Internal Mammary Artery Perforator Research Articles

Outcomes of internal mammary artery perforator flap in head and neck reconstruction: A systematic review.

This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow-up was 12.6 (IQR: 6-18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications.

The internal mammary artery perforator flap in pharyngoesophageal, cervical tracheal, and cutaneous neck reconstruction.

The internal mammary artery perforator (IMAP) flap is an evolution of the deltopectoral flap that is harvested based upon a single perforator from the internal mammary artery. Its favorable characteristics include pliability as a fasciocutaneous flap, ease of harvest, and minimal donor site morbidity. In this paper, we report our harvest technique and the versatility of the IMAP flap for pharyngoesophageal, cervical tracheal, and cutaneous neck defects. We seek to highlight the IMAP as a useful regional reconstructive option in both the primary and salvage reconstructive setting. As such, this flap is an important option in the head and neck reconstructive surgeon's armamentarium.

Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction.

Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm-1.2 mm). The average vein diameter was 2.0 mm (1.5-3.0 mm). The incision to closure lasted 330 minutes (313-348 minutes). Flap ischemia was 105 minutes (82-118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22-30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.

Internal mammary artery perforator flap in the management of tracheoesophageal fistulae.

A pathological communication between the trachea and oesophagus - a tracheoesophageal fistula - may be congenital or acquired, benign or malignant, necessitating a multidisciplinary approach. Conservative attempts at closure of this abnormal connection are ineffective; the interposition of healthy vascular tissue offers the least chance of recurrence. Outcomes of an islanded fasciocutaneous internal mammary artery perforator flap applied for tracheoesophageal fistula management were assessed in four radiated patients with laryngeal carcinoma using retrospective records. Four male patients, with an average age of 60.75 years, underwent tracheoesophageal fistula closure between September 2017 and February 2021. A left-sided second internal mammary artery perforator flap was used in all cases, with an average dimension of 10.5 × 4.5 cm. There were no complications of tracheoesophageal leak, flap issues or donor site morbidity on follow up. Recent advances in angiosomal territory mapping and microvascular dissection techniques, combined with an understanding of tracheoesophageal fistula pathology, have changed management perspectives in these difficult-to-treat patients.

Arterial Supply of the Breast and Nipple-areola Complex: A MRI and Cadaveric Study

Introduction: Preservation of the Nipple-areola Complex (NAC) is currently being attempted for a better aesthetic and functional outcome, necessitating precise knowledge of its vascular supply to minimise postoperative necrosis. Aim: To determine the source, branches, and pattern of arterial supply to breast parenchyma and the NAC using Magnetic Resonance Imaging (MRI) and cadaver. Materials and Methods: The present retrospective observational study was conducted in the Department of Anatomy, AIIMS, New Delhi, India, from March 2015 to October 2016. Total of 50 MRI scan images of female patients who underwent breast MRI as part of their preoperative assessment were collected and retrospectively reviewed. Cadaveric dissection was performed on 11 breasts (5 left and 6 right) obtained from 10 female cadavers with no breast pathology. Radiographic and cadaveric data pertaining to the source, branches, and pattern of arterial supply to breast parenchyma and the NAC were collected. Data was studied using statistical tests like Dunn test followed by Bonferroni correction and Signed-rank test. Results: The MRI scans revealed that most vessels bilaterally supplying the medial half of the breast originate from the Internal Mammary Artery (IMA), while those supplying the lateral half arise from the Lateral Thoracic Artery (LTA), and the branches of IMA were found to be consistently supplying the NAC. Cadaveric dissection confirmed, in all cases except one, that the principal parenchymal and NAC supply on either side arises from the IMA. Conclusion: IMA perforators supply the NAC most consistently and the major part of the breast parenchyma, as well. MRI breast is the most precise modality currently available for the preoperative evaluation of breast vascularity during conservative mastectomies.

Internal mammary artery perforator (IMAP) flap plus superior epigastric artery perforator (SEAP) flap as salvage breast reconstruction after multiple surgical failures: a case report

Internal mammary artery perforator (IMAP) flap plus superior epigastric artery perforator (SEAP) flap as salvage breast reconstruction after multiple surgical failures: a case report

Novel use of interosseous absorbable mattress sutures for secondary sternal fixation: A case series

There is currently no consensus on the treatment of median sternotomy patients presenting secondarily with deep sternal wound infection or symptomatic sternal nonunion. We have developed a novel approach to sternal bone fixation when concerns for open wounds or microbial colonization preclude the use of permanent hardware placement: (1) sternal closure with absorbable interosseous monocortical horizontal mattress sutures followed by (2) multilayered soft tissue closure with pectoralis major advancement or turnover flaps. Benefits of this technique include: closure of retrosternal dead-space, tension offloading of the soft tissue closure, repair of transverse sternal fractures, and preservation of internal mammary artery (IMA) perforators for potential pectoralis turnover flaps. In our early experience, this technique has been successful at promoting functional sternal union - even in secondary closure of high-risk patients contraindicated for permanent hardware placement.

