From Innovation to Underutilization: Why Chest Wall Perforator Flaps Have Not Achieved Widespread Adoption—Insights from the Literature and a High-Volume Single-Center Cohort

Background/Objectives: Chest wall perforator flaps (CWPF) have emerged as versatile muscle-sparing volume replacement techniques in oncoplastic breast surgery (OBS), facilitating breast conservation in selected patients with favorable tumor-to-breast ratio. However, their adoption into routine practice remains limited. The aim of this study was to explore the factors contributing to the underutilization of CWPF in OBS through a narrative review of the current literature along with insights from a high-volume single-center experience in Greece. Materials and Methods: A comprehensive search of PubMed/MEDLINE and Scopus (2004–2026) was performed using predefined keywords related to CWPF, partial breast reconstruction (PBR), breast-conserving surgery (BCS) and OBS. Eligible studies addressing surgical outcomes, patient selection, technical variations, patient satisfaction and barriers to implementation were analyzed qualitatively, due to heterogeneity of study designs and outcome reporting. The institutional cohort included patients undergoing CWPF-based PBR following BCS between May 2018 and December 2025, with data extracted from a prospectively maintained institutional database and analyzed descriptively. Results: The literature confirmed CWPF as safe and feasible with low complication rates, reassuring oncological outcomes and satisfactory aesthetic results, with lateral intercostal artery perforator (LICAP) being the most commonly reported technique. However, significant variability in patient selection, technical approach and outcome reporting was observed, alongside limited long-term data. Overall, underutilization appears to be primarily driven by insufficient and non-standardized training with a steep learning curve, limited exposure and a persistent gap between perceived importance and routine clinical availability. In our institution, of the 107 patients who were selected for local flaps, 81 patients underwent CWPF reconstruction and were eligible for the study. LICAP was the most frequently used flap (46.9%), followed by lateral thoracic artery perforator (LTAP), anterior intercostal artery perforator (AICAP) and medial intercostal artery perforator (MICAP) variants. Negative margins were achieved in all cases, with a low complication rate (3.7%) and one local recurrence. No re-excision was required. Conclusions: CWPF appear to remain underutilized in routine oncoplastic practice, as indicated by the available literature, reflecting a potential gap between their perceived clinical value and real-world implementation. This underscores the need for structured training and improved dissemination to support broader adoption.