Figure 1. Normal vascular anatomy of the internal mammary artery and vein. (Reprinted with permission from Continuum Health Partners.)
Figure 2. Zigzag skin incision for access over the right side of the chest. (Reprinted with permission from Continuum Health Partners.)
Figure 3. Conventional technique for access to the internal mammary (IM) artery and vein. A, Standard technique. Sagittal view of the IM artery and ribs. CC indicates costrochondral cartilage. B, Incision of perichondrium over the rib segment to be removed. C, Incision through deep perichondrium after removal of the rib to enable access to the IM artery and vein. D, Dissection of the intercostal muscles and perforators from underlying IM vessels. (Reprinted with permission from Continuum Health Partners.)
Figure 4. Conventional technique. Internal mammary artery and vein are rotated superiorly, with vein grafts to the scapular free flap.
Figure 5. Rib-sparing technique. Pectoralis major muscle fibers are separated to gain access to the intercostal space. (Reprinted with permission from Continuum Health Partners.)
Figure 6. Rib-sparing technique. A, Incision of perichondrium of the second and third ribs. CC indicates costrochondral cartilage. B, Intercostal musculature and perichondrium have been removed to allow access to the internal mammary (IM) vessels. (Reprinted with permission from Continuum Health Partners.)
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Jacobson AS, Smith M, Urken ML. Internal Mammary Artery and Vein as Recipient Vessels in Head and Neck Reconstruction. JAMA Otolaryngol Head Neck Surg. 2013;139(6):623–628. doi:10.1001/jamaoto.2013.3062
Author Affiliations: Departments of Otolaryngology–Head and Neck Surgery (Drs Jacobson and Urken) and Surgery (Dr Smith), Beth Israel Medical Center, New York, New York, and Departments of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York (Drs Jacobson, Smith, and Urken).
Importance Free-tissue transfer for head and neck reconstruction has evolved since the mid-1950s. A variety of different recipient arteries and veins have been described for use in head and neck reconstruction. In our experience, the internal mammary artery (IMA) and internal mammary vein (IMV) have become increasingly important for achieving successful microvascular reconstruction.
Objective To illustrate the efficacy of the IMA and IMV recipient vessels in head and neck reconstruction, highlighting the different techniques used to harvest these vessels and outline decision making when approaching a neck where commonly used vessels are unavailable.
Design Retrospective medical record review.
Setting Outpatient clinic setting.
Participants All free-tissue transfers performed between 2005 and 2011. All patients in whom the IMA or IMV recipient vessels were used were included.
Interventions Twelve cases were performed with IMA and IMV harvest.
Main Outcomes and Measures Donor site, flap used, recipient artery and vein, success of transfer, flap survival, and presence of donor site complications.
Results The IMA and IMV were harvested in 12 patients, with 11 successful free-tissue transfers. In 1 patient, the vessels were unusable, and a regional tissue transfer was performed.
Conclusions and Relevance The IMA and IMV are excellent recipient vessels for use in head and neck reconstruction and should be considered for use in challenging reconstructive cases.
Free-tissue transfer for head and neck reconstruction has been evolving since the mid-1950s.1,2 In recent years, flap survival rates have been reported to be 95% to 98%.3-5 Fibrosis due to prior surgery, external beam radiation therapy, and multiple prior operations can lead to the clinical situation known as the “vessel-depleted neck,” forcing reconstructive surgeons to search for recipient vessels outside routine locations and reducing success rates.6-10 A variety of recipient arteries and veins have been described for use in head and neck reconstruction.11-16 Recipient arteries include the superior thyroid, facial, superficial temporal, transverse cervical, thoracoacromial, and internal mammary arteries and the external carotid branches (lingual and internal maxillary arteries). Recipient veins include the superior thyroid, facial, superficial temporal, transverse cervical, external jugular, internal mammary, internal jugular, and cephalic veins. Vessels that are more remote often have no exposure or lower rates of exposure to external beam radiation therapy and therefore can be more favorable for a microvascular anastomosis.
