Internal mammary artery perforators as recipient vessels for deep inferior epigastric perforator flap breast reconstruction using CT angiography

Abstract

Abstract:ObjectiveTo study the anatomy of internal mammary artery perforator (IMAP) in Chinese patients and the utilization rate of IMAP as recipient vessels for deep inferior epigastric perforator(DIEP) flap breast reconstruction.MethodsNinty-eight consecutive cases with DIEP flap in immediate breast reconstruction from January 2016 to December 2018 were analyzed, 32 cases in IMAP group and 66 cases in internal mammary artery group. All cases had preoperative mapping of perforator with ultrasound. A total of 73 cases had preoperative mapping of perforator with CT angiography (CTA) simultaneously since January 2017. The location and diameter of IMAP were analyzed as well as the utilization rate of IMAP as recipient vessels.ResultsIn 98 cases, IMAP was located in the second intercostal space (ICS) in 66 (67.3%) cases, diameter (1.33±0.66) mm, in the third ICS in 24 (24.5%) cases, diameter (0.86±0.28) mm, and in the fourth ICS in 8 (8.2%) cases, diameter (0.65±0.15) mm. IMAP was used in DIEP flaps in 32 (32.7%) case. A total of 28 (87.5%) perforators were located in the second ICS and 4 (12.5%) perforators in the third ICS. There was no significant difference between IMAP group and internal mammary artery group in patient characteristics and flap complications. The utilization rate of IMAP was 39.7% (29/73) in patients using CTA which was much higher than 12.0% (3/25) in patients without using CTA(P=0.01).ConclusionsIMAP as recipient vessel is viable alternative for immediate DIEP flap breast reconstruction when applicable. Preoperative CTA can improve the utilization rate of IMAP. This strategy offers the advantages of decreasing recipient site morbidity, reducing operative time and simplifying procedures.

Key words:Immediate breast reconstruction,Deep inferior epigastric perforator flap,Recipient vessel,Internal mammary artery perforator,CT angiography

CLC Number:

R737.9

JIN Yiting, CHU Chengyu, ZHANG Wei, FU Lina, TANG Weijun, DONG Jiasheng, XU Hua, ZOU Qiang. Internal mammary artery perforators as recipient vessels for deep inferior epigastric perforator flap breast reconstruction using CT angiography[J]. Journal of Surgery Concepts & Practice, 2019, 24(04): 330-336.

