An Appraisal of Internal Mammary Artery Perforators as Recipient Vessels in Microvascular Breast Reconstruction—An Analysis of 515 Consecutive Cases

Abstract

Background:The usage of internal mammary artery perforators (IMAPs) has been described in autologous breast reconstruction although IMAPS are not yet considered standard recipient vessels. It remains unclear if these vessels can be safely used in large flaps after radiation therapy or in delayed breast reconstruction.Methods:Over a 2-year period, 515 free flaps for autologous breast reconstruction were performed on 419 patients by 2 surgeons (S1 and S2). In a retrospective analysis, time of reconstruction, ischemia time, flap weight, diameter of couplers, and complications were analyzed. All 515 flaps were compared in a subset with regard to the 2 surgeons: S1 who always used the IMA as a recipient vessel and S2 who attempted IMAP use if possible.Results:Of all 515 flaps, 424 were abdominal flaps and 91 flaps were from the upper thigh. Three hundred six cases were immediate reconstructions, and 112 were delayed reconstructions. In 97 cases, implants were converted to autologous tissue. In 112 cases, the IMAPs were used; of these, 82 were immediate and 17 were delayed reconstructions, and in 13 cases, implants were removed. Thirty-five percent of all anastomoses to IMAPs had previous radiation therapy. The flap failure rate was 1.9%. In none of these cases, the IMAPs were used. S1 never used the IMAP, and S2 used the IMAP in 37% of all of his flaps.Conclusions:IMAPs were safely used in all kinds of reconstructions and after radiation therapy, with no flap failure or negative effects on mastectomy skin flap perfusion. Using the IMAPs as recipient vessels is a further step toward simplifying microsurgical breast reconstruction.

Comparing the thoracodorsal and internal mammary vessels as recipients for microsurgical autologous breast reconstruction: A systematic review and meta‐analysis

“…It is worth mentioning that the IM artery perforators have been successfully used for breast reconstruction in several series (Follmar et al, 2011;Hamdi et al, 2004;Vollbach et al, 2016). The main goal of attempting this approach is lowering surgical morbidity.…”

“…The reported advantages appear to be sparing the IM vessels for cardiac surgeons and avoiding thoracic and abdominal morbidity (Hamdi et al, 2004;Vollbach et al, 2016). It was also hypothesized that this approach might lower operative time by limiting recipient vessels dissection procedure as well as the need for shorter flap pedicle (Hamdi et al, 2004;Vollbach et al, 2016). However, this option is limited by the technical difficulty and the potential lack of suitable perforators (Follmar et al, 2011;Hamdi et al, 2004;Vollbach et al, 2016).…”

Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients

“…IMA perforators, when preserved, are readily available, obviating the need for further surgical dissection and morbidity. Likewise, their more superficial entrenchment means less interference from cardiorespiratory chest‐wall motion and affords the use of shorter flap pedicles (Baek & Yoon, ; Follmar et al, ; Hamdi et al, ; Saint‐Cyr, Chang, et al, ; Vollbach et al, ).…”

“…The next evolution, the rib sparing approach to the internal mammary vessels, may not be possible in limited interspaces, still necessitating removal of cartilage (Sacks & Chang, ). With the development of microsurgical techniques, several authors have reported the successful use of perforating branches of the internal mammary artery (IMA) (Follmar et al, ; Hamdi, Blondeel, Van Landuyt, & Monstrey, ; Munhoz et al, ; Saint‐Cyr, Chang, Robb, & Chevray, ; Vollbach, Heitmann, & Fansa, ). Perforator to perforator surgery limits the amount of dissection necessary, and obviates the need for rib removal and sacrifice of the IMA for future revascularization procedures (Follmar et al, ; Koshima, Yamamoto, Narushima, Mihara, & Iida, ).…”

“…In the absence of clear anatomical understanding, the use of IMA perforators in microsurgical breast reconstruction can be elusive and coincidental. As a result, a wide range of utilization rates exists in the literature, ranging from 9–45% (Follmar et al, ; Hamdi et al, ; Haywood et al, ; Munhoz et al, ; Saint‐Cyr, Chang, et al, ; Vollbach et al, ). Herein, we intend to evaluate the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume.…”