Oncoplastic techniques for the immediate reconstruction of breast-conserving surgery (BCS) defects broadly fall into three categories: simple local parenchymal mobilization; breast reduction/mastopexy; and volume replacement (1). Several methods of volume replacement have been reported; in this chapter we describe the use of local flaps.

Volume replacement is of most use in the small-/moderate-sized breast that does not have a simple or reduction/mastopexy option (or this is not desired). The aim is to preserve breast appearance with minimal, if any scarring visible from the front and replace volume with well-vascularized breast-like subcutaneous adipose tissue capable of tolerating radiotherapy.

Local perforator flaps harvested from the chest wall around the breast utilize the various adjacent options for vascularization and take advantage of lax lateral chest wall subcutaneous tissue. Their reliability has long been established and their anatomical basis has been well described (2,3,4). For partial breast reconstruction, these flaps have largely superseded the previously described latissimus dorsi (LD) muscle flap with its attendant morbidity loss of function and potential to atrophy (5,6,7,8). They keep donor-site morbidity to a minimum and preserve the option of LD flap reconstruction should it ever be required for salvage or total reconstruction. In addition, the scarring resulting from harvesting tissue lateral or inferior to the breast can usually be hidden in the bra line and these flaps can provide a good-sized skin island if required.

Flaps local to the boundaries of the breast can be classified according to their nutrient vessel:

This flap is based on perforators from the vascular arcade formed by the posterior and anterior intercostal arteries in the upper 6–7 intercostal spaces. Anatomical studies have shown that there are multiple such perforators in and around the breast footprint on the chest wall and between the lateral border of the breast and the anterior border of the LD, particularly in the 4th–6th intercostal spaces. Our experience has shown many of these perforators are closely related to the lateral breast border and are very common in certain locations—they can almost always be found in a triangle created by the lateral and inferior breast creases. As the vascular basis are the perforators there is no movable pedicle with these flaps. The perforators are therefore the fixed or “pivot” point in the movement of these flaps, hence those closer to the breast are more useful. The flap can be delivered into the breast as either a turnover flap (often with a line of perforators) or as a rotation/propeller technique (usually with a single or close cluster of perforators). The plethora of perforators allows these flaps to be placed where donor volume exists and they can usually be based on more than one perforator. If the defect is more medial, the breast tissue lateral to defect will need removing to allow access for the flap.

The lateral thoracic vessels usually arise from the axillary artery, although may arise from the subscapular or thoracodorsal artery. They are always visualized and routinely divided as part of an axillary node clearance procedure. As they course down the lateral border of the breast they give off perforators that allow them to be used for pedicled flaps. Alternatively, they can augment intercostal perforator-based flaps as a turnover flap. Of note, the distal course of the lateral thoracic vessels is variable and occasionally there is no descending branch lateral to the breast and the vessels enter the breast directly just below the axilla. In addition, the descending branch rarely reaches the level of the inframammary fold and in the axilla the vessels are usually closely related to the sentinel node. However, when available, these transposition flaps provide an easy option to fill lateral defects and have the potential to reach medially. As these flaps have a true vascular pedicle they allow transposition of the flap into the breast and can allow breast tissue lateral to a central defect to be preserved.

The TDAP flap is pedicled flap usually based on perforators of the descending branch on the thoracodorsal artery and only occasionally indicated for immediate reconstruction of defects from BCS. However, it has the potential for large volume and long reach. It can be raised on a single perforator with splitting of the muscle, however it is most easily raised with a muscle patch including more than one perforator on an anterior branch of the main descending branch. The thoracodorsal nerve and hence function of the LD muscle is preserved. It is a slightly more technically demanding flap to raise.