Serratus branch as recipient vessel for microvascular tissue transfer in breast reconstruction.

Abstract

Sir: Although the internal mammary vessels remain the recipient vessels of choice in free flap breast reconstruction, the thoracodorsal vessels are still chosen for a variety of reasons. The use of the internal mammary artery as a recipient vessel is justified despite concern for future coronary revascularization.1 The thoracodorsal vessels continue to be used because of surgeon preference and cases of suboptimal internal mammary vessels upon dissection. The potential disadvantages of the thoracodorsal artery and vein as recipient vessels include difficultly in achieving medial fullness in the final breast mound and the inability to use the latissimus flap for future breast reconstruction. We present a case in which the serratus branch is used as recipient vessels for microvascular tissue transfer, with the advantage of preserving the thoracodorsal vessels for future flap reconstruction. The patient is a 44-year-old woman with history of left breast cancer status post mastectomy, who presented for delayed autologous free flap reconstruction. After excision of the previous mastectomy scar, the prepectoral pocket was created. It was noted that the previous mastectomy scar went quite lateral, and therefore, the decision was made to dissect the thoracodorsal vessels. During the dissection, the serratus branch of the thoracodorsal vessels was noted to be quite large and suitable for microvascular anastomosis (Fig. 1). We chose to use the serratus branch as recipient vessels to spare the thoracodorsal vessels. This would allow for future use of her latissimus muscle for breast or general reconstruction. Fig. 1. Dissection of the thoracodorsal vessels. The serratus branch of the thoracodorsal vessels was found large and suitable for microvascular anastomosis. Few studies have described the use of the serratus branch as recipient vessels for microvascular transfer. Arnez et al2 describe a case of a patient who underwent a free transverse rectus abdominis myocutaneous flap reconstruction with the serratus anterior branch as a recipient vessel, thus conserving the remainder of the thoracodorsal vessels in case they were needed in a secondary salvage surgery. In a study describing their experience with 50 free TRAM flap reconstructions, Arnez et al3 describe 1 of 2 reconstructions using the serratus branch, citing the superior back flow of the serratus branch in comparison with the flow of the proximal pedicle. Another group describes their use of the serratus branch as recipient vessels in 4 patients undergoing partial breast reconstruction with mini-superficial inferior epigastric artery and mini-deep inferior epigastric artery perforator flaps to achieve the proper anatomic placement of miniflaps.4 Most cases describe the use of the serratus branch and other distal branches of the thoracodorsal artery as a means to successfully salvage a deep inferior epigastric artery perforator flap through retrograde flow anastomosis.5 In conclusion, the serratus branch of the thoracodorsal vessels provides a viable recipient site for microvascular tissue transfer with the advantages of sparing the thoracodorsal vessels for future latissimus flap reconstruction.