Secondary Logo

Journal Logo

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps

Opsomer, Dries M.D.; D’Arpa, Salvatore M.D., Ph.D.; Benmeridja, Lara M.D.; Stillaert, Filip M.D.; Noel, Warren M.D.; Van Landuyt, Koenraad M.D., Ph.D.

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 554e-564e
doi: 10.1097/PRS.0000000000006066
Breast: Original Articles
Free
SDC

Background: The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein.

Methods: Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively.

Results: Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m2. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps.

Conclusions: The authors’ results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ghent, Belgium; Palermo, Italy; and Paris, France

From the Department of Plastic and Reconstructive Surgery, University of Ghent; the Division of Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo; and the Department of Plastic and Reconstructive Surgery, Saint-Joseph Hospital.

Received for publication August 2, 2018; accepted February 5, 2019.

Presented at 29th Annual Meeting of the European Association of Plastic Surgeons, in Madrid, Spain, May 17 through 19, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Dries Opsomer, M.D., Department of Plastic and Reconstructive Surgery, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium, driesopsomer@gmail.com, Instagram: @dries.opsomer.md

The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard for autologous tissue breast reconstruction after bilateral mastectomy.1,2 The abdominal donor site in most cases provides enough tissue for the creation of two breasts, with minimal morbidity to the lower abdomen and a scar that is considered aesthetically pleasing by most patients.3 Microsurgical anastomosis is generally end-to-end to the internal mammary artery and one of its venae comitantes (internal mammary vein) on either side of the sternum. When the internal mammary vessels on one side are damaged or not usable, alternate recipient vessels are suggested: the thoracodorsal bundle, lateral thoracic artery and vein, serratus vessels, or even perforators from the internal mammary artery and vein.4–8

During previous challenging cases with poor ipsilateral recipient-site vessels, we managed to anastomose the flap’s pedicle to the contralateral internal mammary artery and vein, through a subcutaneous presternal tunnel. Based on this experience, we have adapted the technique for bilateral breast reconstructions. We now routinely anastomose both DIEP flaps to a single set of mammary vessels, usually to the right side (Fig. 1). To accomplish this, we use not only the proximal anterograde internal mammary artery but also the distal retrograde internal mammary artery for flap perfusion, as studies have shown reliable blood flow through these vessels.7,9–15 We have performed a retrospective review to assess the safety of this procedure by comparing flap outcomes and complication rates of the flaps anastomosed to the anterograde artery with those anastomosed to the retrograde artery in the same patient, in a 250-flap series.

Fig. 1.

Fig. 1.

Back to Top | Article Outline

PATIENTS AND METHODS

Between November of 2009 and March of 2018, a total of 125 patients underwent bilateral breast reconstruction to one set of mammary vessels performed by the senior authors (K.V.L., S.D.A., and F.S.). The patient records were reviewed retrospectively, and properties of 250 flaps were analyzed.

All patients deemed fit for bilateral DIEP flap reconstruction were considered for this technique, and there is no algorithm or patient selection process before contemplating this technique. Patient charts were reviewed retrospectively and permission for review was obtained by the local ethical committee (Bimetra Clinics EC/2018/0748). The data collection comprised patient factors (i.e., smoking, comorbidities, body mass index), operative details (i.e., flap weight, ischemia time, total operative time), and postoperative complications.

Back to Top | Article Outline

Statistical Analysis

All statistical analyses were performed using IBM SPSS Version 25 (IBM Corp., Armonk, N.Y.). Before analysis, the normality of the given data was tested using the Kolmogorov-Smirnov goodness-of-fit test. Differences in paired variables were tested using the McNemar test. Differences between multiple groups were tested using the one-way analysis of variance, and an additional linear regression analysis was performed. Statistical significance was set at a value of p < 0.05. The retrogradely perfused DIEP (usually the left side) was compared to its control: the anterogradely perfused DIEP (usually the right side).

Back to Top | Article Outline

Surgical Technique

All patients underwent preoperative contrast-enhanced angiographic computed tomography for perforator choice and identification. The patients were positioned supine with standard antithrombotic prophylaxis.

