Overview

The advent of perforator flaps in the past 2 decades has expanded the horizons of reconstructive surgery. Harvesting a flap without sacrificing the underlying muscle and its functional motor nerves characterizes this technique, which aims to reduce donor site morbidity to an absolute minimum. PPFs are a more recent development and have been widely used for breast reconstruction.

BCT is the surgical excision of a breast cancer with a tumor-free margin while preserving the remainder of the uninvolved breast. Adjuvant breast irradiation is mandatory. This treatment modality has become the first choice for patients with early breast cancers because it has proved oncologically sound with survival rates similar to that of total mastectomy while providing associated aesthetic and psychological benefits. Patient selection, however, is important. A relative contraindication is a woman with a large tumor in a small breast; in these patients, the aesthetic outcome of BCT is poor. To overcome this, oncoplastic techniques that resect the tumor along breast reduction patterns or redistribute the remaining parenchyma via breast rearrangement may be used, along with reduction or mastopexy of the contralateral breast for symmetry. There is a limit, however, to how much volume displacement techniques are able to achieve in masking the volume discrepancy and contour abnormality from tumor resection. Patients with larger tumor-to-breast ratios were not considered suitable candidates for this procedure and were treated with total mastectomy with or without reconstruction. Volume replacement techniques import tissues, mainly from the regions surrounding the breast. The latissimus dorsi (LD) flap is a prime example of a musculocutaneous flap that has been used for partial breast reconstruction. The sacrifice of a substantial muscle, however, results in significant donor site morbidity, in particular, seroma formation and detrimental effects on shoulder function.

PPFs are a recent development in the field of breast reconstruction. Their main role is in the reconstruction of partial mastectomy defects with minimal donor site morbidity by preservation of the underlying muscles. They allow breast surgeons to resect a tumor with as much margins as oncologically necessary without fear of a poor cosmetic result. Moreover, these flaps act as a vascularized tissue scaffold that support the survival of free fat grafts. This is especially important given that adjuvant breast irradiation is mandatory in BCT, and fat transfer may be used to reverse the late sequelae of radiation and function as filler to correct residual volume and contour abnormalities.

Based on the authors’ successful experience with PPFs and fat grafting in partial breast reconstruction, the indications of PPFs could be expanded to include total breast reconstruction. In this novel concept, the PPF functions as a vascularized tissue scaffold for subsequent sessions of fat grafting, to achieve a larger desired volume and contour in the reconstructed breast. This article reviews the concept of PPFs and their current use in breast surgery.