References

[1] Siegel RL, Miller KD, Jemal A.Cancer statistics,2015[J]. CA Cancer J Clin,2015,65(1):5-29.
[2] Zdenkowski N, Tesson S, Lombard J, et al.Supportive care of women with breast cancer: key concerns and practical solutions[J]. Med J Aust,2016,205(10):471-475.
[3] Bains RD, Riaz M, Stanley P.Bilateral free DIEP breast reconstruction using contralateral internal mammary and ipsilateral thoracodorsal vessels[J]. Plast Reconstr Surg,2007,119(4):1385-1386.
[4] Allen RJ, Treece P.Deep inferior epigastric perforator flap for breast reconstruction[J]. Ann Plast Surg,1994,32(1):32-38.
[5] Zoghbi Y, Gerth DJ, Tashiro J, et al.Deep inferior epigastric perforator versus free transverse rectus abdominis myocutaneous flap: complications and resource utilization[J]. Ann Plast Surg,2017,78(5):516-520.
[6] Lee JH, Varon DE, Halvorson EG.Unilateral internal mammary recipient vessels for bilateral DIEP flap breast reconstruction[J]. Plast Reconstr Surg Glob Open,2017, 5(6):e1359.
[7] Mani M, Saour S, Ramsey K, et al.Bilateral breast reconstruction with deep inferior epigastric perforator flaps in slim patients[J]. Microsurgery,2018,38(2):143-150.
[8] Lhuaire M, Hivelin M, Dramé M, et al.Determining the best recipient vessel site for autologous microsurgical breast reconstruction with DIEP flaps: An anatomical study[J]. J Plast Reconstr Aesthet Surg,2017,70(6):781-791.
[9] Chang EI, Chang EI, Soto-Miranda MA, et al.Demystify-ing the use of internal mammary vessels as recipient ves-sels in free flap breast reconstruction[J]. Plast Reconstr Surg,2013,132(4):763-768.
[10] Kim H, Lim SY, Pyon JK, et al.Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruction with the free DIEP flap[J]. Plast Reconstr Surg,2013,131(3):327e-334e.
[11] Fodor L, Bota IO, Filip CI, et al.New trends in breast reconstruction[J]. Chirurgia (Bucur),2011,106(4):485-489.
[12] Yang SJ, Eom JS, Lee TJ, et al.Recipient vessel selection in immediate breast reconstruction with free abdominal tissue transfer after nipple-sparing mastectomy[J]. Arch Plast Surg,2012,39(3):216-221.
[13] Moran SL, Nava G, Behnam AB, et al.An outcome ana-lysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients[J]. Plast Reconstr Surg,2003,111(6):1876-1882.
[14] Murray AC, Rozen WM, Alonso-Burgos A, et al.The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review[J]. Surg Radiol Anat,2012,34(2):159-165.
[15] Santanelli Di Pompeo F, Longo B, Sorotos M, et al. The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: a retrospective study of 256 consecutive cases[J]. Microsurgery,2015,35(1):34-38.
[16] Daniel RK, Cunningham DM, Taylor GI.The deltopectoral flap: an anatomical and hemodynamic approach[J]. Plast Reconstr Surg,1975,55(3):275-282.
[17] Halim AS, Alwi AA.Internal mammary perforators as recipient vessels for deep inferior epigastric perforator and muscle-sparing free transverse rectus abdominis musculocutaneous flap breast reconstruction in an Asian population[J]. Ann Plast Surg,2014,73(2):170-173.
[18] Follmar KE, Prucz RB, Manahan MA, et al.Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction[J]. Plast Reconstr Surg,2011,127(1):34-40.
[19] Saint-Cyr M, Chang DW, Robb GL, et al.Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps[J]. Plast Reconstr Surg,2007,120(7):1769-1773.
[20] Munhoz AM, Ishida LH, Montag E, et al.Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: an anatomical and clinical analysis[J]. Plast Reconstr Surg,2004,114(1):62-68.
[21] Hamdi M, Blondeel P, van Landuyt K, et al. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators[J]. Br J Plast Surg,2004,57(3):258-265.
[22] Haywood RM, Raurell A, Perks AG, et al.Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels[J]. Br J Plast Surg,2003,56(7):689-691.
[23] Baek IS, You JP, Rhee SM, et al.A clinical anatomic study of internal mammary perforators as recipient vessels for breast reconstruction[J]. Arch Plast Surg,2013, 40(6):761-765.
[24] Fansa H, Schirmer S, Cervelli A, et al.Computed tomographic angiography imaging and clinical implications of internal mammary artery perforator vessels as recipient vessels in autologous breast reconstruction[J]. Ann Plast Surg,2013,71(5):533-537.
[25] Munhoz AM, Ishida LH, Montag E, et al.Internal mammary perforator vessels as recipient site for microsurgical breast reconstruction: a comparative histomorphometric analysis and incidence of degenerative vascular changes[J]. Microsurgery,2014,34(3):217-223.
[26] Vollbach FH, Heitmann CD, Fansa H.An appraisal of internal mammary artery perforators as recipient vessels in microvascular breast reconstruction-an analysis of 515 consecutive cases[J]. Plast Reconstr Surg Glob Open,2016,4(12):e1144.
[27] Kim H, Lim SY, Pyon JK, et al.Preoperative computed tomographic angiography of both donor and recipient sites for microsurgical breast reconstruction[J]. Plast Reconstr Surg,2012,130(1):11e-20e.
[28] Rozen WM, Alonso-Burgos A, Murray AC, et al.Is there a need for preoperative imaging of the internal mammary recipient site for autologous breast reconstruction[J]. Ann Plast Surg,2013,70(1):111-115.