Salvage of SIEA flaps using the retrograde internal mammary system

Agarwal, Jayant P.; Ley, Eleazar; Tieman, B A Josh

doi:10.1002/micr.20791

Cited by 9 publications

(5 citation statements)

References 17 publications

(18 reference statements)

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“…The secondary flap artery was anastomosed to the retrograde IMA limb in 64% (16/25) of cases. This reflects the practical ease of a single recipient site and the well-documented adequate retrograde arterial flow ( 19 , 20 ).…”

Section: Discussionmentioning

confidence: 81%

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Malata

Rabey

2015

Front. Surg.

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IntroductionThe deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose.MethodsAll patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database.ResultsOf the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27–54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468–690 min). The median flap weight was 618 g (range = 432–1275 g) and the mastectomy weight was 445 g (range = 220–896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.ConclusionBipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.Levels of evidenceTherapeutic level IV.

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Section: Discussionmentioning

confidence: 81%

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Malata

Rabey

2015

Front. Surg.

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“…Another important point to consider in this analysis is the fact that flow dynamics in the flap and surrounding tissues changes over time. 12 Flow often increases in the immediate postoperative period when the patient's core temperature and blood pressure return to normal and vasospasm dissipates. Veins also dilate to varying degrees in response to the increased pressure and flow.…”

Section: Discussionmentioning

confidence: 98%

“…6,7 Very recently, several case series have shown that the retrograde limb of the internal mammary vein can be successfully utilized as an additional outflow tract in free flap transfer. [8][9][10][11][12] Although the presence of retrograde blood flow through the distal vein following microvascular anastomosis has been documented, it has neither been quantified nor compared with the antegrade vein. Quantitative analysis of flow through the retrograde internal mammary vein (RIMV) would help to determine its reliability as a recipient blood vessel when a secondary source of venous outflow is required to prevent flap venous congestion, or as a primary source of venous outflow when the antegrade internal mammary vein (AIMV) is not an option.…”

mentioning

confidence: 99%

Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction

et al. 2011

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“…5,7,26 Based on this evidence, the use of RIMV is empowered in clinical practice. [1][2][3]10 However, the use of RIMV during DIEP flap breast reconstruction was not solely used for primary flap drainage but was mostly used for super drainage purposes as a second vein. It is unknown whether RIMV as the sole venous drainage was sufficient.…”

Section: Discussionmentioning

confidence: 99%

Safety of Retrograde Flow of Internal Mammary Vein: Cadaveric Study and Anatomical Evidence

Nam

Hong

Kwon

et al. 2020

J Reconstr Microsurg

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Background Additional second vessels may be required to handle multiple flaps used to add breast volume, boost blood flow for supercharging, or use salvage recipient vessels. In these situations, retrograde internal mammary vessel flow can be used although this causes doubts and concerns. Patients and Methods Forty sides of the chests of 20 fresh cadavers with intact thoracic cages and internal mammary veins (IMV) were used in the study. IMV valve numbers and locations were checked, and the bifurcation was confirmed. A retrograde fluorescent angiography and a saline infusion test were followed to confirm flow direction. Results Twenty-eight vessels were identified in 40 sides of the chest; of them, 45% had no valves. A mean 0.7 valves per chest side were identified; 23 (82.1%) of 28 valves were located above the second intercostal space (ICS). A mean 1.76 communicating veins were found between the IMV bifurcation. In all cadavers, a crossing vein connecting the left and right medial IMV was confirmed just below the xiphoid process. Fluorescent angiography and a saline infusion test proved that the retrograde flow was caudal through the bifurcated IMV to the communicating, intercostal, and crossing veins. Conclusion The IMV valve was present in 55% of our subjects and located concentrically above the second ICS level. It is highly unlikely that the retrograde flow was disturbed because the retrograde anastomosis level was below the second ICS. Furthermore, the bifurcation, intercostal, and crossing veins across the xiphoid process enabled valve-less detour flow. Thus, retrograde IMV flow is considered safe.

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Salvage of SIEA flaps using the retrograde internal mammary system

Cited by 9 publications

References 17 publications

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction

Safety of Retrograde Flow of Internal Mammary Vein: Cadaveric Study and Anatomical Evidence

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