The internal mammary artery (IMA) and internal mammary vein (IMV) were first described as recipient vessels in breast reconstruction and recently have been described as the “first-choice” recipient vessels for such procedures.17-19 In our experience, the IMA and IMV have become increasingly important for achieving successful microvascular reconstruction in the vessel-depleted neck. This case series illustrates the efficacy of these recipient vessels in head and neck reconstruction, highlights different techniques used to harvest them, and outlines our decision process when approaching reconstruction in a neck for which commonly used recipient vessels are unavailable.
We retrospectively reviewed medical records in 12 patients in whom free-tissue transfer to the head and neck was planned and prior surgery and radiation therapy precluded using the more typical recipient vessels. Institutional review board approval was obtained. Records were reviewed for defect reconstructed, flap used, recipient artery and vein, success of transfer, prior radiation therapy, prior neck surgery, and complications.
The IMA and IMV are located underneath the superior 6 ribs, just lateral to the sternum (Figure 1). The IMA originates from the subclavian artery and the IMV from the brachiocephalic vein. The second intercostal space is the most reliable location to harvest the vein, which is approximately 3 mm in diameter at this location.11 The IMV decreases in diameter to less than 1.5 mm as it descends inferiorly, and it bifurcates during its descent.11 There is a preference to harvest the IMA and IMV on the right side because the IMA is slightly larger and the IMV bifurcates more distally on this side.11 Above the level of the second rib, the IMA and IMV begin to descend deep into the chest cavity, and additional length is not achieved by dissecting more proximally. Therefore, it is usually not beneficial to dissect proximal to the first intercostal space.
Two basic approaches are used to harvest the IMA and IMV: the conventional technique, which requires removing a small medial section of the rib to access the vessels, and the “rib-sparing” technique. A thorough understanding of these 2 harvest techniques is necessary to avoid donor site complications and maintain efficiency within the operating theater. The normal vascular anatomy of the IMA and IMV can be seen in Figure 1.
In the conventional technique, a skin incision is made to access the right chest (Figure 2). Dissection is performed down through the subcutaneous tissue to the medial border of the pectoralis major muscle. The muscle is divided vertically with electrocautery to gain access to the underlying costochondral junction. The perichondrium is divided over the cartilage of the second rib, and a 2-cm-wide segment of the cartilage is dissected free from the surrounding perichondrium with use of a Freer elevator (Figure 3A and B). A large blunt-tipped rongeur allows easy removal of the rib cartilage while leaving the posterior aspect of the perichondrium intact. The IMA and IMV run from superior to inferior just deep to the perichondrium. The remaining posterior perichondrium is incised sharply in a vertical direction, and Mosquito forceps are then used to trace the vessels inferiorly.
All soft tissue superficial to the vessels (intercostal muscle) is divided sharply until the third rib is reached (Figure 3C and D). A small section of the third rib is similarly removed, and the vessels are traced inferiorly. The fourth, fifth, and sixth ribs can be removed for increased vessel length. Although the arterial caliber may remain of adequate diameter down to this level, the vein usually bifurcates at the level of the third rib and may become small as one proceeds distally. The vessels are eventually ligated and transected distally and then transposed superiorly for use near the neck (Figure 4). Proximally, additional muscle can be removed from the first interspace; however, removal of the first rib cartilage does not add significant vessel length because, at this level, the vessel begins to course deep into the chest.
The rib-sparing technique for harvesting these vessels is used when only a short length of vessel is necessary to achieve a successful anastomosis.20,21 This variation in harvest technique is much more frequently applied in breast reconstruction but has been successfully used for reconstruction in the cervical region when combined with an anterolateral thigh flap, which typically has a long pedicle. In this technique, an incision is made over the parasternal region, starting at the clavicle and extending to the fourth rib (Figure 2). Dissection is performed down to the pectoralis major muscle. The medial border of the pectoralis muscle is then split along its fibers to expose the second intercostal space, and the fibers are held open with Gelpi retractors (Figure 5). If additional exposure is required proximally or distally, the sternal attachment of the pectoralis may be released.