Two teams start the procedure simultaneously. One team harvests both DIEP flaps, including the superficial inferior epigastric veins for extra drainage if necessary. At least one flap pedicle is dissected up to its origin at the external iliac vessels to include a 90-degree angle, which is usually present proximally (Figs. 2 and 3). The second team prepares the mastectomy site bilaterally, with creation of a sufficiently large subcutaneous pocket from the existing inframammary fold to the upper breast border. Scar tissue resection and capsulectomy are performed whenever necessary. Dissection on the left side stops here. On the right side, pectoralis major fibers are split and the cartilage of the third sternocostal junction is excised. The intercostal muscles and perichondrium are dissected to expose at least 3 cm of internal mammary artery and its venae comitantes. The artery is clamped both proximally and distally and cut in the middle, and both veins—if present—are clipped distally and clamped proximally. The clamps are released briefly and pulsatile flow through both ends of the internal mammary artery (anterograde and retrograde) is assessed before continuing.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

A 3-cm-wide presternal subcutaneous tunnel is created at the level of the split pectoralis major fibers, just wide enough to accommodate a Langenbeck retractor (Fig. 4). [See Video (online), which demonstrates a bilateral DIEP flap breast reconstruction with both flaps anastomosed to the right internal mammary vessels. The left flap pedicle is tunneled and anastomosed to the retrograde internal mammary artery and medial internal mammary vein. The right flap pedicle is anastomosed to the right anterograde internal mammary artery and the lateral internal mammary vein.] In the ideal setting, one large-caliber artery and two venae comitantes are found at the third intercostal space.

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video demonstrates a bilateral DIEP flap breast reconstruction with both flaps anastomosed to the right internal mammary vessels. The left flap pedicle is tunneled and anastomosed to the retrograde internal mammary artery and medial internal mammary vein. The right flap pedicle is anastomosed to the right anterograde internal mammary artery and the lateral internal mammary vein.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_7wutztwp"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

Fig. 4.

Fig. 4.

First, the left breast flap is inset, its pedicle tunneled in front of the sternum, and the vessels are transposed without tension to the right internal mammary vessels. The deep inferior epigastric artery (DIEA) of the left breast flap is anastomosed to the retrograde right internal mammary artery and a deep inferior epigastric vein (DIEV) of the left breast flap to one of the internal mammary veins on the right side. Then, the right breast flap DIEA is anastomosed to the anterograde right internal mammary artery and one of the pedicle’s DIEVs to the second internal mammary vein on the right side. Figures 5 and 6 illustrate the view under the microscope of this standard setting.

Fig. 5.

Fig. 5.

Fig. 6.

Fig. 6.

Back to Top | Article Outline

Alternatives for Arterial Anastomosis

We routinely use the retrograde distal internal mammary artery for the left breast flap and the anterograde proximal internal mammary artery for the right breast flap (Fig. 7). If the retrograde internal mammary artery is not available, there are some alternatives. The left flap DIEA can be anastomosed to a side branch of the right breast DIEA (Fig. 8). If a large internal mammary artery perforator is available, this can also be used as a recipient artery for free flap anastomosis.

Fig. 7.

Fig. 7.

Fig. 8.

Fig. 8.

Back to Top | Article Outline

Alternatives for Venous Anastomosis

The epigastric veins should be dissected up to their confluence into a common trunk (Fig. 9). If not, they should be dissected at least proximal to the point where they are interconnected by a connecting branch. If there is only one suitable proximal internal mammary vein, the left flap’s venous anastomosis will be performed end-to-end to one of the collateral veins of the right flap, cut distal to their interconnection and reflected medially (Fig. 10). As a last alternative, the retrograde internal mammary vein is also a viable option for venous drainage (Fig. 11).16

Fig. 9.

Fig. 9.

Fig. 10.

Fig. 10.

Fig. 11.

Fig. 11.

We routinely dissect out the superficial epigastric vein and anastomose it whenever additional venous drainage is necessary. This can be done to a comitant vein of one or both pedicles, or even the thoracoacromial or cephalic vein. [See Figure, Supplemental Digital Content 1, which shows lifeboats for venous drainage through the superficial inferior epigastric vein, including the thoracoacromial pedicle (left), the cephalic vein (center), or an in-flap anastomosis from the superficial inferior epigastric vein to a deep inferior epigastric vein (right), http://links.lww.com/PRS/D674.]

