The incision depends on whether volume is being replaced in the immediate or delayed setting and which type of flap is planned. In the delayed setting, reopening the previous skin incision on the breast often reveals a skin deficit. The wound may gape, demonstrating that skin replacement is required to allow the remaining breast tissue to return to its presurgical position. This may be the case even if no skin was excised at the time of breast-conserving surgery. Despite being an “apparent” skin deficit as a result of scarring and radiotherapy rather than a real deficit, it will need correction to optimise the result.

When the tumour is excised immediately before volume replacement, the breast skin is mobilised in the oncoplastic plane, over and around the tumour. The breast is then mobilised off pectoralis major muscle. The tumour is excised with generous margins and in continuity with lateral tissue to form the access tunnel as required. Bed biopsies are performed and the material removed is sent for frozen section, and a full cavity re-excision is undertaken to maximise the chance of clear margins (Fig. 17.1) [24]. Alternatively, a “delayed-immediate” reconstruction can be undertaken 1 week after tumour excision and when final histopathology results are available [29]. This is a particularly useful option after neoadjuvant chemotherapy when frozen-section analysis is more likely to be falsely negative.

An immediate LD miniflap is best performed via a cosmetically discreet “lazy S” incision in the anterior axillary line, providing access to the breast for tumour excision and the back for raising the LD flap [30]. The LD flap is raised in the plane just beneath the fascia, sparing the subcutaneous fat but taking a layer of fat over the muscle, which contributes to the flap volume (Fig. 17.2). Division of the entire fascial attachment of the LD muscle to teres major muscle, all serratus anterior muscle branches and the tendon of the LD muscle allows full transposition of the flap into the resection defect (Fig. 17.3). This is particularly important when reconstructing more remote defects in the medial or lower pole of the breast. Finally, the tendon needs to be secured to pectoralis major muscle to prevent unintentional tension on the pedicle, before the flap is modelled and sutured into the resection defect (Fig. 17.4). When harvesting the flap it is best to overestimate the volume required to allow for muscle atrophy over time. As a result, the volume of the reconstructed breast should be larger than that of the opposite breast at the end of the procedure, and a good cosmetic result can be anticipated if these key steps are observed (Fig. 17.5).

Perforator flap incisions are planned to incorporate the best perforators, and with a view to minimising the cosmetic defect. This is usually an ellipse in the bra line, sited with the anterior tip at the lateral border of the inframammary fold. Alternatively it may be oriented vertically, sparing the medial back, if the patient wishes. TDAP flaps are raised in a plane above or just below the deep fascia and the perforator is identified and dissected through the muscle and up to the thoracodorsal artery itself until the required pedicle length has been achieved (for details see Hamdi et al. [23]). Perforators from the descending branch of the thoracodorsal artery are preferred over perforators from the transverse branch but the inconsistent perforator size, quality, quantity and location means dissection must be painstaking, and is often reported as tedious [23, 28, 31]. If the perforator is less than 0.5 mm in diameter, the flap is at risk of failure, so conversion to a muscle-sparing LD flap is advised. The flap is brought through the muscle and placed in the defect, such that the anterior border lies medially or is rotated to lie inferiorly.

LICAP flaps are based on the perforators arising from the costal segment of the intercostal artery. In a cadaveric dissection study, Hamdi et al. [19] showed a variable number of intercostal perforators and a dominant perforator in 92 % of cases: these lay, on average 3.5 cm from the anterior border of the LD muscle. If the pedicle is long enough, the flap can be rotated through 180° [19, 21]. If the perforator is eccentric within the area of the flap, this rotation may allow significantly greater reach.

All flaps are partially or totally de-epithelialised, depending on whether skin is required to replace a deficit. If the flap is totally subcutaneous, Doppler monitoring cannot be undertaken.

The literature on volume replacement comprises mainly single-institution series, i.e. level 3 evidence. There is a lack of objective outcome reporting, very few comparative studies and it is likely that publication bias exists. It is not clear whether volume replacement techniques are being widely used by surgeons other than the recognised experts such as Hamdi, Rainsbury and Munhoz. Those achieving less successful outcomes are less likely to report their results.