Free flap survival despite early loss of the vascular pedicle

In Search of Optimal Practice: A Retrospective Comparative Study of Single- Versus Dual-Venous Anastomosis in Microvascular Flaps

Background In the current era of reconstructive surgery, microvascular free flap transfers are the most popular reconstructive procedures performed. The main reason for the failure of the flap and re-exploration is venous thrombosis. Traditionally, most surgeons prefer performing two-vein anastomoses. There is insufficient literature to support that dual-venous anastomosis is better than single-venous anastomosis. In this study, we compared the success rate of single-venous anastomosis with dual-venous anastomosis of different free flap reconstructions. Methodology The retrospective cohort study was conducted with a total of 101 patients. Eighty-three were in the one-vein group, and the remaining 18 were in the two-vein group. Outcomes were compared between the two groups regarding re-exploration and flap failure. Results The overall success rate of free flap reconstruction was 96%. Among the 101 free flaps, 16 flaps had signs of venous compromise and were re-explored. Out of the 16 flaps, 11 flaps (13.2%) were in the one-vein group, and 5 flaps (27.7%) were in the two-vein group. In the two-vein group, 100% of the flaps were salvaged, and in the one-vein group, only 63% of the flaps were salvaged after re-exploration. There was no statistically significant difference between the one-vein group and the two-vein group concerning re-exploration.  Conclusions The rate of re-exploration was lower in the one-vein group when compared to the two-vein group. However, this difference was not statistically significant. Hence, a single-vein anastomosis is sufficient for a successful microvascular free flap. However, the rate of flap salvage is better with two-vein anastomosis if there is venous congestion.

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

Autonomization is a physiological process allowing a flap to develop neo-vascularization from the reconstructed wound bed. This phenomenon has been used since the early application of flap surgeries but still remains poorly understood. Reconstructive strategies have greatly evolved since, and fasciocutaneous flaps have progressively replaced muscle-based reconstructions, ensuring better functional outcomes with great reliability. However, plastic surgeons still encounter challenges in complex cases where conventional flap reconstruction reaches its limitations. Furthermore, emerging bioengineering applications, such as decellularized scaffolds allowing a complex extracellular matrix to be repopulated with autologous cells, also face the complexity of revascularization. The objective of this article is to gather evidence of autonomization phenomena. A systematic review of flap autonomization is then performed to document the minimum delay allowing this process. Finally, past and potential applications in bio- and tissue-engineering approaches are discussed, highlighting the potential for in vivo revascularization of acellular scaffolds.

Recipient bed perfusion as a predictor for postoperative complications in irradiated patients with microvascular free tissue transfer of the head and neck area: a clinical analysis of 191 microvascular free flaps

PURPOSE

Despite microvascular free tissue transfer being the mainstay of care in the reconstruction of larger maxillofacial defects, a significant number of patients experience postoperative complications due to impaired blood supply of the flap. In this context, the early influence of recipient bed perfusion remains unclear, but there is evidence that it is associated with free flap viability immediately after surgery.

METHODS

We analyzed flap and recipient bed perfusion within the first 2 weeks after surgery by using the oxygen-to-see device. One hundred ninety-one patients who underwent free flap surgery in our department were included.

RESULTS

Flow parameters were higher and postoperative complications were less frequent in radial forearm free flaps compared to any other type of flap. Flow parameters of the recipient bed were higher than transferred tissue at all times, implicating flap autonomization is not completed within 2 weeks. Previous radiotherapy significantly decreased flow parameters of the recipient bed but not of the flaps. Furthermore, irradiated patients with postoperative complications were found to have reduced flow parameters of their recipient bed compared to non-irradiated patients with postoperative complications.

CONCLUSION

We conclude that monitoring of recipient bed perfusion is useful for detecting flap compromise of irradiated patients in the early postoperative period.

Long-term survival of implant-based oral rehabilitation following maxillofacial reconstruction with vascularized bone flap

Aim

The aim of the study was to assess the 5-year cumulative survival rate of implant-based dental rehabilitation following maxillofacial reconstruction with a vascularized bone flap and to investigate the potential risk factors which might influence the survival rate.

Materials and methods

A retrospective cohort study was designed. Inclusion criteria involved 18 years old or above patients with the availability of clinical and radiological data and a minimum follow-up 1 year following implant placement. The cumulative survival rate was analyzed by Kaplan–Meier curves and the influential risk factors were assessed using univariate log-rank tests and multivariable Cox-regression analysis.