Back to Top | Article Outline

RESULTS

Mean follow-up was 46 months. The mean age of the patients was 46 years (range, 26 to 68 years), and the mean body mass index was 25 kg/m2 (range, 17 to 36 kg/m2). Ten patients had a history of smoking, three were hypertensive, and three suffered from diabetes. Seventy-six patients underwent prophylactic bilateral mastectomy with immediate reconstruction for BRCA-related elevated cancer risk (Table 1). [See Figure, Supplemental Digital Content 2, which shows a bilateral DIEP flap breast reconstruction after mastectomy for breast cancer, preoperatively (left) and postoperatively (right). Both flaps are anastomosed to the right side internal mammary vessels. Markings on the right arm (left) are performed by the anesthesiologist, http://links.lww.com/PRS/D675.]

Table 1. - Baseline Characteristics and Operative Variables for Women Undergoing Bilateral DIEP Flap Breast Reconstruction to One Set of Internal Mammary Vessels
Characteristic Value (%)
Mean age ± SD, yr 46 ± 10.5
Mean BMI ± SD, kg/m2 25 ± 4.47
Smoking history 10/250
Diabetes mellitus 3 (24)
Hypertension 3 (24)
Age >60 yr 12 (9.6)
Mastectomy tissue, no. of flaps
 Prophylactic 152 (60)
 Secondary 70 (28)
 Tertiary 28 (11.2)
Oncologic treatment
 Chemotherapy, no. of patients 60 (48)
 Radiotherapy, no. of flaps 57 (22.8)
 Hormonal therapy, no. of patients 40 (32)
Operative details
 Mean operative time 7 hr 17 min (± 2 hr)
 Mean ischemia time 57 ± 26 min
 Mean hospital stay 6.9 ± 2.36 days
 Flap weight 492 ± 267 g
Revisions, no. of flaps 24 (9.6)
 Venous thrombosis 18 (7.2)
 Arterial thrombosis 3 (1.2)
 Hematoma 3 (1.2)
Flap failure
 Partial failure with skin necrosis 1 (0.4)
 Total flap failure 9 (3.6)
B
MI, body mass index.

Of the 250 flaps, 152 were primary or prophylactic reconstructions, 70 were secondary reconstructions, and 28 were tertiary reconstructions. Fifty-seven patients underwent adjuvant radiation therapy and sixty underwent chemotherapy. Forty patients received adjuvant hormonal therapy. Mean operative time was 7 hours 17 minutes (± 2 hours), with a mean ischemia time per flap of 57 minutes (range, 35 to 160 minutes). Mean postoperative hospital stay was 6.9 days (range, 3 to 25 days). Flap weight ranged from 100 to 1400 g (mean, 492 g).

We compared these values with a case series of 130 bilateral DIEP flaps performed between January of 2010 and December of 2016 at our institution. This cohort underwent the traditional technique with anastomoses to both internal mammary systems. Mean operative time was 9 hours 34 minutes (137 minutes extra), mean ischemia time was 70 minutes (13 minutes extra), average hospital stay was 8.03 days (1.13 days extra), and average flap weight was 438 g (54 g less).

Revisions were necessary in 24 cases, with the reason for revision being hematoma in three cases, venous thrombosis in 18 cases, and arterial thrombosis in three patients (Table 2). Nine flaps (3.6 percent) resulted in total failure; one resulted in significant partial flap and skin necrosis (0.4 percent). Six of these failed flaps were perfused by the retrograde and four were perfused by the anterograde internal mammary artery (Table 3). Four of the flap failures were tunneled and six were ipsilateral.

Table 2. - Properties of Failed Flaps
Patient Age (yr) Anterograde/Retrograde Tunneled Comorbidities Radiation Therapy/Chemotherapy Oncologic Setting Mechanism
Bilateral 1 30 Anterograde plus retrograde Yes and no Obesity RT plus CT IDC plus prophylactic contralateral Single inflow and outflow flaps; venous congestion
2 32 Anterograde plus retrograde Yes and no Prophylactic Arterial thrombosis of both pedicles
3 36 Anterograde plus retrograde Yes and no Prophylactic Single inflow flaps; arterial thrombosis
Unilateral 4 40 Anterograde Yes RT plus CT Tertiary BRC after implants Venous thrombosis
5 57 Retrograde No RT plus CT IDC, tertiary BRC after implants Venous thrombosis
6 55 Retrograde No Hypertension,
obesity
RT Prophylactic side failed Venous thrombosis
7 51 Retrograde No RT plus CT IDC, tertiary reconstruction Day 3 postoperatively, bra compression and venous congestion unrecognized
R
T, radiotherapy; CT, chemotherapy; IDC, invasive ductal carcinoma; BRC, breast reconstruction.

