Internal Mammary Perforator Research Articles

The articulated dual-supply pedicle for reduction mammoplasty.

Breast reduction surgery achieves symptomatic relief and improved quality of life for patients with excessive breast enlargement. Reduction mammoplasty has evolved over the last century with the introduction of multiple new pedicles and skin excision patterns utilizing the ample blood supply of the breasts. The superior pedicle is a relatively safe technique in small resections, while the superomedial pedicle, supplied by the internal mammary perforators, serves as a proper alternative in broader resections. We aim to introduce the dual-supply pedicle technique, taking advantage of the two efficient workhorse pedicles-the superior and superomedial. A retrospective study of 48 bilateral reduction mammoplasty patients operated over a 2-year period between 2017 and 2019 by a single surgeon (Y.W). Patient characteristics and postoperative outcome data were collected and evaluated. The novel surgical technique showed compatibility with different types of patients and breasts, forming excellent aesthetic outcomes. Complication rates were comparable or lower than previously published series. Major complications requiring revision surgery were encountered in 2 patients (2.08%) and minor complications in 11 patients (11.5%); 4 moderate surgical wound dehiscence, 6 minor surgical wound dehiscence and 1 fat necrosis. The Dual-Supply Pedicle Reduction Mammoplasty is a safe, reproducible technique, with a short learning curve, excellent aesthetical results, and an acceptable complication rate. Level of Evidence is Level III.

Breast Vascularization and Its Implication in Breast Reduction and Mastopexy Surgery: Anatomical Study.

(1) Background: Breast reduction is one of the most frequently performed plastic surgeries in women worldwide. The Wise pattern breast reduction is one of the most frequent skin designs for this surgery. One key point of the surgery is to preserve a well-vascularized NAC by using different surgical pedicles. This study aims to test and update the anatomical knowledge of breast vascularization, the topographic and anatomical basis of the different surgical vascular pedicles, and the differences between the right and left sides. (2) Methods: A descriptive observational anatomical study was carried out on 15 breasts from 10 cryopreserved body donors. A dissection was performed by quadrants to know the affected arteries' origin in the different patterns. (3) Results: The largest and most frequently dissected internal mammary perforator artery was in the second intercostal space. A total of 44.9% of the dissected perforators are located in the upper inner quadrant, compared to 53.5% in the lower quadrants. (4) Conclusions: The upper inner quadrant alone has the most arterial perforators. In contrast, the sum of the two lower quadrants represents the greatest vascularization of the breast, with a small difference between both.

Tumor Contact With Internal Mammary Perforator Vessels as Risk Factor for Gross Internal Mammary Lymph Node Involvement in Patients With Breast Cancer

ImportanceThe identification of internal mammary lymph node metastases and the assessment of associated risk factors are crucial for adjuvant regional lymph node irradiation in breast cancer patients. The current study aims to investigate if tumor contact with internal mammary perforator vessels is associated with gross internal mammary lymph node involvement. MethodsWe included 297 patients with primary breast cancer and gross internal mammary (IMN+) and/or axillary metastases (AXN+) as well as 230 patients without lymph node metastasis. Based on pre-treatment dynamic contrast-enhanced magnetic resonance imaging (DE-MRI), we assessed contact of the tumor to the internal mammary perforating vessels (IMPV). Results59 patients had ipsilateral IMN+ (iIMN+), 10 patients contralateral IMN+ (cIMN+) and 228 patients had ipsilateral axillary metastases without IMN. 230 patients had node negative breast cancer. In patients with ipsilateral IMN+, 100% of tumors had contact with ipsilateral IMPV with 94.9% (n=56) classified as major contact. In iIMN- patients on the other hand, major IMPV contact was observed in only 25.3% (n=116) and 36.2% (n=166) had no IMPV contact at all. Receiver operating characteristic (ROC) analysis revealed that “major IMPV contact” was more accurate in predicting ipsilateral IMN+ (AUC 0.85) compared to a multivariate model combining grade of differentiation, tumor site, size and molecular subtype (AUC 0.65). Strikingly, among patients with contralateral IMN+ (cIMN+), 100% of tumors had contact to a crossing contralateral IMPV, whereas in contralateral IMN- (cIMN-) patients, IMPVs to the contralateral side were observed in only 53.4% (iIMN+) and 24.8% (iIMN-), respectively. ConclusionTumor contact with the IMPV is highly associated with risk of gross IMN involvement. Further studies are warranted to investigate whether this identified risk factor is also associated with microscopic IMN involvement and whether it can assist in the selection of breast cancer patients for IMNI.

