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

Abstract

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.

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

“…On the conservative side, one retrospective study only reported an incidence of 0.8% (n = 120:1) for the two conditions occurring in the same patient [9]. In contrast, others have suggested that the number needed to treat to save one IMA for CABG is 61:1 and that the average surgeon can be expected to preserve 12 IMAs during their career [10,13]. Yet another author reported 81 cases of Table 2 continued Vessel Advantages Disadvantages Internal mammary artery perforators Decreased operative time to expose IMAPs as compared with the IMA and thoracodorsal vessels [9].…”

“…Suitable IMAPs are not always present in the surgical field and are easily damaged during mastectomy depending on the level of institutional experience [9,13].…”

“…Bilateral procedures currently constitute around 10% of breast cancer operations and are becoming increasingly frequent with the greater use of BRCA gene testing and breast MRI [24][25][26][27][28][29]. Numerous studies have reported an increasing trend towards IMA-based breast reconstructions during the past 10-15 years (see Table 2) [13,14,[30][31][32][33].…”

“…Fortunately, they are amenable to surgical intervention in the forms of mastectomy with subsequent breast reconstruction and coronary artery bypass grafting (CABG). However, the optimal techniques for autologous breast reconstruction [1][2][3][4][5][6][7][8], the deep inferior epigastric artery perforator (DIEP) flap using the internal mammary artery as the recipient vessel and the IMA-based CABG, are mutually exclusive as they both require use of the IMAs as an arterial conduit [9][10][11][12][13][14][15]. In theory, this may preclude women with pre-existing DIEP reconstructions from receiving CABGs (with proven survival benefit) and women at increased risk of developing coronary artery disease from receiving what many surgeons consider to be the optimal autologous breast reconstruction post-mastectomy.…”

Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: Review of a single surgeon's early experience

“…[21][22][23] If these are less than 1.5 mm in diameter, the IMA and IMV are preferably dissected at the level of the third or fourth rib. The pectoralis major was split with electrocautery in the direction of its fibers; the costal cartilage was freed of its investing perichondrium and then resected using a rib cutter and/or rongeur, thus allowing access to the IMA and IMV.…”