% of cases (11,31). These can affect both the donor site and the recipient sites. They do not require routine aspiration. Prevention strategies include limiting tissue dissection only to what is necessary for mobilisation and wound closure. Subfascial dissection may lead to less disruption of fat planes and, consequently, fewer seroma collections (42).

Partial necrosis frequently presents as a hard lump of fat necrosis, typically affecting the distal parts of the flap away from the feeding vessel. Incidence varies between 2.5–14% and most cases are managed conservatively (28,29,43). Total flap loss is exceedingly rare (0.6%) (11). Bulky flaps, poor tissue handling, and excessive tension should be avoided at all costs.

Strengths and limitations

This article provides a practical framework for surgeons adopting oncoplastic breast CWPFs into their practice. It leverages relevant evidence and clinical experience to offer practical guidance across preoperative, intraoperative, and postoperative settings.

There are, however, several limitations to this article. It does not intend to provide a comprehensive systematic review of the literature. Also, it does not offer an exhaustive overview of anatomical and technical variations. We acknowledge that a significant proportion of our recommendations are based on the senior author’s experience and prior scientific work. However, we aimed to support these recommendations with relevant evidence wherever possible. In addition, the evidence discussed in this article mainly consisted of retrospective data and single-centre case series. Although these provide valuable real-world insights, the lack of prospective data limits the strengths and highlights the need for further research in the field of CWPF reconstruction.

Future perspectives

With growing adoption of CWPF as a reconstructive approach, two priorities will take centre stage. First, prospective research will refine our understanding and strengthen the evidence behind this technique. The ongoing cohort study, PartBreCon-Pro (https://clinicaltrials.gov/study/NCT06728527), will provide large prospective cohort data, including surgical, oncological, and patient-reported outcomes (44). Second, efforts in education, training, and workshops, including hands-on courses and mentorship, will help build and cultivate the expertise required to drive innovation in this field.

Conclusions

CWPFs allow surgeons to extend the applicability of breast conservation while preserving cosmetic outcomes. A thorough patient selection process is vital. A clear understanding of anatomy and careful tissue handling minimises intraoperative complications. Complication rates are no worse than those of other oncoplastic procedures, data are limited by their retrospective nature. Overall, to conclude, CWPFs expand the armamentarium of oncoplastic techniques, allowing for more breast-conserving surgery.

Figure 3 Markup of AICAP (left breast) and MICAP (right breast) and typical positions of perforators (red dots). Note folding and inset of the flap (in green). AICAP, anterior intercostal artery perforator; MICAP, medial intercostal artery perforator.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Ayush Kapila) for the series “Innovations in Breast Surgery” published in Annals of Breast Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-2026-1-0011/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-2026-1-0011/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-2026-1-0011/coif). The series “Innovations in Breast Surgery” was commissioned by the editorial office without any funding or sponsorship. A.A. was supported by the NIHR Cambridge Biomedical Centre (No. BRC-1215-20014), Addenbrooke’s Charitable Trust grant (No. 900353), NIHR grant (No. NIHR205746), UK Govt. Office for Technology Transfer KAGF via UK Research & Innovation grant (No. 10073066), and Cancer Research UK Primer award (No. EDDPMA-Nov23/100027). None of them were used in the preparation of this manuscript. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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