Results

151 implants were assessed in 40 patients with a mean age of 56.43 ± 15.28 years at the time of implantation. The mean number of implants placed per patient was 3.8 ± 1.3 with a follow-up period of 50.0 ± 32.0 months. The cumulative survival at 1-, 2- and 5-years was 96%, 87%, and 81%. Patients with systemic diseases (HR = 3.75, 95% CI 1.65–8.52; p = 0.002), irradiated flap (HR = 2.27, 95% CI 1.00–5.17; p = 0.05) and poor oral hygiene (HR = 11.67; 95% CI 4.56–29.88; p < 0.0001) were at a significantly higher risk of implant failure.

Conclusion

The cumulative implant survival rate was highest at 1st year followed by 2nd and 5th year, indicating that the risk of implant failure increased over time. Risk indicators that seem to be detrimental to long-term survival include poor oral hygiene, irradiated flap and systemic diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40729-022-00413-7.

Fibula Free Flap Reconstruction of the Maxilla Leading to Extracapsular Ankylosis of the Mandible

After en bloc resection of the maxilla or mandible, surgeons may choose to replace the missing bone and soft tissue with a fibula free flap (FFF). One of the complications that may arise during the healing of an FFF is heterotopic ossification along the free flap pedicle. Heterotopic ossification is most often noted incidentally on postoperative radiographs and rarely creates a functional deficit. Subperiosteal dissection of the pedicle from the bone during the harvest of the FFF is believed to be the main contributing factor that leads to this formation of bone along the flap soft tissue. Pain or limitation of movement of the jaws, depending on where heterotopic bone forms are related functional issues. Changes in facial appearance due to expansion related to this phenomenon of bone deposition may also occur. This paper presents a patient that developed a functional deficit secondary to heterotopic ossification of an FFF that required surgical intervention. The goal of our surgery is to maintain the blood supply to a vascularized flap while removing the heterotopic bone. We will present the unique aspects of planning this challenging surgery: CASE: A 40-year-old man with a history of right posterior maxillary ameloblastoma underwent a hemi-maxillectomy with FFF reconstruction. The patient developed extracapsular heterotopic bone ankylosis beginning 2 months postoperatively developing severe trismus and required surgical intervention. Radiographic imaging revealed extensive heterotopic ossification of the vascular pedicle that extended from the most proximal positioned end of the fibula to the inferior lateral border of the mandible. A radiographic computed tomography with contrast imaging revealed an intact vascular pedicle with surrounding heterotopic bone. Virtual planning and stereolithic modeling were utilized to plan the heterotopic bone removal. In the operating room, we removed the heterotopic bone in small segments according to the virtual plan to avoid injuring the vascular pedicle. A coronoidectomy was also performed to help gain more range of motion. An adipofascial flap using the buccal fat pad was raised into the area of defect to prevent future recurrence. The patient was put on a strict physical therapy regimen to help regain his range of motion. CONCLUSION: Heterotopic ossifications along free flap pedicles are a known complication of the FFF. A conservative management approach should be used since most postoperative patients will be asymptomatic and findings are incidental on postoperative imaging. Surgery should be reserved for symptomatic patients. Heterotopic ossification needs to be considered as a differential in a microvascular reconstruction postoperative patient when the patient presents with a slow onset of facial swelling, neck mass, or trismus. Virtual planning is an essential tool in the surgeon's planning armamentarium dependent on the timing of the procedure so that the vascular integrity of the flap can be protected after the initial anastomosis.

Autonomization of pectoralis major flap in head and neck surgery

The pectoralis major flap (PMF) is one of the most used pedicled flaps for reconstructive surgery in head and neck. Basing on previous studies observing that a vascular accident or pedicle ligation not always resulted in necrosis of free flaps, sometimes after a short critical period, we describe the possibility to perform the division of the PMF pedicle. The autonomization of PMF is based on the hypothesis that the flap, after a critical period, develops a neoangiogenesis at the free portion in the recipient site. It represents a possible choice in selected patients with relapse or second tumour of the oral floor and/or mobile tongue, who have been already treated with PMF reconstruction. We provide a step-by-step description of the autonomization and use of the modified PMF. Moreover, we reported advantages and pitfalls. The modified PMF represents a safe reconstructive choice for patients advised against a free flap or a second pedicled flap, with good surgical outcomes.

Flap Failure and Salvage in Head and Neck Reconstruction

With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.

Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction

BACKGROUND

Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps.

METHODS

This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed.

RESULTS

Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants.

