Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

Abstract

We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.

Unilateral Internal Mammary Recipient Vessels for Bilateral DIEP Flap Breast Reconstruction

“…Breast cancer and CAD remain 2 leading causes of morbidity and mortality in women. 15 In a recent study, breast cancer survivors had increased incidence of CAD with a hazards ratio of 1.27. 16 Studies also show that radiation can cause coronary stenosis in a dose-dependent relationship.…”

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review

“…Consideration of the availability of recipient site vasculature for flap‐based microsurgical chest wall reconstruction was essential. The most common first‐line recipient vessels in chest wall reconstruction are the IM and TD vessels, and while there is some contention in the literature as to the preferred option, both are widely utilized with success . These are generally well exposed during mastectomy or axillary dissection, and therefore require minimal surgical preparation time.…”

“…These are generally well exposed during mastectomy or axillary dissection, and therefore require minimal surgical preparation time. Their calibre provides a good match for donor vessels, which reduces the risk of anastomotic failure and poor flap perfusion resulting from inadequate arterial inflow or venous drainage of the flap . Using the IM vessels enables a more medially positioned flap and hence more satisfactory recreation of breast mounds than using the thoracodorsal vessel.…”

“…The main IM artery continues to travel inferiorly until it divides into musculophrenic and deep superior epigastric arteries. The IM artery is around 2 mm in diameter at the level of fourth costal cartilage and it usually accompanies 2 veins, up to 3 mm in diameter . The diameter IM perforators are usually between 0.5 and 1.2 mm with an accompanying vein about 1.5 − 3.2 mm in diameter, with higher perforators in higher intercostals spaces …”

The Role of Autologous Fat Grafting in Secondary Microsurgical Breast Reconstruction

“…19 Given that the flaps tend to settle in the lower pole of the breast, it is not surprising that most of our fat grafting occurred into the superior and superior-medial portions of the breast. 21 The fact that we encountered a higher rate of fat grafting in patients undergoing prophylactic mastectomy may be attributable to 2 reasons: First, although an optimal aesthetic result should be the goal of any reconstruction regardless of the indication, patients undergoing prophylactic mastectomy tend to strive for an even more complete rehabilitation and cosmesis, and are more willing to undergo additional surgery to achieve this goal. Although this fact may also be surgeon and technique related, we now, whenever possible, therefore avoid harvest of the ribs but only expose the interspace.…”