Floor plan - 2013 Annual Meeting - American Association for Hand ...

Utilization of the Internal Mammary Intercostal Perforator Instead of the True Internal
Mammary Vessels as the Recipient Vessels for Breast Reconstruction
Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA
Gedge D. Rosson, MD; Eduardo D. Rodriguez; Jaime I. Flores; Michele A. Manahan; Nia D. Banks; Navin K. Singh;
Johns Hopkins School of Medicine
OBJECTIVE:
Although autologous free tissue transfer has become a mainstay in breast reconstruction, there exist inherent controversies regarding
the procedure, including choice of recipient vessels. For the past few years, our institution has preferred the routine use of the internal
mammary artery and vein for DIEP and SGAP flap reconstruction. In an effort to decrease any potential morbidity at the recipient site
by preserving the internal mammary artery for potential use as a coronary artery bypass conduit in the future, we aim to use the internal
mammary intercostals perforator as a recipient vessel if suitable. We have implemented the following protocol: preoperative mapping
of the perforators along the sternal border with a hand-held Doppler, intraoperative exploration to find a suitable perforator, and
costal cartilage resection if necessary to expose the true internal mammary vessels. Our previous cadaver studies showed that the
largest internal mammary intercostal perforator is usually located in the 2nd or 3rd intercostal space. In this study we sought to evaluate
the utility of the internal mammary intercostal perforator for microsurgical breast reconstruction.
METHODS:
We retrospectively reviewed a single surgeon's first 101 DIEP flap breast reconstructions, performed during a 1 ? year period from July
2005 through January 2007. Recipient vessel selection, flap failure, and development of fat necrosis were critically analyzed.
RESULTS:
Of these 101 flaps reviewed, 22 DIEP flaps were anastomosed to an internal mammary intercostal perforator in the 2nd or 3rd interspace.
When broken down into groups of 20 flaps, a statistically significant pattern of increasing frequency of usage emerges. In the
first 20 flaps an IM perforator was used for only one flap (5%), while in the final 20 flaps an IM perforator was used for 9 flaps (45%).
Overall, four flaps had partial flap fat necrosis of less than 5% of the flap volume and one patient had total failure of the flap due to
venous congestion; however none of these were in the flaps using the IM intercostal perforator.
CONCLUSIONS:
The probable need for use of the internal mammary artery for future coronary artery bypass graft is rare in our breast cancer reconstruction
patients. However, we have implemented an approach to utilize the IM intercostal perforating vessels as the recipient vessels when
suitable. Although the learning curve is steep, use of these vessels can be performed safely without increased fat necrosis and preserve
the internal mammary artery for potential future life-saving surgery.
Microvascular Free Tissue Transfer for Breast Reconstruction in the Elderly: A Safe and
Effective Option
Institution where the work was prepared: Georgetown University Hospital, Washington, DC, USA
Jeffrey M. Jacobson, MD; Maurice Y. Nahabedian, MD; Georgetown University Hospital
While nearly half of breast cancer cases involve women 65 years of age or older, there is a paucity of literature reviewing microvascular
free tissue transfer for breast reconstruction in this age group. The objective of this study was to evaluate the safety and efficacy of
microvascular free tissue transfer for breast reconstruction in women 65 years of age and over. Between 1997 and 2007, 890 women
underwent immediate or delayed microvascular breast reconstruction by a single surgeon. Of these, 21 (2.4%) were performed on
women 65 years of age or older (mean age 68, range 65-82). Women were assessed for candidacy, evaluated for medical co-morbidities,
and cleared for surgery by their primary care physician. Reconstructions were unilateral in 18 women and bilateral in 3, immediate
in 17 cases and delayed in 7, and the specific flaps included the DIEP (16), free TRAM (7), and SGAP (1). 14 DIEP flaps were based off
of a single perforator (87.5%) and 2 DIEP flaps were based off of 2 perforators (12.5%). The free TRAM flaps were MS-0 in 1 case (14%),
MS-1 in 2 cases (29%), and MS-2 in 4 cases (57%). Recipient artery and vein included the internal mammary in 14 women (67%) and the
thoracodorsal in 7 women (33%). Co-morbidities included diabetes mellitus (4.8%), tobacco use (4.8%), hypertension (33%), and preoperative
XRT (9.5%). Cancer stage ranged from 0 to 2B. Mean follow-up was 26.6 months (range, 5-84 months). Complete success
without morbidity was achieved in 17 women (81%). Surgical complications occurred in 4 women including failure of 1 DIEP flap secondary
to venous thrombosis, 2 abdominal bulges following unilateral and bilateral DIEP flaps, and fat necrosis (