Preserving the Internal Mammary Artery End-to-Side Microvascular Arterial Anastomosis for DIEP and SIEA Flap Breast Reconstruction : Plastic and Reconstructive Surgery

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Preserving the Internal Mammary Artery End-to-Side Microvascular Arterial Anastomosis for DIEP and SIEA Flap Breast Reconstruction

Bank, Jonathan M.D.; Nathan, Sandeep M.D.; Song, David H. M.D., M.B.A.

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Plastic and Reconstructive Surgery: July 2012 - Volume 130 - Issue 1 - p 187e-188e
doi: 10.1097/PRS.0b013e318254fa3f
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In the October 2011 issue of the Journal, Apostolides et al.1 presented their experience with end-to-side anastomosis of the deep inferior epigastric artery perforator to the left internal mammary artery. This study was performed with the forethought of preserving the left internal mammary artery for potential need for future coronary revascularization, and demonstrated the feasibility of performing breast reconstruction with this modified technique. In response to this study, we hereby present a case that underscores the relevance of this modification.

A 58-year-old woman with left breast ductal carcinoma in situ and type 1 diabetes mellitus underwent a left mastectomy and immediate reconstruction with abdominal autologous tissue. A free flap based on the right superficial inferior epigastric artery and vein was devised [superficial inferior epigastric artery (SIEA) adipocutaneous free flap], and anastomosed to the left internal mammary artery and left internal mammary vein. Toward the end of the procedure, the patient became hypotensive and was found to have a non–ST segment elevation myocardial infarction. She was brought to the cardiac catheterization suite 12 hours after surgery and was found to have normal coronary vessels. Given the rarity of this conjuncture, we requested that the cardiologist perform imaging of the flap. The left internal mammary artery was injected with contrast material and a rare image of the flap vessels was obtained, showing a patent anastomosis (Fig. 1) between the left internal mammary artery and the SIEA branching into the flap. The patient had an uneventful recovery with antiplatelet therapy and was discharged on postoperative day 3.

Fig. 1:
The arrowhead indicates anastomosis between the left internal mammary artery and the SIEA; the large arrow indicates the left internal mammary artery (3 mm); and the small arrow indicates SIEA branching into the flap (1 mm).

Although anecdotal, this event highlights an increasing prevalence of autologous tissue breast reconstruction involving vessels that may be needed for coronary revascularization, and offers a less hypothetical scenario for application of the technique described in the context of breast reconstruction by Hemphill et al.2 and recently studied by Apostolides et al.

Jonathan Bank, M.D.

Section of Plastic and Reconstructive Surgery, Department of Surgery

Sandeep Nathan, M.D.

Section of Cardiology

David H. Song, M.D., M.B.A.

Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Ill.


The authors have no financial interest to declare in relation to the content of this communication.


1. Apostolides JG, Magarakis M, Rosson GD. Preserving the internal mammary artery: End-to-side microvascular arterial anastomosis for DIEP and SIEA flap breast reconstruction. Plast Reconstr Surg. 2011;128:225e–232e.
2. Hemphill AF, de Jesus RA, McElhaney N, Ferrari JP. End-to-side anastomosis to the internal mammary artery in free flap breast reconstruction: Preserving the internal mammary artery for coronary artery bypass grafting. Plast Reconstr Surg. 2008;122:149e–150e.


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