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• W2105781957 abstract "Dear Sir—Free transverse rectus abdominus myocutaneous (TRAM) flaps and the deep inferior epigastric perforator (DIEP) variant have become the ‘gold standard’ in autologous breast reconstruction. Selection of the recipient vessel is a critical consideration. The thoracodorsal and internal mammary vessels are the most commonly used recipient vessels for free tissue breast reconstructive surgery.Several individuals/institutions have highlighted the benefits and disadvantages of the internal mammary and thoracodorsal vessels as recipients in microvascular breast reconstruction. However, there have been no studies looking at the practice and experiences of a large representative group of reconstructive surgeons regarding recipient vessel choice in breast reconstruction.In 2003, we sent postal questionnaires to UK plastic surgeons with an interest in breast reconstruction. Questions related to experience with thoracodorsal and internal mammary vessels in free TRAM (including DIEP) reconstruction. Surgeons were asked what their preferred and backup recipient vessels were for both immediate and delayed reconstruction. Experience using the thoracodorsal and internal mammary vessels was assessed with regards to a number of parameters. These were: availability of vessels, quality of vessels, ease of dissection, ease of anastomosis, calibre match, pedicle length, flap insetting, success and complications.Of the 54 surgeons who completed the survey (75% response), 53 were performing both immediate and delayed reconstruction. One surgeon performed delayed reconstruction only. Table 1, Table 2 show preferred recipient vessel choice for delayed and immediate reconstruction, respectively. It can be seen from the tables that the internal mammary vessels are the preferred choice for both delayed and immediate reconstruction with 70.4% (p<0.01 using chi-squared test) and 56.6% (p<0.05) of surgeons preferring them, respectively.Table 1Preferred recipient vessel in delayed breast reconstructionRecipient vesselNumber of surgeonsIM38/54 (70.4%)TD12/54 (22.2%)TD or IM2/54 (3.7%)Other vessel2/54 (3.7%)IM, internal mammary; TD, thoracodorsal. Open table in a new tab Table 2Preferred recipient vessel in immediate breast reconstructionRecipient vesselNumber of surgeonsIM30/53 (56.6%)TD18/53 (34.0%)TD or IM3/53 (5.7%)Other vessel2/53 (3.8%)IM, internal mammary; TD, thoracodorsal. Open table in a new tab Thirty-one of 47 (66.0%) surgeons recorded the thoracodorsal vessels as their backup, compared to 12 of 47 (25.5%) favouring the internal mammary vessels as their backup (p<0.01).Just under half (46.3%) the 54 surgeons had changed their practice on average 3.9 years previously. Of these the vast majority (84.0%) had previously used the thoracodorsal vessels as their preferred recipient vessels.When asked to compare the two vessels on a number of parameters, ease of anastomosis and insetting of the flap came out highly significantly in favour of the internal mammary vessels. 85.7% (compared to 16.7% for thoracodorsal) of surgeons stated that insetting of the flap using the internal mammary system was excellent or good (p<0.01). Likewise, 87.8% (compared to 37.5% for thoracodorsal) rated ease of anastomosis as excellent or good (p<0.01).In 1996 Dupin et al. argued that, ‘the internal mammary system should be brought back into the armamentum for free flap breast reconstruction’.1Dupin C.L. Allen R.J. Glass C.A. Bunch R. The internal mammary artery and vein as a recipient site for free-flap breast reconstruction: a report of 110 consecutive cases.Plast Reconstr Surg. 1996; 98: 685-689Google Scholar Several other papers and anatomical studies have demonstrated the reliability and advantages of using the internal mammary system.2Clark C.P. Rohrich R.J. Copit S. et al.An anatomical study of the internal mammary veins: clinical implications for free tissue transfer breast reconstruction.Plast Reconstr Surg. 1997; 99: 400-404Google Scholar, 3Ninkovic M. Anderl H. Hefel L. Scharbegger A. Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.Br J Plast Surg. 1995; 48: 533-539Google Scholar, 4Hefel L. Schwabegger A. Ninkovic M. Wechselberger G. Moriggi B. Waldenberger P. Internal mammary vessels: anatomical and clinical considerations.Br J Plast Surg. 1995; 48: 527-532Google Scholar, 5Ninkovic M. Schwabegger A. Anderl H. Internal mammary vessels as a recipient site.Clin Plast Surg. 1998; 25: 213-221Google Scholar, 6Feng L.J. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels.Plast Reconstr Surg. 1997; 99: 405-416Google Scholar, 7Majumder S. Batchelor A.G.G. Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations.Br J Plast Surg. 1999; 52: 286-289Google ScholarAdvantages of the internal mammary system are said to include: (1) availability, particularly in delayed reconstruction, (2) more versatile flap insetting, (3) pedicle free from arm and shoulder movement, (4) higher arterial pressure, (5) negative pressure in vein and (6) surgeon and assistant comfort.Disadvantages of the internal mammary vessels are said to include: (1) extra time and dissection in immediate reconstruction, (2) removing rib cartilage, (3) delicate veins/variable anatomy and, (4) future availability of vessels for coronary bypass.In 2001, Beckenstein and Grotting stated that the thoracodorsal vessels were the most commonly used vessels in immediate reconstruction, with the internal mammary vessels having a role in delayed reconstruction or in cases where the axilla had been irradiated.8Berkenstein S.M. Grotting J.C. Breast reconstruction with free-tissue transfer.Plast Reconstr Surg. 2001; 108: 1345-1353Google ScholarIt would appear, that in the UK, the internal mammary vessels have become the recipient vessels of choice in free tissue breast reconstruction. What is surprising is that over half the respondents (56.6%) stated that the internal mammary vessels were their first choice in immediate reconstruction. This is interesting as there is no scarring in the immediate setting and the thoracodorsal vessels are easily accessible in the axilla.Flap insetting and ease of anastomosis are significant factors in favour of the internal mammary vessels. The shift in practice in favour of the internal mammary vessels seems to correspond to the recent trend in the literature advocating use of these vessels.2Clark C.P. Rohrich R.J. Copit S. et al.An anatomical study of the internal mammary veins: clinical implications for free tissue transfer breast reconstruction.Plast Reconstr Surg. 1997; 99: 400-404Google Scholar, 3Ninkovic M. Anderl H. Hefel L. Scharbegger A. Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.Br J Plast Surg. 1995; 48: 533-539Google Scholar, 4Hefel L. Schwabegger A. Ninkovic M. Wechselberger G. Moriggi B. Waldenberger P. Internal mammary vessels: anatomical and clinical considerations.Br J Plast Surg. 1995; 48: 527-532Google Scholar, 5Ninkovic M. Schwabegger A. Anderl H. Internal mammary vessels as a recipient site.Clin Plast Surg. 1998; 25: 213-221Google Scholar, 6Feng L.J. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels.Plast Reconstr Surg. 1997; 99: 405-416Google Scholar, 7Majumder S. Batchelor A.G.G. Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations.Br J Plast Surg. 1999; 52: 286-289Google Scholar Dear Sir—Free transverse rectus abdominus myocutaneous (TRAM) flaps and the deep inferior epigastric perforator (DIEP) variant have become the ‘gold standard’ in autologous breast reconstruction. Selection of the recipient vessel is a critical consideration. The thoracodorsal and internal mammary vessels are the most commonly used recipient vessels for free tissue breast reconstructive surgery. Several individuals/institutions have highlighted the benefits and disadvantages of the internal mammary and thoracodorsal vessels as recipients in microvascular breast reconstruction. However, there have been no studies looking at the practice and experiences of a large representative group of reconstructive surgeons regarding recipient vessel choice in breast reconstruction. In 2003, we sent postal questionnaires to UK plastic surgeons with an interest in breast reconstruction. Questions related to experience with thoracodorsal and internal mammary vessels in free TRAM (including DIEP) reconstruction. Surgeons were asked what their preferred and backup recipient vessels were for both immediate and delayed reconstruction. Experience using the thoracodorsal and internal mammary vessels was assessed with regards to a number of parameters. These were: availability of vessels, quality of vessels, ease of dissection, ease of anastomosis, calibre match, pedicle length, flap insetting, success and complications. Of the 54 surgeons who completed the survey (75% response), 53 were performing both immediate and delayed reconstruction. One surgeon performed delayed reconstruction only. Table 1, Table 2 show preferred recipient vessel choice for delayed and immediate reconstruction, respectively. It can be seen from the tables that the internal mammary vessels are the preferred choice for both delayed and immediate reconstruction with 70.4% (p<0.01 using chi-squared test) and 56.6% (p<0.05) of surgeons preferring them, respectively. IM, internal mammary; TD, thoracodorsal. IM, internal mammary; TD, thoracodorsal. Thirty-one of 47 (66.0%) surgeons recorded the thoracodorsal vessels as their backup, compared to 12 of 47 (25.5%) favouring the internal mammary vessels as their backup (p<0.01). Just under half (46.3%) the 54 surgeons had changed their practice on average 3.9 years previously. Of these the vast majority (84.0%) had previously used the thoracodorsal vessels as their preferred recipient vessels. When asked to compare the two vessels on a number of parameters, ease of anastomosis and insetting of the flap came out highly significantly in favour of the internal mammary vessels. 