CONCLUSIONS

Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.

In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation

BACKGROUND

The vessel-depleted, irradiated, and frozen neck, as well as severe atherosclerosis of recipient vessels represent challenging problems in free flap transfer. Extracorporeal free flap perfusion theoretically allows free flap reconstructions in the absence of local donor vessels, but is associated with a number of technical issues. In this study, a novel technique is presented using a commercially available system for extracorporeal membrane oxygenation (ECMO), modified for small blood volumes.

METHODS

After preclinical testing, an ECMO system certified for lung support was used to establish blood flow through the flap's artery with oxygenation, decarboxylation and warming of diluted packed blood cells. Venous blood was allowed to flow passively into a separate container. Perfusion was performed for 15 min at intervals of 4 h over 4-6 days.

RESULTS

Five patients with soft tissue defects requiring free flap reconstruction were included. Either primarily thinned anterolateral thigh (ALT) flaps (n = 3) or radial forearm flaps (n = 2) were used. We observed infection of the perfusate, with consequent subtotal flap loss, in one patient, complete epithelial loss in two patients, venous congestion in one case, and almost uneventful healing in the fifth patient. With conservative wound care and a split thickness skin graft in one case, stable wound coverage was achieved in all patients except one, who had secondary healing. None of the patients required a second flap for sufficient coverage.

CONCLUSIONS

The technique described is associated with the risks of infection, flap congestion, nutritive hypoperfusion, and consequent tissue loss. Nevertheless, stable defect closure seems to be achievable even in patients with depleted recipient vessels.

Late free flap failure in head and neck reconstruction: A systematic review

Our objectives were to review all reported cases of late flap failure in head and neck surgery and describe any relevant patterns. We conducted a systematic review of all published cases of free flap failure after postoperative day 7 in head and neck surgery from January 1990 to January 2018. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. A total of 45 cases of late free flap failure in the head and neck were identified. Among the 34 cases in which the necessary data were available for analysis, 50% of late failures occurred between postoperative day 7 and 14. Common reasons for failure were abscess and vascular compromise. We conclude that most late flap failures occur in the second postoperative week. In patients with risk factors for flap failure, close monitoring for up to 14 days after surgery could detect flap compromise before the flap is lost.

Flap-Mastopexy in Autologous Breast Reconstruction: Timing and Technique

BACKGROUND

Techniques in breast reconstruction have significantly advanced the possibility to create more natural and aesthetically appealing breasts. Despite thorough preoperative planning and vigilant operative technique, symmetry remains a concern for select patients who have undergone autologous breast reconstruction. Although symmetry procedures of the contralateral breast have been well described in the literature, little has been published regarding secondary revision in the autologous reconstructed breast, leaving uncertainty as to the appropriate timing and technique for revision procedures that will not hinder the viability of the flap. In this article, we provide an effective, reproducible and safe method of mastopexy after autologous breast reconstruction.

METHODS

A retrospective review of all patients undergoing autologous breast reconstruction by a single surgeon between 2007 and 2014 was performed. Patients who underwent mastopexy after autologous breast reconstruction were included. Patient characteristics, type of reconstruction, staging of procedures, secondary operations, and complications were recorded.

RESULTS

Ten patients with asymmetric autologous breast reconstruction underwent flap mastopexy in 1 or both breasts. Indications for mastopexy included asymmetry resulting from immediate loss of autologous flaps, unilateral fat necrosis, scarring after mastectomy flap necrosis, excess ptosis, and volume asymmetries. No flap loss, fat necrosis, or nipple loss occurred after flap mastopexy.

CONCLUSIONS

The autologous mastopexy technique is a useful option in secondary refinement procedures for breast reconstruction. It provides a reliable and predictable method to adjust the inframammary fold, increase projection, and address excess ptosis. It has a low complication rate and can be safely and reliably performed as early as 3 months after initial reconstruction.

Long-Term Patency of Twisted Vascular Pedicles in Perforator-Based Propeller Flaps

Background:

Propeller flaps require torsion of the vascular pedicle of up to 180 degrees. Contrary to free flaps, where the relevance of an intact vascular pedicle has been documented, little is known regarding twisted pedicles of propeller flaps. As secondary surgeries requiring undermining of the flap are common in the extremities, knowledge regarding the necessity to protect the pedicle is relevant. The aim of this study was a long-term evaluation of the patency of vascular pedicle of propeller flaps.

