Recipient Vessels In Breast Reconstruction Research Articles

Relationship between rib cartilage resection and postoperative chest recession deformity in breast reconstruction

The most versatile recipient vessels for breast reconstruction are the internal mammary artery and vein. For microvascular anastomosis, one or two costal cartilages are often dissected to increase the length of the vessel and the degree of freedom. In some cases, the resection of the rib cartilage causes long-term depression at the dissected site, compromising its cosmetic appearance. A total of 101 patients were examined, with 111 sides in which the internal mammary artery and vein were used as the recipient vessels. The patients were followed up for at least 6 months. A total of 37 of 38 patients with complete rib cartilage preservation had no depression, and 1 patient had a slight depression. In the case of partial resection of the rib cartilage, 37 of the 46 sides had no depression, 8 sides had mild depression, and 1 side had an obvious depression. When more than one rib cartilage was removed, 11 of the 27 sides had no depression, 11 had mild depression, and 5 had an obvious depression. The Spearman rank correlation coefficient was 0.4911936. This study reported the relationship between rib cartilage resection and postoperative concave deformity in breast reconstruction surgery using free flap transfer and the internal mammary artery and vein as the recipient vessels. A strong correlation was found between the extent of rib cartilage resected and the degree of depression. Minimizing rib cartilage resection when using the internal mammary artery and veins may minimize postoperative chest recession deformity and provide a well-dressed breast reconstruction.

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.

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.

Revisiting the internal mammaries as recipient vessels in breast reconstruction: considerations in current practice.

The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future. The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009-2011, 2011-2013, 2014-2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology's atheroscletoric and cardiovascular disease (ASCVD) risk calculator. There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009-2011, n = 55; 2012-2014, n = 50; 2015-2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009-2011 = 32.7%, 2012-2014 = 28.0%, 2015-2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009-2011 = 25.5%, 2012-2014 = 20.0%, 2015-2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups. Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.

Studying the blood pressures of antegrade and retrograde internal mammary vessels: Do they really work as recipient vessels?

The proximal ends of internal mammary (IM) vessels are now the most common recipient vessels for breast reconstruction. On the other hand, bilateral deep inferior epigastric artery perforator (DIEP) flaps are often needed according to the territory and the volume required for reconstruction. The usefulness of retrograde IM vessels as second recipients has recently been reported, but there are very few quantitative studies on the hydrodynamics of the retrograde IM vessels. Because the flow is dependent on the pressure differential, the blood pressures of the antegrade IM artery (AIMA), antegrade IM vein (AIMV), retrograde IM artery (RIMA), retrograde IM vein (RIMV), and recirculated intraflap vein (FV) were investigated to solve this question and to confirm the reliability and usefulness of the retrograde IM vessels. Ten free flap breast reconstructions were included in this study. The IM vessels were exposed, and the pressures were measured. After recirculation, the FV pressures were measured when the flap was not ischemic or congestive. Systemic blood pressure was also recorded during the whole measurement period. The AIMA and RIMA pressures were 70.4±8.2mmHg and 54.0±8.6mmHg (p=0.000003), respectively, while the systemic pressure was 65.1±10.0mmHg. The AIMV pressure was always smaller than the RIMV pressure; the mean AIMV pressure was 5.3±1.6mmHg. In addition, the FV pressure was greater (p=0.03) than the RIMV pressure (17.7±9.9mmHg), while the RIMV pressure was 8.7±2.0mmHg. Both the RIMA and RIMV are useful and reliable as second recipients for bipedicled free flap transfers. This is a great benefit because it would provide two recipients in one surgical site and would be especially useful in thin patients or patients with previous abdominal scars requiring double pedicled DIEP flaps. Therapeutic Study, Level IV.

