Summary Introduction: Anatomy and classification of intercostal perforator flaps in addition to our experience with will be demonstrated for different indications. Material and methods: The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They are classified as following: dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery perforator (LICAP); and anterior intercostal artery perforator (AICAP) flap. Results: Between 2001 and 2004, 20 pedicled (ICAP) flaps were harvested in 16 patients. The indications were: immediate partial breast reconstruction in eight patients who had a quadrantectomy for breast cancer; midline back and sternal defects in three patients who had radical excisions for a dermatofibrosarcoma or malignant melanoma; and autologous breast augmentation (four bilateral and one unilateral flap) in five post-bariatric-surgery patients. The average flap dimension was 18!8 cm 2 (range 8!5-24!12 cm 2 ). There were two DICAP flaps, two (AICAP) flaps and 16 (LICAP) flaps. All but two flaps were based on one perforator. Mean harvesting time was 45 min for a single flap. Bilateral breast augmentation with LICAP flap necessitated longer operative time (range 2-3 h) depending whether it was combined or not with mastopoexy. Complete flaps survival was obtained. All donor sites were closed primarily. Conclusion: The (ICAP) flaps provide valuable options in breast surgery; and for challenging defects on the trunk without sacrifice of the underlying muscle.

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During the last decade the concept of perforator flap surgery has greatly refined reconstructive microsurgery in general and reconstructive breast surgery in particular. Harvesting a flap without sacrificing the underlying muscle or the functional motor nerves characterizes this technique. Perforator flaps aim to reduce donor-site morbidity to an almost absolute minimum, respecting one of the main adagio's in medicine: primum non nocere. Pedicled perforator flaps have not yet been commonly used or widely described for breast reconstruction. Although the thoracodorsal and intercostal arteries provide many perforators to the region of the back, only the latissimus dorsi muscle or musculocutaneous flaps are in common usage in breast surgery, despite resulting in loss of the largest muscle in the body. Pedicled perforator flaps are a relatively new concept, not yet in wide usage for breast reconstruction. Our clinical experience using pedicled perforator flaps in breast surgery will be presented.

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This study measured the number of complications after deep inferior epigastric perforator (DIEP) flap reconstruction performed under opioid-free anesthesia (OFA) combined with goal-directed fluid therapy or opioid anesthesia with liberal fluid therapy (OA). This retrospective cohort study consisted of 204 patients who underwent DIEP flap reconstruction at AZSint Jan Brugge between April 2014 and March 2019. Primary outcomes were complications, according to the Clavien-Dindo classification and the length of hospital stay (LOS). The secondary outcomes were flap failure, postoperative nausea and vomiting (PONV), postoperative pain, postoperative opioid consumption, and postoperative skin flap temperature. OFA included