85.7% (compared to 16.7% for thoracodorsal) of surgeons stated that insetting of the flap using the internal mammary system was excellent or good (p<0.01). Likewise, 87.8% (compared to 37.5% for thoracodorsal) rated ease of anastomosis as excellent or good (p<0.01). In 1996 Dupin et al. argued that, ‘the internal mammary system should be brought back into the armamentum for free flap breast reconstruction’.1Dupin C.L. Allen R.J. Glass C.A. Bunch R. The internal mammary artery and vein as a recipient site for free-flap breast reconstruction: a report of 110 consecutive cases.Plast Reconstr Surg. 1996; 98: 685-689Google Scholar Several other papers and anatomical studies have demonstrated the reliability and advantages of using the internal mammary system.2Clark C.P. Rohrich R.J. Copit S. et al.An anatomical study of the internal mammary veins: clinical implications for free tissue transfer breast reconstruction.Plast Reconstr Surg. 1997; 99: 400-404Google Scholar, 3Ninkovic M. Anderl H. Hefel L. Scharbegger A. Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.Br J Plast Surg. 1995; 48: 533-539Google Scholar, 4Hefel L. Schwabegger A. Ninkovic M. Wechselberger G. Moriggi B. Waldenberger P. Internal mammary vessels: anatomical and clinical considerations.Br J Plast Surg. 1995; 48: 527-532Google Scholar, 5Ninkovic M. Schwabegger A. Anderl H. Internal mammary vessels as a recipient site.Clin Plast Surg. 1998; 25: 213-221Google Scholar, 6Feng L.J. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels.Plast Reconstr Surg. 1997; 99: 405-416Google Scholar, 7Majumder S. Batchelor A.G.G. Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations.Br J Plast Surg. 1999; 52: 286-289Google Scholar Advantages of the internal mammary system are said to include: (1) availability, particularly in delayed reconstruction, (2) more versatile flap insetting, (3) pedicle free from arm and shoulder movement, (4) higher arterial pressure, (5) negative pressure in vein and (6) surgeon and assistant comfort. Disadvantages of the internal mammary vessels are said to include: (1) extra time and dissection in immediate reconstruction, (2) removing rib cartilage, (3) delicate veins/variable anatomy and, (4) future availability of vessels for coronary bypass. In 2001, Beckenstein and Grotting stated that the thoracodorsal vessels were the most commonly used vessels in immediate reconstruction, with the internal mammary vessels having a role in delayed reconstruction or in cases where the axilla had been irradiated.8Berkenstein S.M. Grotting J.C. Breast reconstruction with free-tissue transfer.Plast Reconstr Surg. 2001; 108: 1345-1353Google Scholar It would appear, that in the UK, the internal mammary vessels have become the recipient vessels of choice in free tissue breast reconstruction. What is surprising is that over half the respondents (56.6%) stated that the internal mammary vessels were their first choice in immediate reconstruction. This is interesting as there is no scarring in the immediate setting and the thoracodorsal vessels are easily accessible in the axilla. Flap insetting and ease of anastomosis are significant factors in favour of the internal mammary vessels. The shift in practice in favour of the internal mammary vessels seems to correspond to the recent trend in the literature advocating use of these vessels.2Clark C.P. Rohrich R.J. Copit S. et al.An anatomical study of the internal mammary veins: clinical implications for free tissue transfer breast reconstruction.Plast Reconstr Surg. 1997; 99: 400-404Google Scholar, 3Ninkovic M. Anderl H. Hefel L. Scharbegger A. Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.Br J Plast Surg. 1995; 48: 533-539Google Scholar, 4Hefel L. Schwabegger A. Ninkovic M. Wechselberger G. Moriggi B. Waldenberger P. Internal mammary vessels: anatomical and clinical considerations.Br J Plast Surg. 1995; 48: 527-532Google Scholar, 5Ninkovic M. Schwabegger A. Anderl H. Internal mammary vessels as a recipient site.Clin Plast Surg. 1998; 25: 213-221Google Scholar, 6Feng L.J. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels.Plast Reconstr Surg. 1997; 99: 405-416Google Scholar, 7Majumder S. Batchelor A.G.G. Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations.Br J Plast Surg. 1999; 52: 286-289Google Scholar" @default.
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