Is There a Need for Preoperative Imaging of the Internal Mammary Recipient Site for Autologous Breast Reconstruction?

Abstract

Preoperative imaging of recipient-site vasculatur in autologous breast reconstruction may potentiate improved outcomes through the identification of individual variations in vascular architecture. There are a range of both normal and pathologic states which can substantially affect the internal mammary vessels in particular, and the identification of these preoperatively may significantly affect operative approach. There are a range of imaging modalities available, with ultrasound particularly useful, and computed tomography angiography (CTA) evolving as a useful option, albeit with radiation exposure. The benefits of CTA must be balanced against its risks, which include contrast nephrotoxicity and allergic reactions, and radiation exposure. The radiation risk with thoracic imaging is substantially higher than that for donor sites, such as the abdominal wall, with reasons including exposure of the contralateral breast to radiation (with a risk of contralateral breast cancer in this population 2 to 6 times higher than that of primary breast cancer, reaching a 20-year incidence of 15%), as well as proximity to the thyroid gland. Current evidence suggests that although many cases may not warrant such imaging because of risk, the benefits of preoperative CTA in selected patients may outweigh the risks of exposure, prompting an individualized approach.

The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure

“…Chest X‐rays cannot accurately and reliably be used to measure the ICD as it would lead to variability according to the magnification of the X‐ray, the position of the patient and the precise angle at which the X‐ray is taken. CT scanning carries the risk of allergic reactions to the contrast medium, nephrotoxicity from contrast, and radiation exposure which is higher for the recipient site (thorax) than for the donor site (abdomen) including exposure of the contralateral breast and thyroid to radiation . Although Tuinder et al suggest using MRI to image the recipient site when it is already being performed for staging of breast cancer, this still involves the use of a contrast medium.…”

“…CT scanning carries the risk of allergic reactions to the contrast medium, nephrotoxicity from contrast, and radiation exposure which is higher for the recipient site (thorax) than for the donor site (abdomen) including exposure of the contralateral breast and thyroid to radiation. 29 Although Tuinder et al 23 suggest using MRI to image the recipient site when it is already being performed for staging of breast cancer, this still involves the use of a contrast medium. Contrast-enhanced magnetic resonance angiography (MRA) has been reported as an alternative method of imaging the flap vessels, with better delineation of the perforator venous system, absence of ionising radiation, and a better side-effect profile of the contrast agents used compared to CT angiography.…”

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

“…The customary choice has been ultrasonography, given its ease and noninvasiveness; and ultrasonography has merit in assessing vessel caliber or differentiating between arteries and veins (Han, Yoon, & Park, ). CTA has the resolution of angiography and is particularly useful in perforator identification with high sensitivity and specificity (Han et al, ; Rozen, Alonso‐Burgos, Murray, & Whitaker, ). It is a widely used, noninvasive imaging technique for mapping the vascular supply to body regions, and can provide detailed knowledge of arterial and venous architecture, including vessel origin, caliber, course, length, and branching patterns (Bluemke & Chambers, ).…”

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

“…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.…”