Contact of the Tumor with the Internal Mammary Perforator Vessels as Risk Factor for Internal Mammary Lymph Node Involvement Based on Dynamic Contrast Enhancing MRI Imaging in Breast Cancer Patients

Distant metastasis free and overall survival of high-risk breast cancer patients can be improved with irradiation of the lymphatic system. However, inclusion of internal mammary region (IMN) markedly increases the dose to the heart. Hence, an estimation of the individual risk of subclinical involvement is necessary in order to balance the oncological benefit versus the cardiac toxicity. In randomized studies the risk stratification for IMN involvement is mainly based on the tumor location (medial, central vs. lateral). The aim of this study was to evaluate whether the contact of the tumor with the internal mammary perforator vessels (IMPV) is an additional risk factor for IMN involvement. For this trial we retrospectively examined 104 sets of pre-treatment dynamic contrast enhanced magnetic resonance imaging (DE-MRI) scans of locally advanced breast cancer patients. All patients had ipsilateral clinical suspect lymph nodes in the axillary region and either positive (n = 52) or negative lymph nodes (n = 52) in the internal mammary region. Based on the DE-MRI we assessed the tumor location as well as contact to the internal mammary perforating vessels (IMPV). Contact between tumor and IMPV was classified into either predominant, minor or no contact. Criteria for a predominant IMPV contact was defined as: main vessel contact or contact to multiple (> = 5) side branches. The tumor location of IMN+ patients were medial in 19.2% (10/52), central in 26.9% (14/52), lateral in 28.8% (15/52) and multicentric in 25.0% (13/52) of. In IMN- patients, tumor location was medial in 9.6% (5/52), central in 26.9% (14/52), lateral in 42.3% (22/52) and multicentric in 21.2% (11/52) in IMN- patients. The tumor size ranged from T1-T4 with most patients staged as T2 (48.1% (IMN+) vs. 38.5% IMN-). Most patients had hormone receptor positive / Her2neu negative disease (36.5% (IMN+) vs. 46.2% (IMN-). 100 % of tumors in IMN+ patients had contact with IMPV: in 94.2% (49/52) criteria for predominant IMPV contact was fulfilled; in the remaining 3 cases (5.8%) the tumor had minor IMPV contact. In IMN- patients however, 36/52 of cases (69.2%) had direct IMPV contact. Predominant contact was found in only 23.1% (12/52), minor IMPV contact in 46.2% (24/52). Predominant contact of the tumor with IMPV appears to be a potential risk factor for IMN involvement in breast cancer patients and could be used for stratification for IMN-irradiation in future trials.

Internal Mammary Perforator Preserving Nipple-Sparing Mastectomy (IMP-NSM) to Reduce Ischemic Complications

Internal Mammary Perforator Preserving Nipple-Sparing Mastectomy (IMP-NSM) to Reduce Ischemic Complications

Utilization of the internal mammary perforators as the recipient vessels for microsurgical breast reconstruction: A systematic review and meta-analysis of the literature.

The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels. A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery). Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%. With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction.

Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps

The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.

Creating a context for recipient vessel selection in deep inferior epigastric perforator flap breast reconstruction

In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction. We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p<0.05. There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p>0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p<0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p>0.05). Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars.

The deep inferior epigastric perforator flap: where we started and where we are now.

The deep inferior epigastric perforator (DIEP) flap has been performed since the early 1990s. This represented a significant advancement from the prior autologous options that required removal of all or a portion of various muscle groups. Over the years numerous advancements and modifications have been made to DIEP flap reconstruction that have further facilitated our ability to provide this option following mastectomy. Advancements with preoperative preparation, intraoperative techniques, and postoperative management have served to determine eligibility for DIEP flap reconstruction, improve surgical outcomes, reduce complications, reduce surgical operative time, and facilitate postoperative monitoring. Preoperative advancements have included vascular imaging to identify perforators. Intraoperative advancements have included using the internal mammary perforators as the optimal recipient vessels rather than the thoracodorsal, having a two-team approach with microsurgical reconstruction to reduce operative time and improve outcomes when compared to the single surgeon strategy, using a venous coupler rather than hand sewing the anastomosis, using tissue perfusion technology to determine the perfusion limits within the flap. Postoperative advancements include the use of technology to optimally monitor flaps as well as the use of using enhanced recovery after surgery pathways to improve the postoperative experience and promote early and safe discharge from the hospital. This manuscript will review the evolution of the DIEP flap as it relates to comparing our earlier techniques and strategies compared to our current techniques and strategies following mastectomy and breast reconstruction.

Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design.

The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. Therapeutic, IV.

The Free Superficially Based Low-Abdominal Mini Flap for Oncoplastic Breast Reconstruction.

Volume replacement in oncoplastic breast reconstruction most commonly uses pedicled flaps. In thin patients with small breasts, free-tissue transfer may be better suited to preserve breast size. Evidence on microvascular oncoplastic reconstruction is limited, and reconstruction has often required sacrifice of potential future donor sites. The free superficially based low-abdominal mini (SLAM) flap uses a narrow strip of lower abdominal tissue based on superficial perfusion of the abdominal wall that is anastomosed to chest wall perforators to preserve the ability to perform future abdominally based autologous breast reconstruction. Five patients underwent reconstruction with SLAM flaps for immediate oncoplastic reconstruction. Their mean age was 49.8 years, and their mean body mass index was 23.5. Tumor location was most commonly in the lower outer quadrant (40%). Average lumpectomy weight was 30 g. Two flaps were based on the superficial inferior epigastric artery, and three, on the superficial circumflex iliac artery. Recipient vessels included internal mammary perforators (40%), serratus branch (20%), lateral thoracic vessel branch (20%), and lateral intercostal perforators (20%). All patients underwent radiation therapy without delay and maintained volume, symmetry, and contour at an average period of 11.7 months after surgery. There were no cases of flap loss, fat necrosis, or delayed wound healing. The free SLAM flap allows for immediate oncoplastic breast reconstruction in thin, small-breasted patients with limited regional tissue without sacrificing future potential donor sites for autologous breast reconstruction. Therapeutic, IV.

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.

COMBINATION OF LICAP AND IMAP FLAP FOR TREATMENT OF LONG-LASTING CUTANEOUS FISTULAS OF THE CHEST WALL WITH OSTEOMYELITIS

Patients presenting large chest wall defects often represent a challenge, the more when other conditions, like osteomyelitis, may complicate the wound healing process. We present a case of long-lasting cutaneous fistulas of the chest wall caused by ribs and sternum osteomyelitis, refractory to both conservative and surgical treatment. Both lateral intercostal perforator flap and internal mammary perforator flap were performed in the same surgery for chest wall coverage after accurate debridement. The procedure allowed for resolution of osteomyelitis and wound healing with no recurrence. The purpose of this report is to highlight how, in apparently untreatable cutaneous fistulas caused by ribs and sternum osteomyelitis, an accurate debridement and coverage with perforators propeller flaps may be successful.

Double-pedicle unaffected split-breast flap for unilateral breast reconstruction.

In some breast cancer patients with a contralateral unaffected hypertrophic and ptotic breast, autologous small-breast reconstruction with contralateral breast reduction is a good option. The current study is aimed to assess the efficacy of the double-pedicle unaffected split-breast (USB) flap harvested from the central half of the unaffected breast for unilateral breast reconstruction with contralateral transverse scar reduction mammoplasty. Between February 2003 and May 2020, 14 patients underwent breast reconstruction using the USB flap. The mean patient age was 59.1 (range: 48-76) years, and the mean body mass index was 24.2 (range: 19.5-33.3)kg/m2 . This flap comprised half of the contralateral breast tissues with the 3rd or 4th internal mammary perforator (IMAP) and the lateral thoracic vessel (LTA/V). After USB flap elevation and LTA/V resection, flap perfusion from the IMAP was evaluated on indocyanine green (ICG) angiography. The medial pedicle USB flap was rotated 180° and was transferred to the affected site via the midline. The LTA/V was anastomosed to the recipient vessel to supercharge the distal part of the USB flap, which was then used for breast reconstruction. Then, the remaining contralateral upper and lower breast poles were used for transverse scar reduction mammoplasty. The mean flap size was 13.3 × 26.9 (range: 9.5 × 22 to 16 × 29)cm. All flaps and reduced breasts survived without serious complications such as flap necrosis, although there was one patient with hematoma and one patient with hypertrophic scar. ICG revealed poor perfusion in the distal, lateral part of the flap, ranging from 22.0% to 48.5% of the overall flap area. Final aesthetic evaluation was high, with 11 cases (78.6%) being "good" or "excellent" and 3 cases (21.4%) that were either poor or fair. The mean follow-up period for the patients was 53.8 (range: 15-84) months, with none of the patients presenting second primary breast cancer or recurrence in both breasts. USB flap breast reconstruction with contralateral reduction mammoplasty is a valuable option in breast cancer patients with a hypertrophic and ptotic breast.

