Breast reconstruction with free lower abdominal flaps has evolved from TRAM flaps to DIEP flaps and finally to SIEA flaps with the goal of decreasing donor-site morbidity. The SIEA flap has probably minimized donor-site morbidity. Therefore, these authors and others have turned attention to minimizing recipient-site morbidity. Recent reports have shown that internal mammary (IM) perforator vessels can be used as recipient vessels. This presentation reported the largest published series of IM perforator vessels used as free flap recipient vessels. Their reliability was demonstrated, as well as their use with TRAM, DIEP, and SIEA flaps.
A retrospective review of all 686 lower abdominal free flap breast reconstructions performed between April 2001 and June 2005 at the authors' institution revealed 38 cases in which internal mammary perforator recipient vessels were used. All IM perforator vessels used were at the second or third intercostal spaces, were identified superficial to the pectoralis major muscle, and had external diameters of 1.3 mm or greater.
Internal mammary perforator recipient vessels were used in 38 cases. Breast reconstructions were immediate in 76% (29/38) of cases, and delayed in 24% (9/38) of cases. Unilateral and bilateral breast reconstructions comprised 63% and 37% of the cases, respectively. Donor sites included 24% free TRAM, 32% muscle-sparing free TRAM, 26% DIEP, and 18% SIEA flaps. The third intercostal space was used in 97% of cases. The mean external diameter of the internal mammary perforator arteries and veins was 1.9 mm and 3.0 mm, respectively. The mean IM perforator artery and vein diameters were larger on the right side than the left side. There were two arterial thromboses and one venous thrombosis. Flap survival was 97%. Other complications included fat necrosis in 8% of cases, and partial mastectomy skin flap necrosis in 16% of cases. The IM perforator vessels were used as alternate recipient vessels in two cases in which the thoracodorsal and internal mammary vessels were deemed not suitable.
The authors presented the largest published series of IM perforator vessels used as free flap recipient vessels. They demonstrated that selected IM perforator vessels of sufficient caliber are a reliable and less invasive alternative to the IM vessels as recipients for lower abdominal free flap breast reconstruction. Furthermore, the IM perforators provide a better size match with the SIEA flap vessels. They believe that use of selected IM perforator vessels can decrease operative time and recipient-site morbidity.