The Lateral Thoracic Vessels: A Useful Recipient in Immediate Breast Reconstruction

Background Appropriate recipient vessel selection is a crucial aspect of microsurgical reconstruction. The chest wall presents several options for microvascular anastomosis, the most popular being the internal mammary and thoracodorsal vessels, although they may not always be available or suitable for breast reconstruction. We propose that the lateral thoracic vessels are a useful alternative, given their central position and intraoperative exposure in a skin-sparing mastectomy. Methods and Results We have performed four abdominal flaps based on the deep inferior epigastric artery and lateral thoracic vessels as the recipient vessels. The average diameter of the lateral thoracic artery was 2 mm and the vein was 2.75 mm. There were no vessel conversions, flap failures, or complications. Excellent aesthetic results were achieved. The anatomy of the lateral thoracic artery is described. Conclusion The lateral thoracic vessels are advantageous and safe recipient vessels. Their consistent anatomy, central location, and intraoperative exposure make them useful recipient vessels in breast reconstruction.

A Clinical Anatomic Study of Internal Mammary Perforators as Recipient Vessels for Breast Reconstruction

BackgroundPartially resecting ribs of the recipient site to facilitate easy anastomosis of the internal mammary vessels to free flaps during breast reconstruction can cause chest wall pain or deformities. To avoid this, the intercostal perforating branches of the internal mammary vessels can be used for anastomosis. The purpose of this study was to investigate the location and size of the internal mammary perforator vessels based on clinical intraoperative findings and to determine their reliability as recipient vessels for breast reconstruction with microsurgical free tissue transfer.MethodsTwelve patients were preoperatively screened for the presence of internal mammary perforators using Doppler tracing. After modified radical mastectomy was performed by a general surgeon, the location and size of the internal mammary perforator vessels were microscopically investigated. The external diameter was examined using a vessel-measuring gauge from a mechanical coupling device, and the distance from the mid-sternal line to the perforator was also measured.ResultsThe largest arterial perforator averaged 1.5 mm, and the largest venous perforator averaged 2.2 mm. Perforators emerging from the second intercostal space had the largest average external diameter; the second intercostal space also had the largest number of perforators arising from it. The average distance from the mid-sternal line to the perforator was 20.2 mm.ConclusionsInternal mammary perforators presented consistent and reliable anatomy in this study. Based on these results, the internal mammary perforators appear to have a suitable diameter for microvascular anastomosis and should be considered as an alternative recipient vessel to the internal mammary vessel.

Escolha do vaso receptor em reconstrução de mama microcirúrgica

INTRODUCAO: A transferencia microvascular de tecido autogeno se tornou o padrao de referencia para a reconstrucao da mama. Como em qualquer reconstrucao com tecido livre, a escolha do vaso receptor e fundamental para o planejamento adequado na reconstrucao mamaria. O objetivo do presente estudo e determinar quais dentre os vasos receptores disponiveis (a arteria mamaria interna e seus vasos perfurantes ou os vasos circunflexos escapulares) sao mais adequados para a reconstrucao microvascular da mama. METODO: Foi realizada analise retrospectiva de 117 pacientes consecutivas submetidas a reconstrucao da mama microvascular, entre janeiro de 2005 e dezembro de 2007. Foi estabelecido um algoritmo que pode ser aplicado para a selecao do vaso receptor com base em alguns parâmetros, como disseccao axilar, tempo da reconstrucao (imediata ou tardia) e presenca de radioterapia pre-operatoria. Foram avaliadas as complicacoes relacionadas ao retalho, a taxa de conversao e os resultados clinicos. RESULTADOS: A arteria mamaria interna e seus vasos perfurantes e os vasos circunflexos escapulares sao adequados para a reconstrucao da mama, com taxas semelhantes de complicacoes e de viabilidade. Observou-se, tambem, maior risco de perda do retalho com o uso do retalho da arteria epigastrica inferior superficial em comparacao ao retalho da arteria epigastrica inferior profunda ou retalho musculocutâneo abdominal transverso de musculo reto do abdome com preservacao do musculo. CONCLUSOES: A reconstrucao mamaria microcirurgica e um metodo seguro e confiavel, com alta viabilidade do retalho e baixas taxas de complicacao.

