The Role of Intercostal Artery Perforator (ICAP) Flaps in the Transition From Cosmetic to Effective Modern Breast Surgery

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Abstract
Background: Breast conservation surgery (BCS) evolved with oncoplastic techniques to improve aesthetic outcomes while maintaining oncological safety. However, a lack of objective criteria for selecting appropriate reconstruction techniques remains. Objectives: This study presents a novel patient-centered decisional algorithm for oncoplastic breast surgery with intercostal artery perforator (ICAP) flaps, aiming to standardize techniques based on patient expectations and objective symmetry evaluation. Methods: A retrospective observational study was conducted including patients who underwent BCS between January 2020 and December 2023. The decisional algorithm guided surgical planning, considering patient preferences, preexisting breast symmetry or asymmetry, and tumor location. Patient satisfaction was evaluated with the BREAST-Q questionnaire, and symmetry outcomes were assessed by external surgeons with a visual analog scale. Results: Of 900 patients who underwent BCS, 256 (28.44%) required volume replacement with ICAP flaps. Contralateral symmetrization was performed in 86 patients (9.55%) and bilateral mastopexy or breast reduction in 180 cases (20%). During an average follow-up of 22 months, the rate of early minor complications was 10.2%. Major complications requiring reoperation occurred in 7.7% of cases. Postoperative BREAST-Q results showed significant improvement in satisfaction (P < .05), and the mean aesthetic outcome score at 6 months was 4.1. Conclusions: The proposed patient-centered decisional algorithm incorporates both objective preoperative assessment and patient preferences, promoting a tailored approach that enhances functional and aesthetic outcomes while maintaining oncological safety. ICAP flaps represent valuable and less invasive tools for volume replacement, contributing to satisfactory symmetry outcomes. Level of Evidence: 4 (Therapeutic):

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