Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: An anatomical and clinical analysis

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.