Exploring the myth of the valveless internal mammary vein – a cadaveric study

Open-Y technique for the internal mammary vein in the free abdominal flap of unilateral breast reconstruction

BACKGROUND

In microvascular breast reconstruction, the internal mammary vein (IMV) has emerged as the most common recipient vein. The open-Y technique can increase the vessel diameter via the bifurcation site. This study aimed to investigate the open-Y technique for IMV.

METHODS

The characteristics and details of the operative procedure in patients who had undergone unilateral breast reconstruction with and without the open-Y approach for the free abdominal flap were compared. Differences in IMV anastomosis site (the bifurcation of the main duct or that of the perforator branch) were also compared in patients with the open-Y technique. The open-Y technique was performed on the IMV side.

RESULTS

The open-Y and conventional groups included 127 and 62 patients, respectively. The main duct diameter of IMV was significantly smaller (median 2.5 vs. 3.0 mm, P < 0.001), and the rate of right-sided anastomosis (47.2 vs. 82.3%, P < 0.001) was significantly lower in the open-Y group. When comparing the main duct and perforator groups, the branch diameter (1.8 vs. 1.0 mm, P < 0.001) and the diameter after the open-Y technique (5.0 vs. 3.9 mm, P < 0.001) were significantly higher, and the angle of bifurcation (45° vs. 60°, P = 0.007) was significantly lower in the main duct group.

CONCLUSIONS

Given a small venous diameter, the open-Y technique is superior, especially for left-sided breast reconstruction. Owing to the lower angle of bifurcation and large diameter, the open-Y technique at the main duct bifurcation of IMV causes less turbulence in the blood flow.

TAKE HOME MESSAGE

The open-Y technique is especially effective for left-sided breast reconstruction. Considering the lower angle of bifurcation and large diameter, the open-Y technique at the main duct bifurcation of the internal mammary vein causes less turbulence in the blood flow.

Prophylactic Venous Supercharging in Deep Inferior Epigastric Artery Perforator Flap Surgery: A Retrospective Dual-Center Study

BACKGROUND

 Deep inferior epigastric artery perforator (DIEP) flap is nowadays considered the gold standard in breast reconstruction. However, venous congestion is still a leading cause of free flap failure. Despite the conspicuous articles regarding the use of a secondary venous anastomosis, there is a lack in the literature regarding the prophylactic use of a secondary venous route to reduce the incidence of complications during breast reconstruction.

METHODS

 A double-center retrospective study based on women undergoing DIEP breast reconstruction was conducted, dividing patients into case group (DIEP flaps with double venous anastomosis) and control group (DIEP flaps with single venous anastomosis). Demographic and surgical data and complications were compared and statistically analyzed, and a reconstructive algorithm was proposed to improve the flap insetting.

RESULTS

 In total, 154 patients were included in the study, divided into case group (74 patients) and control group (80 patients). The median age at the time of surgery was 49.09 years (range: 29-68 years), slightly lower in group 1 when compared with group 2. The mean body mass index (BMI) was 25.52 kg/m2 (range: 21.09-29.37 kg/m2), in particular 25.47 kg/m2 (range: 23.44-28.63 kg/m2) in group 1 and 25.58 kg/m2 (range: 21.09-29.37 kg/m2) in group 2. No statistical differences were found between groups in terms of BMI and smoking and comorbidities history. The average operative times were 272.16 minutes (range: 221-328 minutes) in group 1 and 272.34 minutes (range: 221-327 minutes) in group 2, with no significant difference between groups, as well as ischemia time (44.4 minutes in group 1 [range: 38-56 minutes] and 49.12 minutes in group 2 [range: 41-67 minutes]). Statistical analysis showed a reduction in short-term complications and a statistically significant reduction for take-backs in the two groups.

CONCLUSIONS

 Our study suggests that venous supercharging of DIEP flap by performing dual venous anastomosis can be routinely and safely done prophylactically, and thus not only after intraoperative assessment of venous congestion, to avoid flap venous congestion and decrease the rates of re-exploration.

Lower Leg Reconstruction With Free Tissue Transfer Using Reverse Flow Recipient Vein: A Case Report

Since the introduction of distally based flap, the concept of reverse flow flap was expanded to free tissue transfers. For recipient vessels, retrograde arterial inflow is considered a safe option for anastomosis. However, the reliability of a retrograde recipient vein remains controversial. This report presents a case of successful lower leg reconstruction with free flap using a retrograde recipient vein. A 43-year-old woman had a mass lesion in the lateral side of the right calf, which was diagnosed as a malignant granular cell tumor. During wide excision of the tumor, the anterior tibial artery (ATA) and veins were ligated and resected at the bifurcation point from the popliteal artery and veins because the tumor abutted on the ATA near the bifurcation. The skin defect measured 17 × 7 cm with the proximal part of the tibia and lateral condyle exposed. A 19 × 7.5 cm anterolateral thigh flap was elevated, and anastomoses were performed using the distal end of the ATA and anterior tibial vein as retrograde recipient vessels. The flap was well perfused, and no signs of venous insufficiency were observed. Complete survival with no postoperative complications was achieved. In free tissue transfers of the lower leg, retrograde venous flow can be considered as a recipient vein when an antegrade vein is not available or has risks of venous insufficiency.

Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery

Purpose

Internal thoracic veins are increasingly used as recipient’s vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins.

Methods

We evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made.

Results

Efficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez’s classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed.

Conclusion

Our study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.

[Application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect]

Objective

To investigate the application of anterior serratus branch of thoracodorsal vessel in repairing chest wall defect.

Methods

Between October 2018 and March 2021, bilateral free lower abdominal flaps were used to repair large-area complex defects after chest wall tumor surgery in 23 patients. The patients were all female; the age ranged from 23 to 71 years, with an average age of 48.5 years. There were 11 cases of locally advanced breast cancer, 4 cases of phyllodes cell sarcoma, 3 cases of soft tissue sarcoma, 3 cases of recurrence of breast cancer, and 2 case of osteoradionecrosis. The size of secondary chest wall defect after tumor resection and wound debridement ranged from 20 cm×10 cm to 38 cm×14 cm, the size of flap ranged from 25 cm×12 cm to 38 cm×15 cm, the length of vascular pedicle was 9-12 cm (mean, 11.4 cm). Fourteen cases of simple soft tissue defects were repaired by flap transplantation; 5 cases of rib defects (<3 ribs) and soft tissue defects were repaired by simple mesh combined with flap transplantation; and 4 cases of full-thickness chest wall defect with large-scale rib defect (>3 ribs) were repaired by "mesh plus bone cement" rigid internal fixation combined with flap transplantation. The anterior serratus branch of thoracodorsal vessel was selected as the recipient vessel in all cases, the revascularization methods include 3 types: the proximal end of the anterior serratus branch plus other recipient vessels (13 cases), proximal and distal ends of anterior serratus branch (6 cases), and proximal ends of two anterior serratus branches (4 cases).

Results

The main trunk of thoracodorsal vessels was preserved completely in 23 patients. All patients were followed up 10-18 months, with an average of 13.9 months. After operation, the flap survived completely, the shape of reconstructed chest wall was good, the texture was satisfactory, and there was no flap contracture deformation. There was only a linear scar left in the flap donor site, and the abdominal wall function was not significantly affected. There was no tumor recurrence during follow-up.

Conclusion

The anterior serratus branch of thoracodorsal vessel has a constant anatomy and causes little damage to the recipient site, so it can provide reliable blood supply for free flap transplantation.

A multidisciplinary approach for autologous breast reconstruction: A narrative (re)view for better management

Breast reconstruction and oncoplastic surgery have become an important part of breast cancer care. The use of autologous breast reconstruction (ABR) has evolved significantly with advances in microsurgery, aiming to reduce donor site complications and improve cosmesis. For years, immediate-ABR was considered a contraindication if postmastectomy irradiation (PMRT) was planned. As a result of de-escalation of axillary surgery the indication of PMRT are increasing along-side with observations that PMRT in the setting of ABR is not contraindicated. Surgical techniques may result in different amount and areas of breast residual glandular tissue and patient selection is important to reduce potential residual disease. Meticulus radiation planning is important to potentially reduce complications without compromising oncologic outcomes. Surgical techniques change constantly in aim to improve aesthetic results but should most importantly maintain priority to the oncological indications. By multidisciplinary team work with a comprehensive understanding of each discipline, we can preserve the accomplishments of breast surgery in the setting of PMRT, without compromising disease control.

Internal Mammary Vein Valves: A Histological Study

It is widely accepted that the internal mammary vein (IMV) is valveless. However, few anatomical studies are available on the presence or absence of IMV valves. To test the hypothesis that the IMV is valveless, we performed microscopic histological examination of the IMV. IMV samples were collected from 10 human fresh frozen cadavers. For a control, the small saphenous vein (SSV) was obtained. Histological stains were performed. Microscopic examination showed that a venous valve was found in 8 of 20 IMVs. The structure of the valve leaflet consisted of two parts. There was a “thick part” located near the wall of the vein that consisted of smooth muscle cells and fibers. There was also a “thin part” located near the center of the venous lumen that lacked smooth muscle cells. The size of the thick part of the IMV valve was smaller than the SSV valve, whereas there was no difference in the size of the thin part between the IMV and SSV. IMV valves exist. Our results that an IMV valve was present in less than half of IMVs and there was a small-sized valve leaflet suggest that the IMV valve may be rudimentary.

