Breast Reconstruction with Free Bipedicled TRAM or DIEP Flaps by Anastamosis to the Proximal and Distal Ends of the Internal Mammary Vessels

Abstract

Breast reconstruction in patients who have already undergone traditional radical mastectomy can be very challenging for plastic surgeons. These patients require not only correction of breast deformities but also correction of subclavian and anterior axillary fold deformities. Usually the entire transverse rectus abdominal myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap (including zone IV) must be used. To achieve this, bipedicled deep inferior epigastric vessels (DIEV) are needed to ensure that the entire flap will survive completely. On the chest, however, it is difficult to find two sets of suitable recipient vessels for the two pedicles. The thoracodorsal vessels have often been damaged during axillary dissection or radiation therapy. In the past, surgeons have used the proximal end of the internal mammary artery and vein (IMA, IMV) as the recipient vessels in breast reconstruction with free flaps, with ligation of the distal ends. Here, we use both the proximal and distal ends of IMA and IMV as recipient vessels for end-end anastomoses to the bipedicled deep inferior epigastric artery and deep inferior epigastric vein vessels in seven TRAM cases and five DIEP cases. Very satisfactory results are obtained. Our clinical and experimental studies indicate that the distal IMA has reduced perfusion pressure but still can provide excellent flow and flap perfusion. This technique allows reliable use of two pedicles for survival of the entire flap.