Table 3. - Anastomotic Details of Failed Flaps
Recipient Vein Recipient Artery Failed
Left Right Left Right Left Right
Bilateral
1 Anterograde R IMV medial* Anterograde R IMV lateral* Retrograde R IMA* Branch L DIEA* Yes* Yes*
2 Anterograde R IMV medial* Anterograde R IMV latera* Anterograde R IMA* Retrograde R IMA* Yes* Yes*
3 Anterograde R IMV medial* Anterograde R IMV lateral* Anterograde R IMA* Branch L DIEA* Yes* Yes*
Unilateral
4 Side branch R DIEV* Anterograde R IMV Anterograde R IMA* Retrograde R IMA Partial* No
5 Anterograde R IMV plus branch R DIEV Anterograde R IMV* Anterograde R IMA Retrograde R IMA* No Yes*
6 L IMV lat* L IMV med Retrograde L IMA* Anterograde L IMA Yes* No
7 Anterograde R IMV Branch L DIEV* Anterograde R IMA Retrograde R IMA* No Yes*
R
, right; L, left; IMV, internal mammary vein; IMA, internal mammary artery; DIEA, deep inferior epigastric artery; DIEV, deep inferior epigastric vein.
*
Failed flap.

We investigated our revised flaps with exclusion of the failures, the revisions for hematoma, and the flaps that were satisfactory and did not need supplemental microsurgery. Two left breast flaps anastomosed to a flipped-over DIEV from the right flap were saved by anastomosing the superficial epigastric vein to the cephalic vein. All reoperations of the venous anastomosis were performed on anterograde/proximal draining internal mammary veins. Because of the retrospective nature of our research, there is no detailed information on the specific amount of fat necrosis that occurred postoperatively, but no reoperations were necessary for this indication.

Statistical analysis showed no significant difference in flap failures comparing the anterogradely perfused versus the retrogradely perfused flaps (95 percent CI, −2.25 to 8.87; p = 0.500, McNemar test). There was no statistically significant difference in flap failure comparing the tunneled contralateral flaps with the ipsilateral flaps (95 percent CI, −4.56 to 8.98; p = 1.00, McNemar test).

A regression analysis was performed investigating the correlation of flap failure to the risk factors diabetes mellitus, hypertension, smoking, and age in a linear model. The results of the analysis of variance test confirmed that all these factors have to be assumed equal to 0 (p = 0.64, analysis of variance) and that the failure rate is independent of the risk factors diabetes mellitus, hypertension, smoking, and age. An additional regression analysis for the aforementioned risk factors confirmed these findings (p = 0.65, p = 0.32, p = 0.26, and p = 0.27, r2 linear for all). A similar analysis for the revision rate showed no correlation with the risk factors diabetes mellitus, hypertension, smoking, and age [p = 0.91 (analysis of variance); p = 0.58 (r2 linear), p = 0.84 (r2 linear), p = 0.52 (r2 linear), and p = 0.75 (r2 linear)].

Back to Top | Article Outline

DISCUSSION

Tunneling a DIEP flap to reach the contralateral internal mammary vessels is a technique that we started using in breast reconstruction cases where no suitable ipsilateral recipient vessels were available. This can be attributable to infection, bad scarring after radiation therapy, or vascular or congenital anomalies (Figs. 12 and 13).

Fig. 12.

Fig. 12.

Fig. 13.

Fig. 13.

When the internal mammary system is not available, laterally based pedicles such as the thoracodorsal system, the lateral thoracic artery and vein, the serratus system, or even the subscapular system can be used.5–8 This sometimes leads to suboptimal flap orientation because of pedicle length issues.

After axilla dissection or radiotherapy, the axillary vessels can be damaged or scarred, complicating dissection. In our experience, microsurgery to the internal mammary system is usually more comfortable than working in the axilla, for both surgeon and assistant. It usually allows for easy positioning of the flap.

