Does Size Matter: Evaluating the Difference between Right and Left Internal Mammary Veins in Free Flap Breast ReconstructionFunding None.
17 December 2018
28 May 2019
14 July 2019 (eFirst)
Background Venous congestion in breast free flap reconstruction continues to be a major reason for flap compromise requiring reoperative exploration and possible flap failure. We aim to investigate whether size of the internal mammary vein (IMV) (1) varies between the left and right sides, (2) changes with certain patient demographics or preoperative factors, and (3) correlates with postoperative complications.
Methods We performed a retrospective cohort study examining all patients undergoing free flap breast reconstruction from September 2005 to March 2016 using internal mammary recipient veins. Venous coupler size was used as a surrogate measure of IMV diameter. Preoperative patient characteristics and factors were collected. Postoperative outcomes assessed included thrombosis, flap loss, fat necrosis, and mastectomy flap necrosis. Multivariate analyses were performed to evaluate if preoperative factors affected IMV diameter and to determine if coupler size and flap side were independent risk factors for postoperative complications.
Results We examined 372 patients with a total of 561 flaps. One hundred eighty-nine patients received bilateral flaps with the IMV as a recipient. The right IMV (n = 286, average = 2.97 mm, standard deviation [SD] = 0.41) was significantly larger than the left (n = 275, average = 2.89, SD = 0.35, p = 0.008). Preoperative factors and postoperative complications were not statistically different between the left and right cohorts. The multivariable linear regression model with coupler size as the dependent variable found older age trended toward a larger coupler size but this was not significant (p = 0.05). In multilinear regression analysis, the postoperative outcomes did not have significant covariates.
Conclusion We found that IMV size significantly differs between the right and the left sides. However, incidence of postoperative complications was not significantly different between the left and right sides, and the multivariate analyses did not identify flap side as an independent risk factor for adverse outcomes. Prospective studies evaluating actual IMV diameter and associated complications may potentially elucidate clinical significance.
- 1 Fischer JP, Wes AM, Nelson JA. , et al. Propensity-matched, longitudinal outcomes analysis of complications and cost: comparing abdominal free flaps and implant-based breast reconstruction. J Am Coll Surg 2014; 219 (02) 303-312
- 2 Lee CD, Butterworth J, Stephens RE, Wright B, Surek C. Location of the internal mammary vessels for microvascular autologous breast reconstruction: the “1-2-3 rule”. Plast Reconstr Surg 2018; 142 (01) 28-36
- 3 Greer-Bayramoglu RJ, Chu MWA, Fortin AJ. Feasibility of internal mammary vessel use in breast reconstruction versus coronary artery bypass surgery: an anatomic, cadaveric evaluation. Plast Reconstr Surg 2011; 127 (05) 1783-1789
- 4 Hamdi M, Rasheed MZ. Advances in autologous breast reconstruction with pedicled perforator flaps. Clin Plast Surg 2012; 39 (04) 477-490
- 5 Macadam SA, Bovill ES, Buchel EW, Lennox PA. Evidence-based medicine: autologous breast reconstruction. Plast Reconstr Surg 2017; 139 (01) 204e-229e
- 6 Schwabegger AH, Ninković MM, Moriggl B. , et al. Internal mammary veins: classification and surgical use in free-tissue transfer. J Reconstr Microsurg 1997; 13 (01) 17-23
- 7 Feng LJ. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels. Plast Reconstr Surg 1997; 99 (02) 405-416
- 8 Schipper RJ, Lobbes MBI, Dikmans RE, Beets-Tan RG, Smidt ML, Boetes C. Bilateral analysis of the cross-sectional area of the internal mammary arteries and veins in patients with and without breast cancer on breast magnetic resonance imaging. Insights Imaging 2013; 4 (02) 177-184
- 9 Jacobson JI, Suarez EL. Microsurgery in anastomosis of small vessels. Surg Forum 1960; 11: 243-245
- 10 Kulkarni AR, Mehrara BJ, Pusic AL. , et al. Venous thrombosis in handsewn versus coupled venous anastomoses in 857 consecutive breast free flaps. J Reconstr Microsurg 2016; 32 (03) 178-182
- 11 Jandali S, Wu LC, Vega SJ, Kovach SJ, Serletti JM. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg 2010; 125 (03) 792-798
- 12 Head LK, McKay DR. Economic comparison of hand-sutured and coupler-assisted microvascular anastomoses. J Reconstr Microsurg 2018; 34 (01) 71-76
- 13 Hanson SE, Mitchell MB, Palivela N. , et al. Smaller diameter anastomotic coupling devices have higher rates of venous thrombosis in microvascular free tissue transfer. Plast Reconstr Surg 2017; 140 (06) 1293-1300
- 14 Broer PN, Weichman KE, Tanna N. , et al. Venous coupler size in autologous breast reconstruction--does it matter?. Microsurgery 2013; 33 (07) 514-518
- 15 Chang EI, Chang EI, Soto-Miranda MA, Nosrati N, Robb GL, Chang DW. Demystifying the use of internal mammary vessels as recipient vessels in free flap breast reconstruction. Plast Reconstr Surg 2013; 132 (04) 763-768
- 16 Venturi ML, Poh MM, Chevray PM, Hanasono MM. Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction. Microsurgery 2011; 31 (08) 596-602