Examination of Sensory Recovery of Breasts Reconstructed With Silicone Breast Implants After Nipple-Sparing Mastectomy

Background: Reconstructed breast with silicone breast implants (SBIs) after nipple-sparing mastectomy (NSM) provides high patient satisfaction from a cosmetic point of view, but low patient satisfaction with respect to hypoesthesia of the reconstructed breast, and reinnervation is required. Currently, few reports are available on reinnervation in breast reconstruction with implants, and detailed data on desensitization of reconstructed breasts are lacking. Therefore, we examined perceptual data after NSM with respect to reinnervation. Methods: In our department, after NSM, tissue expander or SBI was used to perform 1-stage or 2-stage breast reconstruction, and touch, warm and cold, and pain sensations in 31 cases more than 1 year after completion of reconstruction were examined. Results: All tests of sensations tended to be better in the medial region than in the lateral region, but no correlation with postoperative years was found. In the comparison of the incision lines, in the Semmes-Weinstein monofilament test (SW test), a significant difference was observed between the inframammary fold (IMF) incision and the para-areola incision in the breast D region, between the lateral incision and the para-areola incision, and between the IMF incision and the para-areola incision in the areola b region. In addition, linear regression analysis of postoperative years did not establish a predictive formula for the SW test or pain sensation in any of the 9 regions. Conclusions: The difference in the excision range was considered to be the largest factor affecting hypoesthesia. We also speculated that preservation of the internal mammary artery perforators during mastectomy led to preservation of the anterior cutaneous branch of the intercostal nerves, and therefore, the perception of the medial region was better than that of the lateral region. In the case of NSM in which the anterior cutaneous branch was preserved, the recovery of outer perception including that of the nipple-areolar complex (NAC) was poor, so it was considered that nerve reconstruction between the lateral cutaneous branch and the NAC was effective for reinnervation.

A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels.

The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies). Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%). This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.

Impact of internal mammary artery perforator propeller flaps combined with radiotherapy in the treatment of large chest keloids: Our experience.

Keloids are benign skin hyperplasias but have a tumor-like appearance. Clinical management of keloids remains challenging. We retrospectively evaluated the safety and efficacy of internal mammary artery perforator propeller flaps combined with timely radiotherapy in the treatment of large chest keloids. From June 2017 to May 2020, 25 patients with large chest keloids (average size 4.82 cm ± 2.53 cm × 9.04 cm ± 4.86 cm) who received both radiotherapy and internal mammary artery perforator flaps transplantation in our department were included. After surgical removal of the keloids, various propeller flaps based on the unilateral internal mammary artery were designed and applied to repair the defects. Timely and full-dose radiotherapy was performed for these patients after the operation. After keloid resection, the dimensions of the defect area were 3 cm-15 cm × 4 cm-25 cm, and the sizes of the flaps were 3 cm-16 cm × 4 cm-27 cm. For all 25 patients, the flaps survived, and the incisions healed in one stage. During the follow-up (median 18 months), no local recurrence was observed, and the itching and pain symptoms in the scar area were significantly relieved. Both physicians and patients were satisfied with the results. The application of internal mammary artery perforator propeller flaps combined with radiotherapy in the treatment of chest keloids can effectively reduce the recurrence of keloids and relieve the related symptoms. It also has advantages including minimized donor site damage, short operation time and speedy postoperative recovery, suggesting its great clinical value.

Modification of Rotation-Advancement Split Pectoralis Major (RASP) Turnover Flap Technique for Median Sternotomy Wound Dehiscence.

