Breast Reconstruction with Free Bipedicled TRAM or DIEP Flaps by Anastamosis to the Proximal and Distal Ends of the Internal Mammary Vessels

ABSTRACT

Breast reconstruction in patients who have already undergone traditional radical mastectomy can be very challenging for plastic surgeons. These patients require not only correction of breast deformities but also correction of subclavian and anterior axillary fold deformities. Usually the entire transverse rectus abdominal myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap (including zone IV) must be used. To achieve this, bipedicled deep inferior epigastric vessels (DIEV) are needed to ensure that the entire flap will survive completely. On the chest, however, it is difficult to find two sets of suitable recipient vessels for the two pedicles. The thoracodorsal vessels have often been damaged during axillary dissection or radiation therapy. In the past, surgeons have used the proximal end of the internal mammary artery and vein (IMA, IMV) as the recipient vessels in breast reconstruction with free flaps, with ligation of the distal ends. Here, we use both the proximal and distal ends of IMA and IMV as recipient vessels for end-end anastomoses to the bipedicled deep inferior epigastric artery and deep inferior epigastric vein vessels in seven TRAM cases and five DIEP cases. Very satisfactory results are obtained. Our clinical and experimental studies indicate that the distal IMA has reduced perfusion pressure but still can provide excellent flow and flap perfusion. This technique allows reliable use of two pedicles for survival of the entire flap.

KEYWORD

Bipedicled deep inferior epigastric perforator flap - free transverse rectus abdominal myocutaneous flap - proximal and distal ends of internal mammary artery - breast reconstruction

REFERENCES

• 1 Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock.  Plast Reconstr Surg . 1975;  56 178-181
• 2 Fujino T, Harashina T, Enomoto K. Primary breast reconstruction after a standard radical mastectomy by a free flap transfer.  Plast Reconstr Surg . 1976;  58 371-375
• 3 Shaw W W. Breast reconstruction by superior gluteal microvascular free flaps without silicon implants.  Plast Reconstr Surg . 1983;  72 490-501
• 4 Senkai L, Yangqun L, Jun X. Breast reconstruction with free superior gluteal microvascular flap (one case report.) Chin J Plast Surg Burns .  1990;  6 228-229
• 5 Blondeel P N, Boeckx W D. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery.  Br J Plast Surg . 1994;  47 495-501
• 6 Green G E, Sterzer S H, Reppert E H. Coronary artery bypass grafts.  Ann Thorac Surg . 1968;  5 443-446
• 7 Vineberg A, Wright J. A Myocardial Revascularization by Arterial/Ventricular Implants.  Boston, MA: PSG, Inc. 1982: 59-150
• 8 Van Son A J, Smedts F. Histology of the internal mammary artery versus the inferior epigastric artery.  Ann Thorac Surg . 1992;  53 1147-1149
• 9 Girerd X J, Acar C, Mourad J J. Incompressibility of the human arterial wall: an in vitro ultrasound study.  J Hypertens Suppl . 1992;  10 S111-S114
• 10 Takemura H, Kawasuji M, Sakakibara N. Quantitative hemodynamic assessment of internal mammary artery grafts using transthoracic duplex imaging.  Nippon Kyobu Geka Gakkai Zasshi . 1994;  42 2171-2177
• 11 Van Son A J, Skotnicki S H, Peters M B. Noninvasive hemodynamic assessment of the internal mammary artery in myocadial revascularization.  Ann Thorac Surg . 1993;  55 404-409
• 12 Fuda P, Pigatto A, De Gasperis C. Structural and morphometric analysis of the internal mammary artery used in coronary bypass surgery.  Minerva Cardioangiol . 1995;  43 21-27
• 13 Folts J D, Gallagher K O, Kroncke G M. Myocardial revascularization of the canine circumflex coronary artery using retrograde internal mammary artery flow without cardiopulmonary bypass.  Ann Thorac Surg . 1981;  31 21-27
• 14 Zheng W, Yuanzhong S, LiangHua Z. Experimental study of bypass surgery with retrograde flow of internal mammary artery anastomosed to right coronary artery.  Chin J Experimental Surg . 1987;  4 75-77
• 15 Paletta C E, Vogler G, Freedman B. Viability of the rectus abdominis muscle following internal mammary artery ligation.  Plast Reconstr Surg . 1993;  92 234-238