Reply: The Anterior Intercostal Artery Flap

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We appreciate the opportunity to respond to the interesting comments made by Tenna et al. regarding our recent article “The Anterior Intercostal Artery Flap: Anatomical and Radiologic Study,” published in Plastic and Reconstructive Surgery in March of 2017. We thank Dr. Tenna and colleagues for their thoughtful input. We were unaware that these authors had previously published a preclinical anatomical study on these flaps.1 Nevertheless, both of these studies provide complementary information, and the preclinical data reported by those authors are consistent with our detailed anatomical and radiologic study in a clinical sample.
We fully agree with Tenna et al. that the intercostal artery perforator flap is widely used as a propeller flap in trunk and dorsal reconstruction.2 However, we believe that the novel contribution of our study is that it was specifically designed to assess the anterior intercostal artery perforator3 to determine whether the distribution of perforators makes this flap suitable for filling breast quadrants after quadrantectomy.
At our hospital (as in Dr. Tenna’s institution), the anterior intercostal flap is a standard technique in oncoplastic breast cancer surgery, supported by published articles.4 We agree with Tenna and colleagues that angio–computed tomography is less useful for assessing the anterior intercostal artery perforator flap than it is in other flaps. For this reason, hand-held Doppler ultrasound is the preferred imaging technique before surgery. Unlike the technique described by Tenna et al., we typically use only one perforator because this allows for better movement, making it easier to adapt the flap to the breast.5 (SeeVideo, Supplemental Digital Content 1, which demonstrates the anterior intercostal flap surgical technique, available in the “Related Videos” section of the full-text article on or, for Ovid users, at
In our experience, an important advantage of the anterior intercostal artery perforator flap is that it can be harvested rapidly, providing a reliable, consistent flap for reconstruction in the upper trunk and overall oncoplastic breast surgery. In addition, because the anterior intercostal artery perforator flap is an anterior fasciocutaneous flap, donor-site morbidity is reduced and other muscle flaps in the latissimus dorsi are conserved. The main potential drawback is the risk of an unsightly scar, although it occurs in a few cases. In addition, as noted by Tenna et al., scar retraction requiring lipofilling can also occur. Importantly, the anterior intercostal artery perforator flap technique does not appear to negatively affect patient satisfaction with treatment outcomes, nor does it adversely affect health-related quality of life.
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