Versatility of the Anterior Intercostal Artery Perforator Flap in Breast Reconstruction
Sean Li1 Christopher Reid1 Sarah Blair2 Frederic Kolb1 1Department of Surgery, Division of Plastic Surgery, UC San Diego 2Department of Surgery, Division of Breast Surgery, UC San Diego
Background The anterior intercostal artery perforator (AICAP) flap is a versatile locoregional option for the reconstruction of chest wall and abdominal defects. Breast oncoplastic surgery represents its primary indication where it is used to avoid post-quadrantectomy deformation. However, its versatility and proximity to the breast makes it suitable for a wide array of other breast reconstruction indications. We recently found it most useful for salvaging implant-based reconstructions after skin and nipple-sparing mastectomies. Although these techniques have improved the cosmetic results of mastectomies, their advantages can be jeopardized by the necrosis of the mastectomy skin flap, a complication reported in 5 to 30% of cases especially in previously irradiated breasts. Methods We present 3 cases illustrating the range of indications of the AICAP flap in breast reconstruction. The first illustrates the classic oncoplastic technic after quadrantectomy for a T3 IDC. The two others illustrate implant salvage indications. The second patient with history of a previous inverted T mastopexy- and implant augmentation, presented with an IDC that was treated by a mastectomy using the previous inverted T incision. An immediate retropectoral implant-based reconstruction with mesh was performed. The T-junction dehisced at post-op day 15 leading to return to the OR for a salvage adipofascial AICAP flap to cover the lower pole and avoid implant exposure (Figures 1-3). The second patient presented with a left breast cancer recurrence, previously treated by chemotherapy, lumpectomy, and radiotherapy. After BRCA1 mutation diagnosis, a bilateral wise pattern Nipple sparing mastectomy with immediate deep inferior epigastric perforator (DIEP) flap was performed. Loss of the left DIEP flap complicated the post-op course. Reconstruction was salvaged was by a retropectoral expander placement with mesh. Expansion was rendered impossible by the irradiated and the inverted T skin flap closure was threatened. An implant salvage AICAP flap with inferior pole skin interposition was successfully performed. Results All AICAP flap survived with no donor site complication. The first patient resulted in no breast deformity and was able to start radiotherapy in time reconstruction and had no complications. The second case was able to go through adjuvant radiotherapy with one week of delay. The adipofascial layer over the lower pole gave to the breast a more natural shape although fat grafting will be necessary to improve post-radiation result. The third patient presents a drastic improvement of her breast shape. A revision is planned to match the 2 breasts. Conclusion Significant mastectomy skin flap necrosis threatens the success of prosthetic reconstruction. Local breast skin replacement options for salvage surgery are limited and usually relies on a latissimus dorsi musculocutaneous flap with its scar and functional morbidities. The AICAP flap is a versatile locoregional solution for implant salvage and primary breast reconstruction with low functional and cosmetic morbidity at the donor site.
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