The Deltopectoral/Internal Mammary Artery Perforator Flap Revisited: Design Variations Based on Cadaveric and Clinical Investigation.

Current understanding of the vascular anatomy of the anterior chest wall suggests that perfusion of the deltopectoral flap may be compromised when crossing the midline at the anterior thoracic wall. The traditional deltopectoral flap is designed longitudinally over the ipsilateral side to avoid the risk of distal flap necrosis. The purpose of this article is to present our experience and results with 26 deltopectoral flaps that were designed and raised with the perforating vessels on the ipsilateral side with the majority of the flap crossing the midline extending to the contralateral side. This anatomic variation in flap design indicates that the sternal midline is not a barrier and that the internal mammary perforator flap may be raised on different longitudinal axes.

SWIM Flap: Skin-Sparing, Wise Pattern, Internal Mammary Perforator Breast Reconstruction

Here we present a novel method of breast reconstruction, a skin-sparing, wise pattern, internal mammary perforator (SWIM) flap. The nipple-sparing mastectomy is completed as per the oncological standard. Reconstruction is then performed, using only local flaps to create a breast. The nipple is carried on a medial flap that is based on the internal mammary perforators. A lateral intercostal artery perforator (LICAP) flap can also be utilized for additional volume. There is no implant or anastomosis required and no muscle is sacrificed. Incisions are closed based on a classic Wise pattern. Seven patients underwent bilateral SWIM flaps for a total of fourteen breasts, with minimal complications limited to minor wound healing and one case of operative fat necrosis. All patients were satisfied with their results, with two patients desiring larger breast size and undergoing fat grafting at a secondary surgery.

Abstract P4-13-04: Robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction : A preliminary study

Abstract Background: Robotic nipple-sparing mastectomy (RNSM) could be a significant advancement in the treatment of selected breast cancers and prophylaxis. The aim of this prospective study was to assess feasibility of the RNSM with immediate prosthetic breast reconstruction (IPBR) on the first 50 consecutive cases performed in Gustave Roussy. Methods: RNSM with IPBR was offered to patients with breast cup size A, B or C and ptosis grade ≤ 2. In case of oncologic surgery, RNSM was offered only if the patient fulfilled oncological indications for NSM (NAC). In case of prophylactic surgery, RNSM was offered only if a high-risk genetic mutation had been identified or if the patient was at high risk of breast cancer. The primary endpoint was the conversation rate to open technique. The duration of the surgery, the rate of postoperative complications, the length of the scar, the duration of drainage and hospital stay, the rate and duration of rehospitalization were also analyzed. Results: Of 50 RNSM with IPBR from December 2015 to April 2017, 1 case of conversion to open technique occurred (2%) because of an uncontrolled bleeding from an internal mammary perforator. Two infections occurred (4%) : one led to implant loss. There were no cases of mastectomy skin flap or NAC necrosis. No other major complications were observed. The duration of the whole procedure was reduced gradually from 214 min to 86 min. Length of scar was between 2.5 and 5 cm. Patients were discharged home between the 4th and the 10th postoperative day after the removal of the drain. Conclusion: Preliminary data attest to the feasibility, the reproducibility and the safety of this approach. However, long-term data are needed to confirm the reduced rate of skin and NAC necrosis compared to the open technique, the oncological safety and the aesthetic stability of the result. Citation Format: Sarfati B, Struk S, Leymarie N, Honart JF, Rimareix F, Delaloge S, Saghatchian M, Ghouadni A, Alkhashnam H, Mazouni C, Kolb F. Robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction : A preliminary study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-04.

Microsurgical refinements with the use of internal mammary (IM) perforators as recipient vessels in transverse upper gracilis (TUG) autologous breast reconstruction.

