Perforator Flap Breast Reconstruction Using Internal Mammary Perforator Branches as a Recipient Site: An Anatomical and Clinical Analysis

Abstract

A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

“…Thus, alternatively free tissue transfer including the deep inferior epigastric perforator (DIEP), pedicled thoracodorsal perforator flap (TAP), free TRAM or the gluteal artery perforator (GAP) flaps can be indicated with a lower donor site morbidity. In fact, the DIEP flap diverges from abdominal myocutaneous flaps with maintenance of well-vascularized tissue and total abdominal muscular and aponeurotic layer preservation [89][90][91][92][93][94] . Mosahebi et al [83] in a series of 61 NSM reconstructions compared alloplastic and autologous tissue in terms of aesthetic outcome and satisfaction survey.…”

“…Thus, a correct selection of a suitable recipient pedicle is decisive for a successful outcome [90,[92][93][94] . In NSM, the use of internal thoracic recipient vessels can be troublesome since the surgical exposure is restricted [8,95] .…”

Internal mammary artery perforator (IMAP) flap for tracheostoma reconstruction

“…Munhoz et al 20 reported on an injection study in cadavers and a clinical assessment during breast reconstruction on the size, site, and consistency of the IMAP vessels. Those on the right chest were situated 13 mm (mean) and on the left, 14 mm, from the lateral border of the sternum, with a mean arterial diameter of 0.85 mm.…”

Um longo debate: albumina versus soro fisiológico

“…, realizaram uma outra metaanálise com 55 pesquisas avaliando 3.504 pacientes, concluindo que não foi observado nenhum efeito na mortalidade com a utilização da albumina e que os achados confirmavam a segurança do uso da albumina. A pesquisa SAFE é precursora de uma nova era em cuidados intensivos, caracterizada por um estudo randomizado, com uma grande população de pacientes e foi popularizada pelos especialistas em cardiologia 5 . Em termos práticos, a pesquisa conclui que a administração de albumina é segura e Panorama Internacional que os fatores que podem influenciar a escolha da ressuscitação fluídica para os pacientes criticamente enfermos incluem a preferência individual do clínico intensivista, tolerabilidade do tratamento, sua segurança e os custos, já que tanto a albumina quanto o soro fisiológico são clinicamente equivalentes para a ressuscitação do volume intravascular em uma população heterogênea de pacientes em UCI.…”

“…Em geral, por serem vasos de pequeno calibre, demanda paciência e aprimoramento técnico por parte do cirurgião. Detalhes anatômicos na distribuição dos vasos perfurantes na região do abdome 4 , bem como a qualidade dos vasos receptores para a realização das anastomoses na região torácica 5 , são também aspectos relevantes na opção por esta modalidade de reconstrução. Estes fatos constituem uma desvantagem em relação aos tradicionais retalhos pediculados, prejudicando assim a reprodutibilidade destes procedimentos.…”