The Role of ICAP Flaps in the Transition From Cosmetic to Effective Modern Breast Surgery

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-centred decisional algorithm for oncoplastic breast surgery using 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, pre-existing breast symmetry/asymmetry, and tumor location. Patient satisfaction was evaluated using BREAST-Q questionnaire, while symmetry outcomes were assessed by external surgeons using a visual analog scale (VAS). 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. Post-operative BREAST-Q results showed significant improvement in satisfaction (p<0.05), while the mean aesthetic outcome score at 6 months was 4.1. Conclusions: The proposed patient-centred 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.