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.