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Leach et al. Plast Aesthet Res 2023;10:39 https://dx.doi.org/10.20517/2347-9264.2023.32 Page 3 of 11

Direct anastomosis of the free flap to internal mammary perforator branches (IMPB) has been described by
several authors [14,17,22] . Munhoz et al. reported on five patients who underwent anastomosis of SIEA flaps to
[17]
the 2nd intercostal space IMPB with no immediate complications . All patients were evaluated with
preoperative CT scan to evaluate both the donor superficial inferior epigastric artery and vein, as well as the
recipient pectoralis muscle perforators and their course . Rad et al. discussed a series of nine patients who
[17]
underwent IMPB anastomosis using a coupler for both arterial (1.5 mm-2.0 mm) and venous
(2.0 mm to 3.0 mm) . Handheld Doppler was used to preoperatively map perforators which were then
[18]
explored for suitability for anastomosis, typically at the second and third ICS .
[18]
The concern for chest wall deformity may be alleviated with suturing of the flap over the area of rib
resection, utilizing a rib-sparing technique, or using intercostal perforators as recipient vessels. While
contour deformity and chronic pain have been described, these have not been noted in the senior author’s
practice with rib-resection at the 3rd or 4th rib and suturing of the flap medially to the chest wall to cover
the defect. This allows for a widened exposure, which can be beneficial in the case of microsurgical
education of trainees as it facilitates the ease of anastomosis.

MASTECTOMY SKIN FLAP NECROSIS
Evaluating the viability of mastectomy skin flaps prior to reconstruction is important to try to minimize
mastectomy skin flap necrosis (MSFN) or massive skin necrosis (> 30% of the breast), as these
complications can lead to prolonged healing and the need for additional interventions. In autologous
reconstruction, this is particularly important during an immediate reconstruction. Risk factors that have
been identified to contribute to MSFN include smoking [23-25] and increased BMI [25,26] . Nykiel et al. reviewed
944 autologous breast reconstructions including 204 free flaps and radiation was not a significant factor in
[25]
the development of MSNF which occurred in 30% of the free flap cases . Patel et al. discussed the
treatment of 12 patients (of 805 reviewed), including 15 breasts (of 1,076 reviewed), who developed massive
[23]
MSFN after autologous breast reconstruction between 1997 and 2010 . Of the patients who developed
MSFN, 41.7% were current smokers and 16.7% were former smokers at the time of preoperative evaluation.
Treatment initially started with allowing an eschar to form and separate. Antibiotics were only started for
secondary cellulitis. Wound healing varied from 30 to 300 days, with 87% of the patients requiring late scar
[23]
revision at an average of 8.9 months after initial surgery . Nykiel et al. published a treatment algorithm for
MSFN in 2014, recommending surgical intervention if wound healing was anticipated to be greater than 3
weeks . Regression analysis showed full-thickness wounds greater than 6 cm and partial-thickness
[25]
2
2
[25]
wounds greater than 5 cm took longer than 21 days to heal without clinical debridement and closure .
Given the significant impact on healing time, increased clinical care, potential for additional procedures,
and impact on patient satisfaction caused by MSFN, several modalities have been evaluated to try to
decrease the incidence. The use of indocyanine green fluorescence angiography (ICGFA) has been
demonstrated to reduce the rate of MSFN to 13% from 23.4% in skin-sparing mastectomies undergoing
reconstruction, effectively reducing those requiring reoperation from 14% to 6% . A 2018 systematic
[27]
review evaluated publications reporting clinical judgment versus indocyanine green (ICG) or fluorescein for
rates of MSFN and reoperation. Clinical judgment had a mean of 19.4% MSFN and 12.9% reoperation. ICG
and fluorescein had mean rates of MSFN of 7.9% and 3%, and mean rates of reoperation of 5.5% and 0%,
respectively. Of note, only a single study evaluating the use of fluorescein was included in the review
(34 breasts) compared to 13 studies using ICG (652 breasts) . Additional imaging modalities that have
[28]
been explored include hyperspectral imaging, which found a cutoff of tissue oxygenation at a depth of 1 mm
(StO2%) < 36.29% led to a greater than 50% chance of mastectomy skin flap necrosis .
[29]