Improving Outcomes in Immediate Prepectoral Reconstruction of Large and Ptotic Breast: The Reliability of Fifth Anterior Intercostal Artery Perforator Flap

Background and objective: Conservative mastectomy is burdened by possible necrosis of the breast skin and nipple-areola complex, particularly among patients with macromastia and severe ptosis undergoing heterologous reconstruction. It is well known that anterior fifth intercostal artery perforator plays a critical role in nipple-areola complex blood supply. Our study investigates outcomes of large or ptotic breasts, undergoing immediate prepectoral direct-to-implant breast reconstruction covered by dermoadipose flap based on the fifth anterior intercostal artery perforator. Methods: We conducted a retrospective study on 70 consecutive patients who underwent skin-reducing mastectomy, with or without nipple preservation, using an inverted T-pattern. Setup of a dermo-adipose flap with an inferior pedicle, based on the anterior intercostal artery perforator of the fifth intercostal space was performed, according to preoperative Doppler ultrasound. Immediate breast reconstruction was performed using Microthane implants. We assessed rate of mastectomy flap necrosis (Mayo Clinic Classification), at 12 months follow up, pre- and postmastectomy satisfaction with breast, physical well-being of the chest with BREAST-Q questionnaire, and spinal pain using the McGill Pain Questionnaire. Results: No complications such as hematoma, seroma, or implant infections occurred. Ischemic complications were observed in 11 cases (13.9%), however, only in one case was implant removal necessary. Satisfaction with breast appearance, chest physical well-being, and the pain rating index all significantly improved postoperatively. Conclusions: Direct to implant reconstruction using the inferiorly pedicled flap based on the AICAP is a reliable and reproducible technique that offers favorable results with low complication rates in large or ptotic skin reducing mastectomies.