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Tang et al. Plast Aesthet Res 2024;11:61 https://dx.doi.org/10.20517/2347-9264.2024.117 Page 9 of 15

Recipient site preparation
The use of the antegrade and retrograde internal mammary vessels on the side of the mastectomy allows for
the perfusion of two flaps used for both breasts. Exposure of the internal mammary vessels is performed in a
routine fashion, with excision of the third or fourth rib cartilage. To maximize the recipient vessel exposure
for two sets of anastomoses, soft tissue resection of the intercostal muscles typically extends from the rib
superior to the excised cartilage to the rib below. For the planned augmentation, a subglandular pocket is
created for the flap through an inframammary fold (IMF) incision. The IMF incision needs to be long
enough to accommodate the volume of the flap. Once the subgladular pocket is created, a tunnel measuring
approximately 5 cm wide is then created over the sternum connecting the subgladular pocket to the
contralateral mastectomy defect. This limited subcutaneous tunnel is wide enough to allow for the passage
[7,8]
of the pedicles, while limiting the risk of symmastia .

Microvascular anastomosis
We typically perform the anastomosis of the larger flap first. The flap is harvested by dividing the deep
inferior epigastric artery and vein. The flap is then weighed and flushed with heparinized saline from the
arterial end. Under magnification from an operative microscope, the internal mammary artery (IMA) and
vein (IMV) are divided. The anterograde side of the recipient vessels is divided proximally, leaving the rest
of the retrograde recipient vessels as long as possible for the contralateral flap. The larger flap (used for the
mastectomy reconstruction) is first anastomosed in an end-to-end fashion to the antegrade vessels; arteries
are hand-sewn and veins are coupled.

The smaller flap for augmentation is then harvested and prepped in the same manner as the larger flap. Of
note, the flap should be oriented on the chest in such a way that the pedicle, often a single perforator, is
located as medial as possible to maximize reach for anastomosis to the contralateral chest recipient site.
Afterwards, the flap is de-skinned, and occasionally, a thin skin paddle is preserved at the IMF for flap
monitoring. A lighted retractor is helpful when advancing the flap and pedicle into the subglandular pocket.
The flap vessels are placed into a one-inch penrose drain and carefully guided into the subcutaneous tunnel
over the sternum [Figure 6] . Under direct visualization, the flap vessels are positioned into the
[4]
subcutaneous tunnel, ensuring that they are not kinked or twisted to reduce the risk of vascular
compromise . The augmentation flap is carefully advanced into the subglandular pocket. The flap vessels
[7]
are then anastomosed to the retrograde internal mammary vessels [Figure 7]. In our experience, the
retrograde internal mammary vessels have reliable and sufficient blood flow to perfuse the augmentation
flap, since the flap is typically small and the internal mammary artery is a high-flow system . In addition,
[8]
using the retrograde internal mammary vessels avoids the need for additional dissection through the costal
cartilages on the augmentation side and allows for a relatively short incision along the inframammary fold.
If the retrograde internal mammary vessels are noted to be injured or found to be insufficient for perfusion
of the augmented flap, consideration can be given to using alternative recipient vessels, such as the long
thoracic vessels or the thoracoacromial vessels; our priority is ultimately a successful breast reconstruction,
and as such if the augmentation is not possible based on the vasculature, that portion of the procedure does
not have to be done (patients are counseled about this possibility preoperatively). The authors prefer to use
an implantable venous Doppler (Synovis GEM FlowCoupler), particularly when a flap is completely buried
without any skin paddle.

Flap inset and closure
The flaps are secured onto the chest wall using dissolvable sutures and drains are placed in both breasts.
Inset of the buried flap for the augmentation side can be performed with [Figure 8] or without a skin paddle
inset at the IMF. When present, the skin paddle can easily be excised during a secondary revision
procedure.