The transverse upper gracilis (TUG) flap is the senior authors' second choice for autologous breast reconstruction when the DIEP flap is not available. It provides durable, pliable tissue with well hidden scars. The main criticism of this flap is the limited volume, donor site complications, short pedicle and vessel mismatch depending on which recipient vessels are used. We described methods of reducing vessel mismatch, complications of venous coupler and refinements to help give a more superior aesthetic outcome. We describe several maneuvers to help reduce vessel mismatch with the use of the internal mammary (IM) perforator vessels with a modification of the Harashina fish-mouth technique or the use of a vessel bifurcation to increase vessel diameter. We also describe the optimum method of perforator preparation and potential methods to prevent palpable venous couplers. The author's describe their case series of 14 TUG flaps to reconstruct 13 breasts in 12 patients. Eight unilateral, 2 partial breast reconstruction, 1 bilateral and 1 bilateral TUG flap for a unilateral reconstruction was carried out. All flaps survived with one partial flap necrosis, one donor site seroma and two cases of palpable/tender venous couplers. The mean reconstructed breast was 320 grams. The TUG flap is a reconstructive challenge, but with correct planning a good aesthetic outcome is possible. The IM perforator is our first choice recipient vessel in TUG breast reconstructions. With meticulous preparation and by overcoming vessel mismatch the use of this recipient vessel is a reliable option.

Computed tomography angiographic study of internal mammary perforators and their use as recipient vessels for free tissue transfer in breast reconstruction.

Context:The internal mammary artery perforator vessels (IMPV) as a recipient in free flap breast reconstruction offer advantages over the more commonly used thoracodorsal vessels and the internal mammary vessels (IMV).Aims:This study was designed to assess the anatomical consistency of the IMPV and the suitability of these vessels for use as recipients in free flap breast reconstruction.Patients and Methods:Data from ten randomly selected female patients who did not have any chest wall or breast pathology but had undergone a computed tomography angiography (CTA) for unrelated diagnostic reasons from April 2013 to October 2013 were analysed. Retrospective data of seven patients who had undergone mastectomy for breast cancer and had been primarily reconstructed with a deep inferior epigastric artery perforator free flap transfer using the IMPV as recipient vessels were studied.Results:The CTA findings showed that the internal mammary perforator was consistently present in all cases bilaterally. In all cases, the dominant perforator arose from the upper four intercostal spaces (ICS) with the majority (55%) arising from the 2nd ICS. The mean distance of the perforators from the sternal border at the level of pectoralis muscle surface on the right side was 1.86 cm (range: 0.9–2.5 cm) with a mode value of 1.9 cm. On the left side, a mean of 1.77 cm (range: 1.5–2.1 cm) and a mode value of 1.7 cm were observed. Mean perforator artery diameters on the right and left sides were 2.2 mm and 2.4 mm, respectively.Conclusions:Though the internal mammary perforators are anatomically consistent, their use as recipients in free tissue transfer for breast reconstruction eventually rests on multiple variables.

Commentary on: Nipple-Sparing Mastectomy Through an Inframammary Fold Incision with Implant-Based Reconstruction in Patients with Prior Cosmetic Breast Surgery.

Nipple-sparing mastectomy (NSM), as the latest evolution of mastectomy technique, has proven to result in improved reconstructive and aesthetic outcomes in breast cancer care.1 Moreover, the oncologic safety of this approach in selected patients is now well-established.2 The procedure may be performed through a radial, transverse areolar, lateral, inferolateral, double concentric periareolar, vertical infraareolar, or inframammary incision . This procedure affords the possibility for immediate autologous reconstruction, reconstruction with a tissue expander and subsequent expander implant exchange, or the direct-to-implant method. Patient and technical risk factors that increase risk of complications, namely skin and nipple-areola complex ischemia and necrosis, have been described. Smoking, body mass index, breast size, and preoperative radiation are predictors of complications.1,3-8 An increased rate of nipple necrosis is associated with the periareolar/circumareolar and trans-areolar incision patterns compared with radial or inframammary approaches.1,3,9,10 A higher incidence of nipple necrosis is seen when the selected implant with its larger volume is placed at the time of mastectomy as opposed to the more conservative two-stage tissue expander-based reconstruction strategies.1,3,4 Reconstruction with autologous tissue rather than implant-based strategies may also confer protection from ischemic complications in terms of reconstruction failure.11 Prior breast surgery, with resultant scaring and disruption of native blood supply, has a clear potential to affect the complication profile of nipple-sparing mastectomy procedures and increase the risk of skin and nipple area complex ischemia and necrosis. Nipple-sparing results in a nipple-areola complex and skin envelope that is largely dependent on the sub-dermal plexus for vascularity, given that intercostal and internal mammary perforators are often likely to be disrupted.12 Augmentation …