Combination of Hatchet and Anterior Intercostal Artery Perforator Flaps in Oncoplastic Breast-conserving Surgery

Oncoplastic breast-conserving surgery aims to achieve oncological safety and aesthetic preservation. Here, we report a novel hybrid oncoplastic breast-conserving surgical technique that combines volume displacement and replacement using hatchet and anterior intercostal artery perforator (AICAP) flaps. A 71-year-old woman with centrally located breast cancer extending to the lower inner quadrant underwent wide local excision, incorporating the nipple-areolar complex, resulting in a 90-mm cylindrical defect. Reconstruction was planned using a hatchet flap elevated from the inferolateral breast and extended laterally along the inframammary fold. An AICAP flap harvested from the upper abdomen was preoperatively designed to ensure adequate central volume restoration and address the anticipated volume deficiency. The flap included a crescent-shaped skin paddle with an attached tongue-shaped fat pad that was de-epithelialized, folded, and used to fill the central defect. Subsequently, the hatchet flap was advanced over the folded intercostal flap to restore the contour and symmetry. Both flaps demonstrated satisfactory perfusion, as confirmed using intraoperative indocyanine green angiography. The patient recovered uneventfully and was discharged on postoperative day 6. Three months later, the reconstructed breast exhibited good projection and a soft tissue quality. This case highlights the utility of combining the hatchet and AICAP flaps in hybrid oncoplastic breast-conserving surgery. Importantly, this technique provides a reliable and aesthetically favorable solution for reconstructing large central-to-lower breast defects.