Pectoralis major muscle flap was used alone or mostly combined with rectus muscle or omentum to cover the whole sternal defect.[1] [2] [3] Disadvantages are additional abdominal incisions, herniation of bowel, introducing infection to abdominal cavity. D. A. Staffenberg introduced “Rotation-Advancement Split Pectoralis (RASP) major muscle turnover flap” technique for median sternotomy wound dehiscence.[4] In his technique, one-side split pectoralis major muscle flap was turned over based on internal mammary artery perforators and the other side pectoralis muscle flap advanced to the defect based on thoracoacromial pedicle. In our technique, we modified the split pectoralis muscle upper flap that was islanded based on the thoracoacromial pedicle to achieve more mobilization, less bulging contour deformity, and use the dominant blood supply.

The internal mammary artery perforator flap for neck reconstruction after palliative resection of advanced anaplastic thyroid cancer: a case report

IntroductionDefects of the neck after palliative resection of exulcerated tumors could be reconstructed with different skin flaps.Case presentationThe present report describes the case of a 40-year-old Caucasian female patient with advanced anaplastic thyroid cancer. The exophytically growing, bad-smelling massive exulcerated tumor caused an esthetic defect, neck mobility restrictions, and mental state deterioration.Primary diagnosis, interventions, and outcomesPalliative debulking of the tumor was performed. The 10 × 5 cm skin defect of the neck was successfully reconstructed with an internal mammary artery perforator island flap. The donor site was closed primarily. The patient had an uneventful clinical course; the cosmetic results and mental state were very pleasing.ConclusionsThe present case illustrates that palliative resection of the tumor and plastic reconstruction of the neck defect promoted other treatments such as radiation or chemotherapy due to the improved local situation.

Troubleshooting recalcitrant tracheoesophageal prosthesis site leak with internal mammary artery perforator flap: a case report

BackgroundAn enlarged tracheoesophageal puncture (TEP) site is a grave complication of voice prosthesis rehabilitation.Case presentationWe report a case of periprosthetic leakage with an enlarged tracheoesophageal fistula causing aspiration, not responding to conservative management and primary closure. Internal mammary artery perforator (IMAP) flap was subsequently used in the management. The flap was successfully taken up at the recipient site with no leak post-operatively as confirmed by barium swallow, thereby preventing further aspiration.ConclusionThough minor degrees of TEP leak usually respond to conservative management, the recalcitrant ones require active intervention which one should be aware of.

Contemporary Nipple-Sparing Mastectomy Technique to Preserve the Internal Mammary Perforator Blood Flow to the Nipple and Analysis of Outcomes

Introduction: Nipple-sparing mastectomy (NSM) with immediate breast reconstruction is commonly performed; however, nipple-areolar complex (NAC) necrosis can represent a devastating complication. This study describes a contemporary NSM technique based on contrast-enhanced breast MRI blood flow data, to preserve the internal mammary artery perforator (IMP) blood supply to the NAC during NSM (IMP-NSM). Methods: A single-surgeon comparative analysis of consecutive patients who underwent IMP-NSM between 2018 and 2020 vs historic control of conventional NSM (performed in 2016 and 2017) was performed. The IMP-NSM surgical technique involves preservation of the IMP blood supply to the NAC with dissection near the sternal border where it perforates the pectoralis major muscle. Clinical outcomes were analyzed with a particular focus on ischemic complication and reoperation for necrosis. Results: Sixty-eight conventional NSM were performed with 19.1% (13/68) developing necrosis (4 partial nipple or areolar, 4 NAC, 5 skin necrosis), which resulted in 9/68 (13.2%) undergoing reoperation for necrosis. In contrast, 114 IMP-NSM were performed based on contrast enhanced breast MRI blood flow patterns. Preoperatively, breast MRI demonstrated IMP dominant NAC blood supply in 91%. In the IMP-NSM cohort, 10.5% (12/114) developed necrosis, of which the majority were partial or resolved non-operatively, with reoperation for necrosis in 3/114 (2.6 %). A significantly lower reoperation rate for necrosis was noted in the IMP-NSM cohort [2.6% vs 13.2%; p = 0.02]. Conclusion: IMP-NSM, a contemporary surgical approach to preserve the dominant vascular supply to the NAC, is associated with significantly lower rates of reoperation for necrosis, thereby improving clinical outcomes.

Nipple Sparing Mastectomy Technique to Reduce Ischemic Complications: Preserving Important Blood Flow Based on Breast MRI.

