Extended applications of chest wall perforator flaps in breast surgery: case series and systematic literature review

Clinical Snapshot

Key Findings

• P Value: Not applicable; descriptive synthesis only

• Effect Size: Flap success rate exceeding 95% across 38 systematic review studies (approximately 324 patients, 349 flaps); 100% flap viability in the institutional case series (n=6)

• Primary Outcome: Flap viability and success rate across extended CWPF applications including skin-replacing excisions, implant salvage, chronic sinus closure, and total autologous reconstruction

• Nnt Or Sensitivity: Major complication rate reported as under 5%; aesthetic satisfaction reported as exceeding 90%; no NNT, sensitivity, specificity, or hazard ratio calculable from available data

• Confidence Interval: Not reported; no formal meta-analysis or confidence interval estimation performed

Clinical Application

Technically feasible in specialist tertiary oncoplastic units with dedicated perforator flap expertise. LICAP, LTAP, and TDAP flaps are established techniques in high-volume centres. Extended indications require advanced perforator mapping (Doppler or CT angiography), experienced surgical teams, and multidisciplinary oncoplastic planning. Not appropriate for general surgical units without dedicated reconstructive expertise. Oncoplastic breast surgery is supported within Australian breast surgical practice through BreastSurgANZ guidelines and the RACGP's endorsement of multidisciplinary breast cancer management. CWPF techniques are performed at major Australian tertiary centres (e.g., Peter MacCallum Cancer Centre, Royal Prince Alfred Hospital, Royal Brisbane and Women's Hospital). These procedures are not separately itemised on the Medicare Benefits Schedule (MBS) as perforator-specific flap codes; billing typically occurs under existing reconstructive flap item numbers. No TGA regulatory implications arise as no devices or therapeutics are involved. The evidence base is insufficient to support formal RACGP or BreastSurgANZ guideline modification at this stage, but the findings support continued specialist adoption and prospective Australian registry data collection. Adult women with complex breast or chest wall defects requiring muscle-sparing reconstruction, particularly those with prior radiotherapy injury, implant failure, post-bariatric contour deformity, or requiring skin-replacing oncologic excisions at tertiary oncoplastic centres

Abstract

PURPOSE: Chest wall perforator flaps (CWPFs) are integral to modern oncoplastic breast surgery, offering volume replacement without muscle sacrifice. While their role in partial breast reconstruction is established, data on extended and non-conventional applications remain limited. This study aims to synthesize current clinical experience and delineate the extended applications of chest wall perforator flaps beyond conventional oncoplastic contexts. METHODS: This study combined a prospective institutional case series from two tertiary centers (Singapore and UK) with a systematic literature review of PubMed, Embase, Web of Science, and Cochrane databases. Eligible studies described CWPF use for extended oncologic, reconstructive, or aesthetic indications. Data were synthesized descriptively according to PRISMA guidelines. RESULTS: Six women underwent LICAP-based reconstruction for complex indications including skin-replacing excisions, implant salvage, chronic sinus closure, and total autologous reconstruction with adjunct lipofilling. All flaps were fully viable with good contour restoration and symmetry, and adjuvant therapy proceeded without delay. The systematic review identified 38 studies (≈ 324 patients, 349 flaps). CWPFs, most commonly LICAP, LTAP, and TDAP, were used for defects following oncologic resection, radiotherapy injury, implant failure, or post-bariatric contour correction. Overall flap success exceeded 95%, with major complications under 5%. Donor-site morbidity was minimal, with high aesthetic satisfaction (> 90%). CONCLUSIONS: CWPFs represent muscle-sparing reconstructive options whose utility may extend beyond conventional oncoplastic indications; this descriptive series supports their feasibility and short-term outcomes across a range of selected clinical settings, suggesting that CWPFs warrant further consideration in the management of complex breast and chest wall defects.

References

1. 1.Goh, S. S. N., Zhou, X., Ng, Q. X., & Kulkarni, D. (2026). Extended applications of chest wall perforator flaps in breast surgery: case series and systematic literature review. Breast Cancer Research and Treatment. https://doi.org/10.1097/GOX.0000000000003263