الفهرس 
ANATOMYOnly 14 pages are availabe for public view
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Abstract
N
owadays the standard practice in microsurgical reconstructive breast surgery is focusing on providing good aesthetic outcome with minimal morbidity. So, attention is no longer given to the donner site only but also to the recipient area. selection of recipient vessels is considered one of the most important and crucial aspects in successful microsurgical breast reconstruction. Anastomosis to different blood vessels was reported in free flap breast reconstruction with the evolution from thoracodorsal to internal mammary vessels. Each of them has its own advantages and drawbacks on the success of achieving good aesthetic new breast. So, internal mammary perforators are adopted to be used as recipient vessels in autologus free flap breast reconstruction as it carry many advantages in comparison to the internal mammary, or thoracodorsal vessels although IMAPS are not yet considered standard recipient vessels. It remains unclear if these vessels can be safely used especially in large flaps after radiation therapy or in delayed breast reconstruction. So, this has naturally led us to study the use of perforating branches of internal mammary vessels and its reliability as recipients for free flap breast reconstruction on Egyptian population.
We performed our prospective exploratory study starting in September 2020 to September 2022 working on microsurgical breast reconstruction at Ain Shams University hospitals. 16 female patients were referred to us for delayed breast reconstruction post mastectomy and received their post-operative radiotherapy. All patients had been reconstructed with free deep inferior epigastric artery perforator (DIEP) flap. Internal mammary perforator vessels were attempted to be used as recipient vessels. Preoperative work up was done; investigating the patients with computed tomographic angiographic scan of the chest and abdomen for assessment of the internal mammary perforator (IMP) and DIEP vessels, getting idea about their location, length and diameter. Also hand-held Doppler was used for mapping of the IMP vessels at the second, third or the fourth intercostal spaces in addition to localize the deep inferior epigastric perforator vessels on the anterior abdominal wall. The used Vessels and flap measurements were taken intraoperatively.
All of the cases had been operated as delayed breast reconstruction. Internal mammary perforator vessels were used in 4 patients (25.0%). Most of the perforator vessels are located in the subcutaneous plane (57.1%). 64.3% of the perforator vessels were located in the third intercostal space and 35.7% in the second. Internal mammary perforators were significantly smaller in diameter than internal mammary vessels. whoever they were suitable and reliable as recipient vessels without significant complications like flap loss, fat necrosis and mastectomy skin flap necrosis, except one patient requiring debridement for fat necrosis.
Internal mammary perforator vessels are reliable and safe to be used as recipient vessels in free flap breast reconstruction achieving less invasive technique than using the internal mammary vessels despite their relatively small size, its use can minimize recipient site morbidity as it has many advantages over both the internal mammary and thoracodorsal vessels including: decreased exposure and preparation time for the recipient vessels, no resection of the costal cartilage or rib, preservation of the internal mammary artery for use in future coronary revascularization, avoidance of axillary dissection, ease of positioning the microscope, minimize other reported complications of using IM vessels like pneumothorax, Contour deformity and intercostal neuralgia.
CONCLUSION
T
his study shows that IM perforator vessels are anatomically consistent and they are a reliable and safe alternative as recipients in microvascular breast reconstruction in selected patients. Despite their relatively small size, severe parasternal fibrosis and damage from mastectomy or radiotherapy, the utilization of IMP vessels in delayed reconstructions is feasible, but patient selection is crucial. IM perforators use as recipient vessels is a further refinement in free flap breast reconstruction concomitant with the era of super microsurgery. This technique adds a valuable advantages in achieving successful breast reconstruction with minimal donor and recipient site morbidity.