Sometimes, a large internal mammary artery perforator is found large enough to perfuse a flap. This is mostly a coincidental intraoperative finding, and we do not recommend relying on preoperative computed tomographic scanning for assessment of their possible use for microsurgical anastomosis. Internal mammary artery perforators have an inconsistent anatomy and run very superficial in the breast skin, meaning they could be damaged during mastectomy.4

A third alternative is performing a flap-to-flap anastomosis, with one DIEP flap pedicle (artery and/or vein) serving as the recipient for the second DIEP flap.5,6 This flap-to-flap anastomosis is a technique we performed quite often for the veins but try to avoid for the arteries, as this relies on a single inflow source for perfusion of both flaps. We believe this is better avoided if alternatives are available.

Internal mammary vessel dissection creates a small window-shaped defect at the upper chest wall. Costal cartilage resection and muscle damage can lead to postoperative pain and sometimes even a visible depression. Although more and more surgeons try to avoid resecting cartilage, it is sometimes necessary for good exposure and comfortable microsurgery. Obviating the need for a bilateral costal cartilage resection in bilateral DIEP flap breast reconstructions might give patients more comfort and less postoperative pain, but we do not yet have data to back this suspicion.

Breast cancer and coronary artery disease are leading causes of mortality in women.17 There is no way of precisely estimating both conditions occurring in the same patient, and reports vary from an incidence of 0.8 percent18 to a number needed to treat to save one internal mammary artery for later coronary artery bypass grafting being 61.19–21 Both diseases are surgically treatable, but the gold standard procedures—DIEP flap breast reconstruction and internal mammary artery–based coronary artery bypass grafting—both rely on the internal mammary artery as an arterial conduit. In our study population, two of the 125 treated patients underwent successful left internal mammary artery coronary bypass surgery during the follow-up period. This is perfectly in line with the number needed to treat reported by Rozen et al.21

Experience with bipedicled DIEP flaps and stacked flaps for unilateral breast reconstruction in large-breasted women has shown the value of the retrograde internal mammary artery.10,12,13,22 Stalder et al. performed intraluminal pressure measurements in 15 retrograde internal mammary arteries and veins and found systolic pressure in the retrograde flow internal mammary artery to be 64.1 percent of systemic systolic pressure. Diastolic blood pressure was 87.3 percent of systemic measurements.13 Although these values are somewhat lower than those measured in the anterograde flow internal mammary artery, our data suggest the blood flow through the retrograde internal mammary artery suffices for autonomous flap perfusion. Studies have shown that arterial flow through a free flap pedicle can increase after anastomosis and adapts to flap requirements.23,24 The pressures measured in the retrograde internal mammary vein were comparable to the central venous pressure.

The technique of performing both flap anastomoses to one side of the sternum might seem complicated or tedious. In practice, both the anterograde and retrograde internal mammary arteries are usually available, and the microsurgical skill required for this procedure is comparable to the conventional technique. Looking over the records of all bilateral DIEP flap patients from the senior authors (K.V.L., S.D.A., and F.S.), we identified four patients with inadequate internal mammary vessels that necessitated conversion to the conventional technique of bilateral internal mammary anastomosis (four or 129). It is imperative that, during flap harvest, the deep inferior epigastric artery and vein are dissected up to their origin in the groin. Several arterial and venous side branches are usually available for flap-to-flap anastomosis and can serve as a lifeboat whenever needed. The flap failure rate reported in this series is nine total failures of 250 free flaps, which is 3.6 percent, and not higher than the reported failure rates for bilateral breast reconstructions.25

It is important to stress that conversion to the conventional technique with flap anastomosis on both sides of the sternum is always possible. Conversion is advised whenever the flow through the retrograde internal mammary artery is deemed insufficient, whenever the veins available are of poor quality, or in cases of revision. To facilitate a possible conversion, the contralateral flap is routinely connected to the retrograde vessels. We do not recommend an arterial flap-to-flap anastomosis to the novice surgeon, as problems with a single inflow source for two flaps will lead to bilateral flap failure.

Back to Top | Article Outline

CONCLUSIONS

The bilateral DIEP flap is our first-choice autologous breast reconstruction in most cases. Our data suggest that the retrograde distal internal mammary artery is reliable for autonomous free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure. Anastomosing both flaps to one set of mammary vessels might reduce chest morbidity postoperatively; however, more importantly, it safeguards the left internal mammary artery for cardiac surgery, should this be needed later in life.

