The Thoracodorsal Artery and Vein as Recipient Vessels for Microsurgical Breast Reconstruction

A clinical application for arterial coupling and histomorphometric comparison of internal mammary and thoracodorsal arteries for safe use

BACKGROUND

In breast reconstruction, arterial coupling has been reported to be more favorable in the thoracodorsal artery (TDA) than the internal mammary artery (IMA). This technique may help overcome anastomosis in a small, deep space. Understanding the arteries' mechanical properties is crucial for breast reconstruction's safety and success.

METHODS

Abdominal-based free flap breast reconstructions performed by a single surgeon between 2020 and 2022 were retrospectively analyzed. The patients were classified by microanastomosis technique (handsewn and coupler device) to compare the rate of vascular revision. Histomorphometric analysis of arterial coupling in TDA and IMA was performed in 10 fresh cadavers for comparing wall thickness and composition, including densities of elastic fiber, smooth muscle, and collagen.

RESULTS

A total of 309 patients (339 reconstructed breasts) were included. There were 29 patients in the TDA handsewn group (A), 38 patients in the TDA coupler group (B), and 242 patients in the IMA handsewn group (C). The rates of arterial revision in groups A, B, and C were 0.00% (95%CI: 0.00%-11.03%), 2.5% (95%CI: 0.44%-12.88%), and 1.49% (95%CI: 0.58%-3.77%), respectively, with no statistically significant differences (p-value = .694). Histologically, the thickness of the tunica media and adventitia between IMA and TDA showed no significant difference. The density of elastic fiber was significantly higher in IMA (16.70%) than in TDA (0.79%) (p-value <.001).

CONCLUSION

The histologic characteristics of TDA are more favorable for arterial coupling than those of IMA. Arterial coupling is a safe option in situations where TDA anastomosis must be performed through a narrow and deep incision.

The posterior approach to the thoracodorsal vessels for microsurgical free tissue transfer

The latissimus dorsi (LD) muscle is a workhorse flap in reconstructive surgery (e.g., breast reconstruction, chest wall defects, and lower limb trauma). The thoracodorsal artery and its venae comitantes supply this muscle. Recipient vessel options for microsurgical free flap reconstruction of the posterior thorax and lower back are limited. The thoracodorsal vessels are an excellent option due to their reliable anatomy and ease of access. In circumstances when the patient is best positioned prone, the posterior approach to access the thoracodorsal vessels is advantageous. We describe the technique to identify and isolate these vessels via a posterior approach.

[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.

Necrosis or Flap Loss After Deep Inferior Epigastric Perforator Reconstruction: Impact of Perforators and Recipient Vessels

Background The aim of this study is to analyze the impact of the number and location of perforators harvested and the recipient vessels used on deep inferior epigastric perforator (DIEP) flap survival and the occurrence of flap necrosis requiring re-operation.

Patients and Methods Four hundred and seventy-one DIEP flap reconstructions, performed between January 2008 and December 2019, were retrospectively analyzed.

Results Flap necrosis requiring re-operation was observed in 40 (9%) of flaps and total flap loss rate was 1% (n = 6). No significant differences were observed between internal mammary vessels (IMV, n = 287, 61%) and thoracodorsal vessels (TDV, n = 184, 39%) regarding postoperative re-anastomosis (p = 0.529) or flap survival (p = 0.646). Intraoperative conversion from IMV to TDV was performed on 64 (14%) patients. TDV were more commonly associated with problems in preparation of the vessels than IMV (p < 0.001). Second vein anastomosis was performed on 18 (4%) patients. In total, 81 flaps (17%) had one perforator, 165 (35%) had two, 218 (46%) had three to five, and 7 (2%) had more than five perforators. Flaps with three to five perforators were more commonly associated with flap necrosis (p < 0.001) than flaps with one or two perforators. Independent factors associated with necrosis were body mass index (BMI) > 30 (odds ratio [OR]: 2.28; 95% confidence interval: 1.06–4.91, p = 0.035) and perforator/s located on the lateral row (OR: 3.08, 95% CI 1.29–7.33, p = 0.011).

Conclusion We conclude that the occurrence of flap necrosis requiring re-operation may be higher in DIEP flaps with more than two perforators or perforator/s located on the lateral row and in obese patients. Neither the recipient vessels used nor the number of perforators harvested had any impact on the flap survival rate.

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.

Use of Single-recipient Vessels for Cross-chest Abdominal Flap-based Breast Augmentation as an Outpatient

Breast reconstruction with autologous tissue following mastectomy for breast cancer has become the standard of care. Microvascular breast augmentation is an alternative for patients with failed breast prostheses, including painful capsular contractures or poor cosmetic outcomes. We present a series of 4 patients who underwent microvascular breast augmentation with cross-chest flap recipient vessels.

Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction

Background

In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured.

Results

The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication.

Conclusion

TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.

Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study

BACKGROUND

Thoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap.

METHODS

A retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups.

RESULTS

No statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group.

CONCLUSIONS

The results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.

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.

Determining the best recipient vessel site for autologous microsurgical breast reconstruction with DIEP flaps: An anatomical study

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operator's experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites.

METHODS

Our series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0 mm with successive half-millimeter graduations.

RESULTS

The median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5 mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5 mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (p = 0.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (p = 0.009).

CONCLUSIONS

This study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.