Arch Hand Microsurg.  2020 Dec;25(4):326-330. 10.12790/ahm.20.0074.

The Retrograde Limb of the Internal Mammary Artery: An Alternative Inflow Option for Free Flap Breast Reconstruction

• Hahn HM
• Cha B
• Lee IJ

• KMID: 2508949
• DOI: http://doi.org/10.12790/ahm.20.0074

Abstract

Autologous breast reconstruction using a free flap is a popular option for breast reconstruction after mastectomy. The internal mammary system is the recipient of choice in autologous breast reconstruction. We present our experience utilizing the caudal limb of the internal mammary artery as the recipient artery. A 44-year-old female patient with invasive ductal carcinoma in her right breast received total mastectomy and reconstruction with the deep inferior epigastric artery perforator flap was planned. During the operation, arterial insufficiency occurred three times; therefore, we decided to change the plan and to perform anastomosis to the caudal limb of the internal mammary artery. Retrograde blood flow of the internal mammary artery was successfully achieved. Immediate postoperative and long-term outcomes of the flap were satisfactory. This inflow option may be useful in cases with arterial insufficiency on conventional anastomosis or in cases with bipedicled or stacked flaps for unilateral breast reconstruction.

Keyword

Breast reconstruction; Microsurgical free flap; Internal mammary artery; Breast cancer

Figure

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  Fig. 1. Preoperative computed tomography angiography for evaluation of the internal mammary arterial system and the deep inferior epigastric arterial system. (A) Vessels (arrow) are the internal mammary artery and vein in the third intercostal space. (B) Vessel (arrow) is the perforator vessel included in the flap.

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  Fig. 2. (A) The mastectomy specimen weight was 505 g. (B, C) The flap was elevated on two perforators of the deep inferior epigastric artery.

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  Fig. 3. (A) On arterial anastomosis between the cranial limb of the internal mammary artery (white arrow) and the deep inferior epigastric artery (arrowhead) using the end-to-end maneuver, arterial insufficiency occurred three times. The deep inferior epigastric vein was anastomosed with the anterograde flow of the internal mammary vein (asterisk). (B, C) We changed the recipient vessel to the caudal limb of the internal mammary artery (yellow arrow) by using the end-to-end maneuver. (D) Patency was tested with the empty-and-refill test and the flow in arterial anastomosis was good.

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  Fig. 4. Long-term clinical photograph at postoperative 6 months. She had a favorable long-term outcome.

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