Short-Term Effects of Radiotherapy Postquadrantectomy on Internal Mammary Artery and Vein

When a tumor local recurrence occurs a possible approach can be a mastectomy with simultaneous breast reconstruction with autologous tissue. The area involved by tangential radiation portals includes also the internal mammary artery and veins, considered by the most part of plastic surgeons to be the best recipient vessels for a free flap in breast reconstruction. Internal mammary vessels receives low but not necessary insignificant doses during whole breast irradiation; arteries and veins are traditionally considered quietly resistant to the irradiation but limited data on the flux in mammary vessels after radiotherapy are available. The goal of our study (37 patients from September 2011 to February 2012) was to evaluate modifications in vascular parameters of the flux at ultrasonography in the internal mammary chain after adjuvant radiotherapy that could influence the choice of the autologous surgical technique (free or pedicled flap) and the choice of the recipient vessels in breast reconstruction. Based on the results of our study, we would recommend avoiding an irradiated recipient site when no irradiated recipient vessels are available; a preoperative ultrasound evaluation is recommended in patients underwent whole breast irradiation.

Does Previous Chest Wall Irradiation Increase Vascular Complications in Free Autologous Breast Reconstruction?

Prior radiation therapy to the chest, in theory, has a detrimental impact on the recipient vessels in breast reconstruction and may impact microvascular success. The purpose of this study was to determine whether prereconstruction radiation therapy affects the rate of vascular complications in free flap breast reconstruction. This was a retrospective review of free flap breast reconstruction performed between 2005 and 2009 by the senior authors. In addition to medical and surgical history, vascular complications were recorded, including intraoperative and postoperative thromboses and technical difficulties resulting in a variation of the standard approach. In total, 226 flaps were placed into an irradiated field, whereas 799 were transposed into a radiation-naive defect. Vascular complications as a whole were more prevalent in the irradiated group (9.6 percent versus 17.3 percent; p = 0.001). In regression modeling, radiation therapy was identified as an independent risk factor (odds ratio, 1.68; 95 percent confidence interval, 1.04 to 2.70). In subanalysis, there is a significantly higher rate of intraoperative vascular complications (7.6 percent versus 14.2 percent; p = 0.003), although individual outcomes did not reach formal significance. Previous irradiation had no effect on delayed vascular complications, flap loss, fat necrosis, infection, skin flap necrosis, hematoma, seroma, or delayed wound healing. Prereconstruction radiation therapy increases the rate of vascular complications in free flap breast reconstruction, the majority of which appear intraoperatively. Although radiation does not hinder the overall success of reconstruction or contribute to postoperative complications, surgeons should be aware that working in a previously irradiated field carries additional technical risk.

Internal Mammary Intercostal Perforators instead of the True Internal Mammary Vessels as the Recipient Vessels for Breast Reconstruction

Free tissue transfer has become a mainstay in breast reconstruction, with the internal mammary system frequently used as the recipient vessels. Sacrificing the internal mammary artery, however, eliminates the potential to use this vessel as a coronary artery bypass conduit in the future and potentially increases recipient-site morbidity. The authors' goal was to evaluate the learning curve and effectiveness of their use of the internal mammary intercostal perforators for microsurgical breast reconstruction. The authors reviewed one surgeon's consecutive series of 100 abdominal adipocutaneous perforator flap breast reconstructions (72 patients) from July of 2005 through January of 2007. The internal mammary perforators were used as recipient vessels in 23 flaps, the traditional internal mammary vessels were used in 66, and the thoracodorsal vessels were used in 11. To see if there was a learning curve, flaps were analyzed in five consecutive cohorts of 20. A learning curve was shown: internal mammary perforators were used in 5 percent of the first cohort and 45 percent of flaps in the final cohort. Flap survival was 99 percent; the one failure occurred in a traditional internal mammary flap reconstruction. Small palpable areas of fat necrosis were observed in one internal mammary perforator flap (4.3 percent) and in five traditional internal mammary or thoracodorsal flaps (6.5 percent). In all the authors' cohorts, internal mammary perforator vessels were used safely without increasing the incidence of flap failure or fat necrosis seen with the traditional approach. The learning curve for this technique resulted in increased use of these internal mammary perforators, indicating that operator experience is critical.

Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Use of internal mammary perforator recipient vessels may decrease recipient-site morbidity in free flap breast reconstruction. However, it is not known whether they are as reliable as the internal mammary vessels or whether their use would result in increased recipient-site complications. A retrospective study of all 686 lower abdominal free flap breast reconstructions performed during a 4-year period at the authors' institution identified 38 cases in which internal mammary perforator vessels were used. A subset of 114 of the 686 cases was studied in which patients were treated by a single surgeon, internal mammary perforator vessel use was attempted, and vessel measurements were taken intraoperatively. Internal mammary perforator recipient vessels were used in 27 percent of cases attempted, 94 percent of which were located at the second or third intercostal space. Internal mammary perforator arteries were significantly smaller in diameter (1.9 mm) than internal mammary arteries (2.6 mm) (p < 0.0001). Despite this, the incidences of flap loss, fat necrosis, and mastectomy skin flap necrosis were not significantly different between the internal mammary and internal mammary perforator vessel groups. The internal mammary and internal mammary perforator veins were similar in diameter. To the authors' knowledge, this is the largest published series of internal mammary perforator vessels used as free flap recipient vessels. In selected cases, internal mammary perforator vessels can be used without increasing the risk of flap loss, fat necrosis, or mastectomy skin flap necrosis, and are equally reliable and require less invasive surgical dissection than internal mammary vessels. The use of internal mammary perforator vessels may safely minimize recipient-site morbidity.

Internal Mammary Perforator Recipient Vessels in Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Internal Mammary Perforator Recipient Vessels in Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Histopathological Damage of Internal Mammary Vessels Used as Recipient Vessels in Breast Reconstruction

Microsurgical techniques have greatly expanded the scope and quality of reconstructive breast surgery. Currently, free DIEAP (deep inferior epigastric artery perforator), SGAP (superior gluteal artery perforator), and SIEA (superficial inferior epigastric artery) flaps are used on a routine basis in the authors' department. The internal mammary vessels are the first choice recipient vessels, and their use as recipient vessels for free-flap breast reconstruction has been well-established. The authors' aim was to study the histopathology of donor and recipient vessels used in free-flap breast reconstruction, and to correlate the results with possible preoperative risk factors such as radiation therapy and chemotherapy.

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

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.

Anatomy of the internal mammary veins and their use in free TRAM flap breast reconstruction

The anatomy of 61 internal mammary veins (IMV) in the 3rd, 4th and 5th intercostal spaces was studied in 34 fresh human cadavers by injection and corrosion methods and surgical dissection. The IMV was present in all 34 cadavers. Four different patterns of venous anatomy were identified: Types 1 (69%) and 2 (26%) were common, Types 3 (3 %) and 4 (2 %) were rare. The most common arrangement (Type 1) consists of the internal mammary vein running medial and parallel to the artery to the 4th intercostal space where it divides into the medial and the lateral IMV, the lateral crossing the internal mammary artery (IMA) anterior to it in direction from medial to lateral. Both veins are connected by interconnecting branches. The mean diameter of internal mammary veins is 2.7 mm (range 1.1–4.8 mm) for the medial and 1.8 mm (range 0.5–3.5 mm) for the lateral one. The mean distance from the lateral border of the sternum of the medial vein is 9 mm (range 2–18 mm) and 14 mm (range 9–24 mm) for the lateral veih. We present a review of 7 patients in whom internal mammary vessels were used as recipient vessels for breast reconstruction with free TRAM flaps with no complications, as well as the advantages and disadvantages of such a procedure.