The Use of a Single Set of Internal Mammary Recipient Vessels in Bilateral Free Flap Breast Reconstruction : Plastic and Reconstructive Surgery

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The Use of a Single Set of Internal Mammary Recipient Vessels in Bilateral Free Flap Breast Reconstruction

Zeltzer, Assaf A. M.D.; Andrades, Patricio M.D.; Hamdi, Moustapha M.D., Ph.D.; Blondeel, Phillip N. M.D., Ph.D.; Van Landuyt, Koenraad M.D., Ph.D.

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Plastic and Reconstructive Surgery 127(6):p 153e-154e, June 2011. | DOI: 10.1097/PRS.0b013e3182131df9
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Bilateral free flap breast reconstructions are mostly performed using two sets of internal mammary vessels as recipients. The purpose of this article is to present the surgical tips for bilateral free flap breast reconstruction using a single set of recipient artery and vein.

A 5-year retrospective review of a series of patients who underwent bilateral breast reconstruction between 2005 and 2009, using one set of recipient vessels for both flaps, is presented. Patient files were reviewed, and demographics, reason for using one set of internal mammary vessels, and operative details were recorded (Table 1). All patients had preoperative abdominal and thoracic computed tomographic mapping showing the position of perforators and the patency of the thoracic vessels.1 All patients underwent bilateral deep inferior epigastric artery perforator flap reconstruction as described previously.2 A preoperative or perioperative decision for using only one set of internal mammary vessels was made, and the contralateral pedicle was passed through a presternal tunnel. Anastomoses were performed as shown in Figures 1 and 2. A skin paddle was left for flap monitoring and a Doppler probe was used to assess the patency of the pedicle passing into the subcutaneous tunnel when no skin paddle was left for monitoring.

Table 1:
Patient Data
Fig. 1.:
Options for anastomosing the arteries of a bilateral free flap breast reconstruction. IMAp, internal mammary artery perforator, proximal; IMAd, internal mammary artery perforator, distal.
Fig. 2.:
Options for anastomosing the veins of a bilateral free flap breast reconstruction. IMAp, internal mammary vein, proximal; IMAd, internal mammary vein, distal.

Results are listed in Table 1. A total of 10 patients were included. No partial or complete flap losses were observed. Only one patient (patient 5) underwent revision 5 hours after surgery. A venous thrombosis was seen at the level of the anastomosis with internal mammary vessels, with complete recovery after revision.

The internal mammary vessels are the first-choice recipients for free flap breast reconstruction, but the thoracodorsal vessels or the internal mammary perforators are regularly used.3 However, the internal mammary artery is also the first-choice donor vessel for coronary artery bypass graft surgery because of its superiority compared with other arterial or venous conducts.4

Although death resulting from an absence of an internal mammary artery donor for coronary artery bypass graft surgery has never been described, some surgeons believe that preservation of one internal mammary artery in bilateral breast reconstruction should be kept in mind in patients with coronaropathy. In addition, the internal mammary vessels sometimes cannot be used for other reasons, such as previous irradiation of the sternal region, that can cause important scarring of the vascular bed and in extreme cases thrombosis.5

The use of a single recipient pedicle can even allow reliable monitoring of completely buried flaps (Fig. 1) (type III). Monitoring is then performed by using a flow-Doppler probe at the level of the presternal passage of the pedicle, but the results must be interpreted with caution.

Obviously, using a single recipient vessel for two free flaps has the risk of thrombosis of the main pedicle, which may result in failure of both flaps. Therefore, such surgical technique should only be performed when indicated and performed by an experienced microsurgeon.

In bilateral free flap breast reconstruction, both internal mammary sites are frequently used; however, in selected cases, it is necessary to have an extra option for anastomosing one of the two flaps. The use of a single internal mammary recipient for bilateral reconstructions is a valuable microsurgical option.

Assaf A. Zeltzer, M.D.

Patricio Andrades, M.D.

Moustapha Hamdi, M.D., Ph.D.

Phillip N. Blondeel, M.D., Ph.D.

Koenraad Van Landuyt, M.D., Ph.D.


1. Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59:594–599.
2. Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg. 1999;52:104–111.
3. Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: The role of the internal mammary perforators. Br J Plast Surg. 2004;57:258–265.
4. Tomizawa Y, Endo M, Nishida H, et al. Use of arterial grafts for coronary revascularization: Experience of 2987 anastomoses. Jpn J Thorac Cardiovasc Surg. 1999;47:325–329.
5. Gansera B, Schmidtler F, Angelis I, et al. Quality of internal thoracic artery grafts after mediastinal irradiation. Ann Thorac Surg. 2007;84:1479–1484.

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