Back to Top | Article Outline

REFERENCES

1. Murphy BD, Kerrebijn I, Farhadi J, Masia J, Hofer SOP. Indications and controversies for abdominally-based complete autologous tissue breast reconstruction. Clin Plast Surg. 2018;45:83–91.
2. Atisha DM, Rushing CN, Samsa GP, et al. A national snapshot of satisfaction with breast cancer procedures. Ann Surg Oncol. 2015;22:361–369.
3. Niddam J, Bosc R, Lange F, et al. DIEP flap for breast reconstruction: Retrospective evaluation of patient satisfaction on abdominal results. J Plast Reconstr Aesthet Surg. 2014;67:789–796.
4. 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. Plast Reconstr Surg. 2004;114:62–68.
5. Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: New horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg. 2007;60:904–912; discussion 913–914.
6. DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: A review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg. 2011;127:1093–1099.
7. Agarwal JP, Gottlieb LJ. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction. Ann Plast Surg. 2007;58:359–363.
8. Ali RS, Garrido A, Ramakrishnan V. Stacked free hemi-DIEP flaps: A method of autologous breast reconstruction in a patient with midline abdominal scarring. Br J Plast Surg. 2002;55:351–353.
9. Chan RK, Przylecki W, Guo L, Caterson SA. Case report: The use of both antegrade and retrograde internal mammary vessels in a folded, stacked deep inferior epigastric artery perforator flap. Eplasty 2010;10:e32.
10. Mayo JL, Allen RJ, Sadeghi A. Four-flap breast reconstruction: Bilateral stacked DIEP and PAP flaps. Plast Reconstr Surg Glob Open 2015;3:e383.
11. Nezic D, Antonic Z, Bojovic Z, et al. How to use the left internal thoracic artery which has been damaged during harvesting? Ann Thorac Surg. 2012;94:269–271.
12. Rosa JH, Sherif RD, Torina PJ, Harmaty MA. Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction. J Plast Reconstr Aesthet Surg. 2017;70:47–53.
13. Stalder MW, Lam J, Allen RJ, Sadeghi A. Using the retrograde internal mammary system for stacked perforator flap breast reconstruction: 71 breast reconstructions in 53 consecutive patients. Plast Reconstr Surg. 2016;137:265e–277e.
14. Blechman KM, Broer PN, Tanna N, Ireton JE, Ahn CY, Allen RJ. Stacked profunda artery perforator flaps for unilateral breast reconstruction: A case report. J Reconstr Microsurg. 2013;29:631–634.
15. Salgarello M, Visconti G, Barone-Adesi L, Cina A. The retrograde limb of internal mammary vessels as reliable recipient vessels in DIEP flap breast reconstruction: A clinical and radiological study. Ann Plast Surg. 2015;74:447–453.
16. Al-Dhamin A, Bissell MB, Prasad V, Morris SF. The use of retrograde limb of internal mammary vein in autologous breast reconstruction with DIEAP flap: Anatomical and clinical study. Ann Plast Surg. 2014;72:281–284.
17. World Health Organization. The Global Burden of Disease: 2004 Update. 2008.Geneva: World Health Organization.
18. Nahabedian MY. The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction: Are we burning a future bridge? Ann Plast Surg. 2004;53:311–316.
19. 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.
20. Follmar KE, Prucz RB, Manahan MA, Magarakis M, Rad AN, Rosson GD. Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction. Plast Reconstr Surg. 2011;127:34–40.
21. Rozen WM, Ye X, Guio-Aguilar PL, et al. Autologous microsurgical breast reconstruction and coronary artery bypass grafting: An anatomical study and clinical implications. Breast Cancer Res Treat. 2012;134:181–198.
22. Hernandez Rosa J, Sherif RD, Torina PJ, Harmaty MA. Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction. J Plast Reconstr Aesthet Surg. 2017;70:47–53.
23. Lorenzetti F, Salmi A, Ahovuo J, Tukiainen E, Asko-Seljavaara S. Postoperative changes in blood flow in free muscle flaps: A prospective study. Microsurgery 1999;19:196–199.
24. Lorenzetti F, Suominen S, Tukiainen E, et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg. 2001;17:163–167.
25. Wade RG, Razzano S, Sassoon EM, Haywood RM, Ali RS, Figus A. Complications in DIEP flap breast reconstruction after mastectomy for breast cancer: A prospective cohort study comparing unilateral versus bilateral reconstructions. Ann Surg Oncol. 2017;24:1465–1474.

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2019 by the American Society of Plastic Surgeons