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Page 8 of 11 Leach et al. Plast Aesthet Res 2023;10:39 https://dx.doi.org/10.20517/2347-9264.2023.32

POSITIVE INTERNAL MAMMARY NODE METASTASIS
The internal mammary vessels are a popular choice as recipient vessels for autologous free flap breast
reconstruction. During the dissection of the internal mammary vessels, lymph nodes may be identified, and
for patients with a history of breast cancer, the concern for possible metastasis is present. In 2011, Yu et al.
discussed their institution’s experience with opportunistic internal mammary lymph node biopsy during
[59]
microsurgical breast reconstruction . They noted 3 prior studies reporting biopsy of internal lymph nodes,
with a total of 9 containing metastasis out of 49 biopsied. Of 293 free flap breast reconstructions, 43 patients
had internal mammary lymph nodes identified during dissection of the internal mammary vessels, with a
total of 6 of these patients having metastasis in the sampled nodes. The treatments varied in their patients,
from radiation to the chest wall and internal mammary lymph node chain, with some patients also receiving
radiation to the supraclavicular fossa, chemotherapy, or no additional treatment. Of the 38 sampled nodes
in the remaining 37 patients, which were negative for metastasis, five were noted to have silicone
granulomas in patients with prior implant-based breast reconstruction, and the remaining 33 showed
inflammatory changes only. It was noted that there was no macroscopic difference identified between these
[59]
nodes . Wright et al. reported on routine internal mammary lymph node sampling in 264 autologous
breast reconstructions (204 patients) . All removed lymph nodes were clinically unremarkable without
[60]
macroscopic evidence of tumor involvement. Six patients had positive metastatic disease, resulting in an
alteration of their adjuvant treatments .
[60]

We recommend a pathologic examination of any lymph nodes identified during the dissection of the
internal mammary vessels and referral to our oncology colleagues for treatment options in the event of
positive nodes.

CONCLUSION
Complications at the recipient site of autologous breast reconstruction can include common surgical
complications (infection, bleeding), recipient site-specific issues (contour deformity, mastectomy skin flap
necrosis), and uncommon complications (pneumothorax, pyoderma gangrenosum, chyle leak, positive
internal mammary nodes). It is important to understand the risks, contributing factors, and treatments for
each. Our hope is this review reinforces treatment options for more common complications as well as
increases awareness of less well-known complications. High clinical suspicion for uncommon complications
can reduce the time to diagnosis and potential additional morbidity from delay in diagnosis and appropriate
treatment.

DECLARATIONS
Authors’ contributions
Literature review and compilations for each topic, introduction, and conclusion: Leach CM
Personal and institutional experiences and recommendations for each topic, introduction, and conclusion:
Collins MS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.