The Combination of Chest Wall Perforator Flaps and Surgeon-Performed Breast Ultrasound: An Effective Synergy to Expand the Boundaries of Breast-Conserving Surgery

Background: Intraoperative ultrasound-guided breast-conserving surgery (IOUS) combined with chest wall perforator flaps (CWPFs) is a promising approach to avoid mastectomy, especially for patients with high anticipated resection-to-breast volume ratios (ARR) who would otherwise be ineligible for breast conservation. Methods: This study prospectively analyzed surgical, oncologic, and cosmetic outcomes for consecutive patients with stages 0 to III breast cancer who underwent IOUS with CWPF-based partial breast reconstruction at a single institution between 2022 and 2024. Results: The study enrolled 73 female patients. The median age was 57 years, and the median tumor size was 32 mm, with 43.8% of lesions being multifocal/multicentric. The median ARR was 30.2%. The flap types included lateral intercostal artery perforator (LiCAP, 53.4%), anterior intercostal artery perforator (AICAP, 8.2%), medial intercostal artery perforator (MICAP, 19.2%), lateral thoracic artery perforator (LTAP, 16.4%), and thoracodorsal artery perforator (TDAP, 2.7%). The median flap volume was 90 cm3 (interquartile range [IQR], 47–140.5 cm), corresponding to 127% of the median specimens’ volume (71.1 cm3). The median operation time was 112 min. The 30-day global complication rate was 16.4%. No flap losses occurred. The positive margin rate was 9.6%, requiring re-excisions (5.5%) and mastectomies (4.1%). Adjuvant radiotherapy was administered to 95.9% of the patients, with no flap-related complications. During a median follow-up period of 14 months, only one distant recurrence was experienced, and no deaths occurred. Both patient- and surgeon-assessed evaluations demonstrated excellent cosmetic outcomes. Lower scores were associated with postoperative complications, re-excisions, and horizontal scars. None of the patients would have preferred mastectomy, and 89% underwent CWPF-based surgery to avoid it. Conclusions: The combination of IOUS and CWPFs yielded favorable surgical, cosmetic, and short-term oncologic outcome. This approach effectively and safely expands the indications for breast conservation, avoiding mastectomies, particularly for patients with small-to-medium breasts and an unfavorable ARR.