Methods:

In a retrospective clinical study, 22 patients who underwent soft-tissue reconstruction with a propeller flap were evaluated after 43 months. A Doppler probe was used to locate and evaluate the patency of the vascular pedicle of the flap.

Results:

The flaps were used in the lower extremity in 19 cases, on the trunk in 3 cases. All flaps had healed. In all patients, an intact vascular pedicle could be found. Flap size, source vessel, or infection could therefore not be linked to an increased risk of pedicle loss.

Conclusions:

The vascular pedicle of propeller flaps remains patent in the long term. This allows reelevation and undermining of the flap. We therefore recommend protecting the pedicle in all secondary cases to prevent later flap loss.

New aspects in free flap surgery: Mini-perforator flaps and extracorporeal flap perfusion

BACKGROUND

The scope of microvascular tissue transfer in the Head and Neck reaches from coverage of simple soft tissue defects to complex 3-D reconstructions using multiple or chimeric flaps. This paper summarises the presentation given at the Congress of the French Society of Oral and Maxillofacial Surgery in Marseille 2017. It was the aim of our work to add further elements to this wide spectrum of reconstructive possibilities.

METHODS

For patients with small intraoral soft tissue defects in whom the use of a radial forearm flap would not be justified because of its donor site morbidity, but who nevertheless would take a benefit from a small free flap, we used mini-perforator flaps from the lower leg. These flaps were raised with negligible morbidity. Moreover, for patients necessarily needing a free flap, but having vessel depleted, irradiated necks, we have developed a first idea of extracorporeal flap perfusion to make microvascular anastomoses unnecessary.

RESULTS

Using donor sites from the lower leg, mini-soleus and medial sural perforator flaps were raised to cover defects of 2×3 to 2×4cm at the anterior floor of the mouth or lateral tongue. The success rate was 91%, and despite their small size, the flaps helped to maintain the mobility of the tongue. The donor site morbidity was minimal. After extensive experimental work on small animals and human tissue, four flaps could successfully be transferred so far by means of extracorporeal perfusion. In these patients, autonomisation took place between 5 and 12 days.

CONCLUSIONS

Although microvascular tissue transfer already allows for reconstruction in almost any possible defect constellation, mini-perforator flaps and machine-perfused transplants seem to represent new aspects of free flap surgery, being useful extensions of the reconstructive surgeon's armament.

Generation, Endothelialization, and Microsurgical Suture Anastomosis of Strong 1-mm-Diameter Collagen Tubes

Tissue-engineered vascular grafts that are based on reconstituted extracellular matrices have been plagued by weak mechanical strength that prevents handling or anastomosis to native vessels. In this study, we devise a method for making dense, suturable collagen tubular constructs of diameter ≤1 mm for potential microsurgical applications, by dehydrating tubes of native rat tail type I collagen and crosslinking them with 20 mM genipin. Crosslinked dense collagen tubes with 1 mm inner diameter yielded ultimate tensile strength of 342 ± 15 gF and burst pressure of 1313 ± 156 mm Hg, comparable to the strength of a rat femoral artery, and supported endothelial cell adhesion and growth. End-to-end anastomosis of 0.5-mm-diameter tubes to explanted arteries displayed anastomotic strength of 82 ± 21 gF, which is sufficient for surgical applications. In vivo implantation of cell-free tubes as interpositional grafts in the rat femoral circulation yielded stable anastomosis with blood flow for 20 min. Seeded dense collagen tubes represent a promising alternative to venous graft that can potentially be used to bridge between short artery stubs in replantation surgeries.

Behavior of anastomozed vessels and transferred flaps after anastomosed site infection in head and neck microsurgical reconstruction

OBJECTIVE

This report evaluates the behavior of anastomosed vessels and transferred flaps after anastomosed site infection in head and neck reconstruction.

PATIENTS AND METHODS

Eleven free-flap cases after infection at the vascular pedicle site were included, the patency of which was observed macroscopically after re-exploration and pus drainage. Location was in the tongue (5 cases), oropharynx (3 cases), mouth floor (1 case), mandible (1 case), and hypopharynx (1 case). Transferred flaps originated from rectus abdominis (3 cases), anterolateral thigh (3 cases), radial forearm (3 cases), jejunum (1 case), and latissimus dorsi (1 case). Days for infection found were ranged 3-14 days postoperatively. Causes of infection were the salivary fistula formation in 5 cases, and precise etiology was not defined in the other 6 cases.

