Internal Mammary Artery Perforators for the Salvage of a Superficially Dominant Free Flap Breast Reconstruction

Abstract

Sir: The deep inferior epigastric perforator (DIEP) flap is becoming widely popular for autologous breast reconstruction because preservation of the rectus abdominis musculature can lead to less abdominal wall morbidity and postoperative pain. Alternatively, a muscle-sparing free transverse rectus abdominis musculocutaneous flap offers many similar advantages. In both cases, deep inferior epigastric vessels are usually anastomosed to the recipient internal mammary vessels in the third intercostal space. However, perforating vessels from the internal mammary circulation have also proven to be reliable recipients for anastomosis.1,2 Using the internal mammary perforators primarily obviates the need for partial rib resection and allows the internal mammary vessels to be preserved for potential future use as coronary revascularization grafts. To our knowledge, use of internal mammary perforators for salvage of a congested flap with patent internal mammary anastomoses has not been previously described. In a recent case of a bilateral free flap breast reconstruction, we noted mild congestion in half of the flap, shortly after dividing the superficial inferior epigastric vein (SIEV). The congestion improved slightly with time while the flap remained connected to the deep circulation, and the decision was made to complete the procedure as a muscle-sparing free transverse rectus abdominis musculocutaneous flap with one arterial anastomosis from the deep inferior epigastric artery to the internal mammary artery, and two venous anastomoses from the inferior epigastric venae comitantes to the two internal mammary veins that were present. The other half of the flap had a normal appearance, and a DIEP flap was performed to reconstruct the left breast. However, the right breast flap appeared mildly congested at the completion of the operation, initially improved, and then worsened over the first postoperative day, necessitating operative exploration. At the time of exploration, all arterial and venous anastomoses were found to be widely patent but, once the SIEV was opened, a continuous jet of venous flow was seen, indicating venous congestion despite the two venous anastomoses (Fig. 1). We augmented the venous outflow by coupling a saphenous vein graft between the SIEV and a perforating vein of the internal mammary circulation in the second intercostal space that had been left intact during the mastectomy (Fig. 2). After placement of the interposition graft, the abnormal tissue turgor and congested color of the flap improved immediately and remained normal throughout the postoperative course.Fig. 1.: A continuous jet of venous blood from the SIEV after venotomy in preparation for salvage vein grafting.Fig. 2.: A saphenous vein graft interposed between the SIEV of the flap and a perforating vein of the internal mammary circulation.This case demonstrates the importance of preserving alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant hemiflap can become congested, even when harvested as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously reported a technique for venous augmentation in a DIEP flap by draining the SIEV to one of the venae comitantes.3 Other options for venous augmentation include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle to the cephalic vein4 or to recipient thoracodorsal, lateral thoracic, or intercostal veins.5 Internal mammary perforators should be added to the list of venous augmentation recipient vessels. We recommend routine dissection and preservation of the superficial inferior epigastric vessels during flap harvest, and close communication with the breast surgeons to preserve any sizable internal mammary perforators found during the mastectomy. No additional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult. DISCLOSURE No financial support or benefits have been received by any of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article. Brian D. Cohen, M.D. Nicholas Vendemia, M.D. Division of Plastic and Reconstructive Surgery New York-Presbyterian Hospital New York, N.Y. Jason A. Spector, M.D. Division of Plastic and Reconstructive Surgery Weill-Cornell Medical Center/New York-Presbyterian Hospital New York, N.Y. Christine H. Rohde, M.D. Division of Plastic and Reconstructive Surgery Columbia University Medical Center/New York-Presbyterian Hospital New York, N.Y.