Nipple-sparing mastectomy (NSM) with immediate breast reconstruction is commonly performed. However, nipple areolar complex (NAC) and mastectomy skin necrosis represent significant complications requiring reoperation and revision. Breast MRI, often obtained for oncologic assessment, can visualize the dominant breast and NAC vascular supply. This study describes the surgical technique utilizing breast MRI blood flow information to preserve important NAC blood supply, thereby, reducing ischemic complications. After IRB approval, a prospectively maintained database of all NSM by a single breast surgeon from 2018 to 2020 formed the study group. Preoperative contrast enhanced Breast MRI analysis determined the dominant NAC blood supply. Intraoperatively, the dominant Internal Mammary Artery Perforator (IMP) to the NAC was preserved (IMP-NSM). The IMP-NSM surgical technique preserving the IMP blood flow, evaluation of breast MRI blood flow patterns, surgical findings, and ischemic complications were analyzed. 114 NSM were performed in 74 patients (mean age: 49years [range, 22-73years], BMI 25.8kg/m2 [range, 19-41kg/m2]). Breast MRI identified the dominant IMP to the NAC in 92%. IMP preservation was successful in 89% (101/114). Necrosis requiring NAC removal occurred in 0.9% (1/114), and skin necrosis reoperation in 1.8% (2/114). Including all post-operative necrosis occurred in 10.5% (12/114), statistically significantly lower compared to the literature for NSM assessing MRI blood flow data without surgical IMP preservation (necrosis 24.4%, p < 0.001) (Bahl et al. in J Am Coll Surg 223(2):279-285, 2016) utilizing Doppler for IMP preservation (necrosis 37%, p < 0.001) (Swistel et al. in Plast Reconstr Surg Glob Open 2(8):e198, 2014) and dividing the IMP in all (necrosis 31.4%, p < 0.001) (Ahn et al. in Eur J Surg Oncol 44(8):1170-1176, 2018). The IMP-NSM surgical technique preserves the dominant blood supply to the NAC, thereby, decreasing ischemic complications.

Clinical application of expanded internal mammary artery perforator flap combined with vascular supercharge in reconstruction of faciocervical scar

Objective: To summarize the clinical experience of expanded internal mammary artery perforator (IMAP) flap combined with vascular supercharge in reconstruction of faciocervical scar. Methods: The retrospective observational study was conducted. From September 2012 to May 2021, 23 patients with postburn or posttraumatic faciocervical scars who met the inclusion criteria were admitted to Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine, including 18 males and 5 females, aged from 11 to 58 years, all of whom were reconstructed with expanded IMAP flaps. At the first stage, one or two skin and soft tissue expander (s) with appropriate rated capacity were implanted in the anterior chest area according to the location and size of the scars. The IMAP, thoracic branch of supraclavicular artery, and lateral thoracic artery were preserved during the operation. The skin and soft tissue expanders were inflated with normal saline after the operation. The flaps were transferred during the second stage. The dominant IMAP was determined preoperatively using color Doppler ultrasound (CDU) blood flow detector. The faciocervical scars were removed, forming wounds with areas of 9 cm×7 cm-28 cm×12 cm, and the perforators of superficial temporal artery and vein or facial artery and vein were preserved during the operation. The flaps were designed according to the area and size of the wounds after scar resection with the dominant IMAP as the pedicle. Single-pedicle IMAP flaps were used to repair small and medium-sized wounds. For larger defects, the blood perfusion areas of vessels in the anterior chest were evaluated by indocyanine green angiography (ICGA). In situations where the IMAP was insufficient to nourish the entire flap, double-pedicle flaps were designed by using the thoracic branch of supraclavicular artery or lateral thoracic artery for supercharging. Pedicled or free flap transfer was selected according to the distance between the donor areas and recipient areas. After transplantation of flaps, ICGA was conducted again to evaluate blood perfusion of the flaps. The donor sites of flaps were all closed by suturing directly. Statistics were recorded, including the number, rated capacity, normal saline injection volume, and expansion period of skin and soft tissue expanders, the location of the dominant IMAP, the total number of the flaps used, the number of flaps with different types of vascular pedicles, the flap area, the flap survival after the second stage surgery, the occurrence of common complications in the donor and recipient areas, and the condition of follow-up. Results: Totally 25 skin and soft tissue expanders were used in this group of patients, with rated capacity of 200-500 mL, normal saline injection volume of 855-2 055 mL, and expansion period of 4-16 months. The dominant IMAP was detected in the second intercostal space (20 sides) or the third intercostal space (5 sides) before surgery. A total of 25 expanded flaps were excised, including 2 pedicled IMAP flaps, 11 free IMAP flaps, 4 pedicled thoracic branch of supraclavicular artery+free IMAP flaps, and 8 free IMAP+lateral thoracic artery flaps, with flap areas of 10 cm×8 cm-30 cm×14 cm. After the second stage surgery, tip necrosis of flaps in three patients occurred, which healed after routine dressing changes; one patient developed arterial embolism and local torsion on the vascular pedicle at the anastomosis of IMAP and facial artery, and the blood supply recovered after thrombectomy and vascular re-anastomosis. Fourteen patients underwent flap thinning surgery in 1 month to 6 months after the second stage surgery. The follow-up for 4 months to 9 years showed that all patients had improved appearances of flaps and functions of face and neck and linear scar in the donor sites of flaps, and one female patient had obvious nipple displacement and bilateral breast asymmetry. Conclusions: The expanded IMAP flap is matched in color and texture with that of the face and neck, and its incision causes little damage to the chest donor sites. When combined with vascular supercharge, a double-pedicle flap can be designed flexibly to further enhance the blood supply and expand the flap incision area, which is a good choice for reconstruction of large faciocervical scar.

