Free tissue transfer has become an accepted and reliable method of breast reconstruction. In most cases, the internal mammary or thoracodorsal vessels are utilized as the standard recipient vessels. The authors reviewed their series of venous outflow alternatives in free breast reconstruction when the internal mammary and thoracododorsal veins were deemed inadequate or unusable.
A retrospective review of all free breast reconstructive procedures at the Mayo Clinic Scottsdale was performed from July 2003 through May 2005. The recipient vein chosen for venous anastomosis was recorded. Outcomes were measured with regard to reexploration, flap failure, and fat necrosis.
One hundred and thirteen free breast reconstructions were performed over a 2-year period (95 deep inferior epigastric perforator flaps, 13 superficial inferior epigastric artery flaps, 4 superior gluteal artery perforator flaps, 1 anterolateral thigh flap). The internal mammary vessels were considered the first choice for recipient vessels and were used in 104 cases. In four cases, the thoracodorsal vessels were used if an axillary dissection had been performed or the internal mammary vessels were unsuitable. In five cases, neither the internal mammary nor the thoracodorsal veins were suitable and alternative venous outflow options were used, all of which occurred on the left side. In these cases, the cephalic vein was used in four cases and the external jugular vein used once. Seven flaps required reexploration due to anastomotic complications (1 arterial thrombosis, 6 venous thromboses), all of which occurred in the left internal mammary group, and 3 flaps failed. Fat necrosis occurred in 12 cases. All cephalic and external jugular recipient veins remained patent with no flap failures or fat necrosis in this group. Two patients in the cephalic vein group had known preoperative lymphedema and were involved in a comprehensive lymphedema control program. Postoperatively, neither patient was noted to have any change in their circumferential arm measurements nor a change in their subjective lymphedema symptoms following cephalic vein transfer for free breast reconstruction.
The cephalic vein or external jugular vein can be considered an excellent alternative for venous outflow in free breast reconstruction if neither the internal mammary nor thoracodorsal veins are deemed adequate or usable. These should be considered as acceptable options especially in left-sided breast reconstructions where the internal mammary veins can be particularly tenuous.
