Anticipated Resection Ratio (ARR) Based Flap Selection for Volume‐Replacement Oncoplastic Breast‐Conserving Surgery: 130 Breast Cancer Patients Cohort From a South Asian Tertiary Cancer Center

ABSTRACT Background Volume‐replacement oncoplastic breast‐conserving surgery (VR‐OBCS) reconstructs the lumpectomy cavity with autologous tissue and spares the contralateral breast. Chest‐wall perforator flaps (CWPFs)—lateral, anterior, and medial intercostal artery perforator (LICAP, AICAP, MICAP) flaps—together with a pedicled latissimus dorsi (LD) flap form the usual toolkit, but most programs depend on hand‐held color Doppler for perforator mapping and indocyanine‐green (ICG) angiography for perfusion assessment, neither of which is widely available in resource‐limited oncology units. We evaluated whether a structured radiological assessment using ARR, BEV, and aORV could facilitate preoperative planning for volume replacement oncoplastic breast‐conserving surgery (VR‐OBCS). Methods Consecutive women undergoing VR‐OBCS at an Indian tertiary cancer center (January 2023–March 2025) were reviewed retrospectively. Eligibility required an anticipated resection ratio (ARR) ≥ 0.15 or expected poor cosmesis after standard BCS; an ARR of 0.20–0.40 was the usual planning range for perforator‐based volume replacement. Flap choice followed a quadrant‐based map; the pedicled LD flap was reserved for defined indications. Perforator zones were identified by intercostal‐space counting; color Doppler and ICG were never used. The primary endpoint was primary R0 resection (SSO–ASTRO 2014 “no ink on tumor”); secondary endpoints included flap loss, Clavien–Dindo morbidity, oncological events, and 12‐month BREAST‐Q satisfaction. Results One hundred thirty women (mean age 47.7 ± 5.5 years) were treated: LICAP in 68 (52.3%), MICAP in 29 (22.3%), AICAP in 21 (16.2%), and pedicled LD in 12 (9.2%); 42.3% received neoadjuvant chemotherapy. Primary R0 was 95.4%, with all six margin‐positive women achieving R0 at re‐excision (final R0 100%). No total or partial flap loss occurred. Thirty‐day morbidity was 25.4% (maximum Clavien–Dindo IIIa) and late morbidity 16.9%. At a median follow‐up of 15.9 months (IQR 12.3–22.6), no locoregional or distant recurrence and no disease‐related death were recorded. The median BREAST‐Q Satisfaction‐with‐Breasts score was 86 (IQR 78–92); none preferred mastectomy. Conclusions Simple preoperative calculation of BEV, aORV, and ARR can guide selection between standard or type I oncoplastic BCS, perforator‐flap volume replacement, and muscle‐based reconstruction. This approach achieved reliable margin clearance, preserved flap viability, and high patient satisfaction without Doppler or ICG, making it a practical planning tool for resource‐limited centers.