Identification of Independent Risk Factors for Skin Complications in a Multifactorial Logistic Regression Analysis of Simultaneous Immediate Autologous Breast Reconstruction and Skin Reduction Mastectomy in Large and Ptotic Breasts Using an Inferiorly Based Deepithelialized Dermal Breast Flap.

Autologous immediate breast reconstruction in large and ptotic breasts remains challenging. We aimed to identify independent risk factors for impaired wound healing and nipple necrosis after skin reducing wise pattern mastectomy in autologous reconstruction with an auxiliary deepithelialized inferiorly based dermal flap (IBDF). Methods. This retrospective study examined patients with wise pattern mastectomy with autologous immediate breast reconstruction (IBR) between 2017 and 2019. All cases of large and ptotic breasts were included. Demographic, oncologic, reconstructive, and surgical data were compiled, and multifactorial binary logistic regression models identified independent predictors for skin complications and nipple areolar complex (NAC) necrosis. Results. Of 591 autologous breast reconstructions, 62 (11%) met the inclusion criteria. Overall wound complication rate was 32% (n = 20, DIEP 11, thigh 9, p = 0.99), including 26% minor (n = 16, non-surgically treated) and 7% major complications (n = 4, surgically treated). Complete NAC necrosis occurred in one case. Nipple sparing mastectomy (NSM) (p = 0.003), high BMI (p = 0.019), longer operation time (p = 0.044) and higher patient age (p = 0.045) were independent risk factors for skin complications. Using internal mammary artery perforators (IMAP) as recipient vessels did not result in increased complication rates (p = 0.59). Conclusion. Higher patient age, BMI, and operation time (OT) significantly increase the risk for skin complications in combined reduction wise pattern mastectomies with autologous IBR. In this context, IBDFs help preserve the inframammary fold, providing vasculature to the T-junction and the mastectomy skin flaps. Acceptable complication rates can be achieved in large and ptotic breasts, regardless of preoperative chemotherapy or radiation. Gentle tissue handling with minimal thermal trauma preserves internal mammary artery perforators (IMAPs) as recipient vessels. In cases of flap failure and alloplastic conversion, the IBDF can serve as an autoderm, protecting the implant from exposure

Usefulness of Indocyanine Green Fluorescence Imaging for Harvesting Internal Mammary Artery Perforator Flaps Around the Inframammary Fold Region

Usefulness of Indocyanine Green Fluorescence Imaging for Harvesting Internal Mammary Artery Perforator Flaps Around the Inframammary Fold Region

Unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps

When the deep inferior epigastric perforator (DIEP) flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps and highlight specific technical considerations. Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average body mass index (BMI) was 23.1kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5h 50min (195-460min) and the mean combined flap weight was 551g (279-916g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n=22), the flaps were oriented horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

The Use of Internal Mammary Artery Perforators as Recipient Vessels in Breast Reconstruction with Free Tissue Transfer

Breast reconstruction has been a hot topic for decades. With rapidly evolving reconstruction techniques, higher standards of quality have been achieved. One of the current gold standard breast reconstructions at the moment is autologous breast reconstruction. The choice of the recipient vessels in microsurgery reconstruction has been a topic of fierce debate. With proponents and opponents of each recipient vessels option justify their choice. One of the most debatable topics is the use of the IMA perforators as recipient vessels in microsurgery for breast reconstruction. In this article we address the pros and cons plus myths and dogma about using the IMA perforators as the recipient vessels in breast reconstruction.