Postoperative patency of the retrograde internal mammary vein anastomosis in free flap transfer

Double Free Transverse Upper Gracilis Flap Breast Reconstruction: Advantages of Using LD Flap as a Salvage Solution

The lower abdominal tissue is still the most common donor site used for free autologous breast reconstruction. If this site is not available, multiple secondary choices exist. The transverse upper gracilis flap is a valuable choice and it can be used alone or in combination with other flaps. We present a case of a 49-year-old patient who underwent delayed unilateral breast reconstruction by using a double transverse upper gracilis flap. Due to venous thrombosis, the flap inserted in the lower pole was lost. We managed the complication tailoring a latissimus dorsi flap to close the defect. We reported the advantages of the latissimus dorsi flap as a rescue solution and its superior aesthetic result in this particular case. Breast reconstruction with transverse upper gracilis flap in addition to the latissimus dorsi flap allowed us to obtain an adequate breast volume avoiding the use of breast implants as desired by the patient. We thought that the double free transverse upper gracilis flap for delayed, or immediate unilateral reconstruction of small to moderate breast could be a valuable option to avoid the use of implants and when abdominal tissue is not available. However, it should be taken into consideration the shortness of the transverse upper gracilis pedicle, the necessity to perform a retrograde flow anastomosis at the level of the internal mammary, and the discrepancy of skin color tones with the receiving site. The latissimus dorsi flap was an excellent rescue solution and put in evidence the aesthetic superiority of this flap compared to the transverse upper gracilis flap.

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.

An unusual "venous circle" of the internal mammary vein encountered during microvascular anastomosis and implications for practice

The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle'.

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.