RESULTS

Disruption of the vascular pedicles occurred with high frequency after infection. Disruption of vein occurred most frequently (5 cases), followed by both artery and vein (2 cases) and artery only (1 case). Of the eight flaps, two flaps failed, but the other six flaps survived despite pedicle disruption, indicating overall survival of nine flaps after pedicle site infection. Five of the nine survived cases were healed with simple washing and ointment application. However, the other four patients, whose cause of infection was a salivary fistula, needed second flap transfer to treat those fistulas.

CONCLUSION

Disruption of anastomosed vessels can occur with high frequency after infection, causing subsequent flap loss. Therefore, surgeons need to deal with pedicle site infection to save the flap. © 2015 Wiley Periodicals, Inc. Microsurgery 36:658-663, 2016.

Single versus dual venous anastomoses of the free fibula osteocutaneous flap in mandibular reconstruction: a retrospective study

OBJECTIVE

The present study was to compare the success rates of single venous anastomosis with dual venous anastomoses of the free fibula osteocutaneous flap in mandibular reconstruction.

PATIENTS AND METHODS

Retrospective review of all cases of mandibular reconstruction using free fibula osteocutaneous flaps performed by a single surgeon in our department during the period January 2005 to April 2012. All the flaps were harvested and transplanted by the standard protocols. Microvascular anastomosis of either one or two veins was performed. In addition to routine clinical evaluation, the viability of the flap was evaluated by a portable Doppler at the tenth day after surgery.

RESULTS

Two hundred and one free fibula osteocutaneous flaps were performed during this time period. Single venous anastomosis was performed in 112 flaps and dual venous anastomoses were performed in 89 flaps. The overall incidence of vascular thrombosis was 3%, and the success rate of the transplantation was 98.5%. Six cases developed vascular thrombosis postoperatively. One was arterial thrombosis that occurred 12 hours after initial operation in the dual venous anastomoses group. Three venous thrombosis occurred 24 hr after the operation in the single venous anastomosis group. In dual venous anastomoses group, two venous thrombosis occurred 3-4 days after initial operation and attempt to salvage failed in both the cases. Fisher's exact test showed that there was no significant difference of the success rate between single and dual anastomoses groups (P = 0.59).

CONCLUSIONS

There is no difference in success rates between single venous anastomosis and dual venous anastomoses for mandibular reconstruction with free fibula osteocutaneous flap.

A review of devices used in the monitoring of microvascular free tissue transfers

The use of microvascular anastomoses to allow transfer of viable tissue is a fundamental technique of reconstructive surgery, and is used to treat a broad spectrum of clinical problems. The primary threat to this type of reconstructive surgery is anastomotic vascular thrombosis, which can lead to complete loss of tissue with potentially devastating consequences. Monitoring of tissue perfusion postoperatively is critical, since early recognition of vascular compromise and prompt surgical intervention is correlated with the ability for tissue salvage. Traditionally, physical examination was the primary means of monitoring, but possesses several limitations. Medical devices introduced for the purposes of flap monitoring address many of these deficiencies, and have greatly enhanced this critical aspect of the reconstructive surgery process.

Can internal thoracic arteries be used for both coronary artery bypass and breast reconstruction?

OBJECTIVES

Recently, the internal thoracic arteries have been preferentially used in autologous breast reconstruction at the levels of the third or fourth intercostal spaces. This may compromise future treatment of occult coronary disease. We hypothesized that internal thoracic artery length at the fourth intercostal space would allow both breast reconstruction and future coronary artery bypass grafting (CABG).

METHODS

Anatomic analysis of 20 female patients undergoing CABG was performed examining internal thoracic artery length from its origin to the third, fourth, fifth intercostal spaces and the left anterior descending (LAD) artery target.

RESULTS

The left internal thoracic artery was anastamosed to the LAD target at a mean length of 11.4 ± 1.4 cm. The mean lengths of the pedicled left internal thoracic artery from its origin to the third, fourth and fifth intercostal space were 8.5 ± 1.0, 10.9 ± 1.2 and 13.0 ± 1.4 cm, respectively. Therefore, the left internal thoracic artery length was adequate at the fourth intercostal space in 6 of 20 (30%) patients.

CONCLUSIONS

Dissection of the left internal thoracic artery to the fourth intercostal space would allow for concomitant use in CABG and breast reconstruction in one-third of cases. However, skeletonization of the internal thoracic artery at the level of the fourth intercostal space would be sufficient for CABG in all cases following autologous breast reconstruction.

Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE

To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps.

BACKGROUND

Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise.

METHODS

The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review.

RESULTS

Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces.

CONCLUSION

We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.