Incidental finding of subclavian artery occlusion and subsequent hypoplastic internal mammary artery as a candidate recipient vessel in DIEP flap breast reconstruction

We report a case of autologous breast reconstruction in which a thoracodorsal vessel was used as a recipient vessel after a hypoplastic internal mammary vessel was found on preoperative computed tomography (CT) angiography. A 46-year-old woman with no underlying disease was scheduled to undergo skin-sparing mastectomy and breast reconstruction using a deep inferior epigastric artery perforator flap. Preoperative CT angiography showed segmental occlusion of the right subclavian artery with severe atherosclerosis and calcification near the origin of the internal mammary artery, with distal flow maintained by collateral branches. The thoracodorsal artery was selected to be the recipient vessel because CT showed that it was of adequate size and was not affected by atherosclerosis. The patient experienced no postoperative complications, and the flap survived with no vascular complications. The breasts were symmetrical at a 6-month follow-up. This case highlights that preoperative vascular imaging modalities may help surgeons avoid using diseased vessels as recipient vessels in free flap breast reconstructions.

Nipple-sparing mastectomy and breast reconstruction with a deep inferior epigastric perforator flap using thoracodorsal recipient vessels and a low lateral incision

BACKGROUND

Nipple-sparing mastectomy poses challenges in providing esthetically-pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple-sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites.

METHODS

Between 2010 and 2016, 79 patients who underwent nipple-sparing mastectomy with autologous breast reconstruction using thoracodorsal (TD) vessels in 30 cases or internal mammary (IM) vessels in 49 cases were investigated. Demographics, intraoperative findings, complications, and quality of life using Breast-Q questionnaire were compared between two groups.

RESULTS

All flap survived. There was no statistical difference in age, BMI, ischemia time, and flap-used percentage. The TD artery had a statistically smaller diameter 1.8 ± 0.4 mm than the IM artery 2.7 ± 0.43 mm (p = 0.02). At a mean follow-up of 44.4 ± 35.2 months, there was no statistical difference in total complication rates between TD and IM groups (23.3% and 36.7%, respectively, p > 0.05). The "psychosocial well-being" of Breast-Q in TD group 83.9 ± 14.6 was statistically greater than IM group 72.8 ± 17.6 (p = 0.04).

CONCLUSIONS

Nipple-sparing mastectomy with immediate breast reconstruction using TD vessels with a low lateral scar is a safe procedure that provides an inconspicuous scar with better cosmesis and minimal complication rate.

Anastomosis of the Superficial Inferior Epigastric Vein to the Internal Mammary Vein to Augment Deep Inferior Artery Perforator Flaps

Use of the retrograde limb of the internal mammary vein has been described previously as a lifeboat for venous congestion but not prophylactically. Maximizing the length of the deep inferior artery perforator (DIEP) flap pedicle, identifying and dissecting the superficial inferior epigastric vein proximally in every patient, and taking advantage of the retrograde internal mammary vein are all technical details that facilitate the additional venous anastomosis and flap inset. Performing a second venous anastomosis routinely using the superficial inferior epigastric vein to the retrograde internal mammary vein helps with flap inset.

Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction

BACKGROUND

Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety.

METHODS

A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes.

RESULTS

A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries.

CONCLUSIONS

The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

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

INTRODUCTION

The 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.

METHODS

All 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.

RESULTS

Of 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.

CONCLUSION

Bipedicled 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 EVIDENCE

Therapeutic level IV.

Salvage of a TRAM breast reconstruction flap using the retrograde internal mammary artery system

Background:

Free tissue transfer provides an optimal means for breast reconstruction in creating an aesthetically natural appearance that is durable over time. The choice of donor vessels vary from surgeon to surgeon, but the internal mammary axis is one of the most popular choices together with the thoracodorsal vessels.

Aims and Results:

We present the case of a salvaged free transverse rectus abdominis myocutaneous breast reconstruction in which end-to-end antegrade anastomosis to the internal mammary artery (IMA) was not possible due to frail vessel walls, but retrograde anastomosis to the IMA and antegrade anastomosis of internal mammary vessel resulted in a perfused and viable flap.

Conclusion:

We suggest the use of the retrograde internal mammary arterial system for microsurgical anastomosis when the anterograde flow is not adequate, the vessel wall is friable, and when other more common options are not available.

[Strategies in case of unusable internal mammary vessels in a mammary reconstruction by DIEP]

INTRODUCTION

We analyzed the strategy of microvascular connection during the DIEP in case of unusable internal mammary vessels in intraoperative period.

MATERIAL AND METHOD

It is about five cases of mammary reconstructions by DIEP practiced in a plastic surgery department. We modified our connections because the quality of the artery and/or the vein was considered insufficient.

RESULTS

In case of internal mammary artery unusable, we changed the donor site and the flap was anastomosed with circumflexe scapular vessels. In case of internal mammary vein judged unusable but with usable artery, we anastomosed the DIEP with the internal mammary artery and with the cephalic vein. We added a venous substitution by the second connection with the deep inferior epigastric venous by coupler's technique.

CONCLUSION

Circumflexe scapular artery was the first alternative of internal mammary artery. In every case we protected the thoracodorsal pedicle.