"Revisiting anastomosis to the retrograde internal mammary system in stacked free flap breast reconstruction: an algorithmic approach to recipient site selection".

BACKGROUND We present our stacked flap breast reconstruction experience utilizing caudal internal mammary vessels (IMV) and intra-flap vessels as second anastomotic sites, and propose an algorithm for recipient vessel selection. METHODS After Institutional Review Board approval, a retrospective review of multi-flap breast reconstructions (double-pedicled deep inferior epigastric perforator (DIEP), stacked profunda artery perforator (PAP), and stacked PAP/DIEP) performed at our institution from 2010-2018 was conducted. Data collected included demographics, recipient vessels used, and intra-/post-operative flap complications. Complications were compared between cranial, caudal, and intra-flap anastomoses. RESULTS 403 stacked flaps were performed in 154 patients. Of 403 arterial anastomoses, 49.9% (201/403) were to cranial IMV, 35.2% (142/403) to caudal IMV, and 14.9% (60/403) to intra-flap vessels. Of 442 venous anastomoses, 33.2% (147/442) were to caudal IMV, 46.1% (204/442) to cranial IMV, and 20.9% (92/442) to intra-flap vessels. Intraoperative revision for thrombosis occurred in 8.5% (12/142) of caudal, 7% (14/201) of cranial, and 11.7% (7/60) of intra-flap arterial anastomoses (p=0.373), and in none of caudal, 1.5% (3/204) of cranial, and 2.2% (2/92) of intra-flap venous anastomoses (p=0.559). Postoperative anastomotic complications occurred in 2.7% (11/403) of flaps and were exclusively due to venous compromise; 54.5% (6/11) were salvaged, 45.5% (5/11) were lost. More lost flaps were due to caudal (4/5, 80%) vs. cranial (1/5, 20%) or intra-flap (0/5) thrombosis (p=.020). CONCLUSION Given increased flap loss with the IMV, if vessel features are equivalent between the caudal IMV and intra-flap vessels, intra-flap vessels should be used as first line choice for second site anastomosis.

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