The perichondrium is incised longitudinally over the second and third intercostal cartilages from the sternal border to the costochondral junction. A Freer elevator is used to elevate the perichondrium off the lower border of the second costal cartilage and the upper border of the third cartilage. The perichondrium is then divided at the inferior aspect of the costal cartilage from lateral to medial, and jeweler-tip bipolar forceps are used to expose the intercostal muscle fibers that overlie the IMA and IMV. The intercostal muscle fibers are first divided between the 2 ribs laterally at the costochondral junction. The muscle is elevated out of the second intercostal space by dividing the attachments to the second and third ribs from lateral to medial (Figure 6).
The vessels are located in a fat pad under the junction of the ribs with the sternum (1-2 cm lateral to the sternum). The IMA lies lateral to the IMV until the vein has bifurcated. There is a thin membrane over the fat pad, creating a plane between the fat pad and the overlying muscle. Perforating vessels may transverse this plane and should be carefully divided with the bipolar cautery or clips. If greater visualization is needed or additional vessel length is desired, the costal cartilage is safely removed with a large rongeur, and dissection may proceed proximally or distally along the vessels as described in the first technique. If the flap has adequate pedicle length, the anastomosis may be performed in the second interspace. The muscle is then carefully released from the Gelpi retractors. If there is any evidence of compression by the pectoralis muscle, the fibers are transected to allow the pedicle to lie naturally without kinking.
Although the rib-sparing technique is used mostly for breast reconstruction, those who perform head and neck reconstruction should be aware of its potential use in this setting. The technique's disadvantage, however, is that it reduces recipient vessel length because the vessels are not fully released from their native location.
Twelve patients, 8 male and 4 female, underwent a total of 11 free-tissue transfers for a variety of reconstructive problems (Table). In all patients, the right IMA was harvested in preparation for a microvascular reconstruction, and the conventional technique, described above, was used in all but 1 patient (patient 9). All patients had undergone prior external beam irradiation and extensive prior neck surgery. All microvascular anastomoses were end to end.
Flaps were successfully transferred in all patients except 1, in whom poor flow in the IMA precluded its use; the reconstructive surgeon did not proceed with harvesting a free flap and performed pectoralis major soft-tissue reconstruction instead. In another patient, a local wound infection required drain placement and 1 week of intravenous antibiotic treatment. Immediate postoperative pain was managed in a standard fashion, with no deviation from the normal pain management regimen used in our patients. There were no complaints of pain specific to the location of the harvest, longer-term pain, or severe cosmetic deformity associated with this recipient vessel donor site. Patient sex did not affect the ability to harvest the vessels, their utility, or the occurrence of short- or long-term postoperative complications.
Patients who have undergone prior neck surgery, chemotherapy, and external beam radiation therapy should be carefully considered for a microvascular procedure. Many of these patients have a vessel-depleted neck, which presents a significant challenge to even the most experienced microvascular surgeons. In this situation, head and neck reconstructive surgeons are forced to search for recipient vessels other than the commonly used external carotid branches (facial artery, superior thyroid artery, lingual artery, and temporal artery), internal jugular vein branches, and external jugular vein. The IMA and IMV are important alternatives that reconstructive surgeons must consider and be prepared to harvest.
When approaching a neck that may be depleted of the commonly used recipient vessels, one must carefully plan the reconstructive procedure, considering which recipient vessels may still be present and usable (based on information from prior operations, radiation fields, and physical examination). The next critical decision is considering which particular free flap will be harvested. Choosing a flap with a long vascular pedicle can alleviate some of the difficulties associated with reaching remote recipient vessels. If it is necessary to harvest a flap with a short vascular pedicle and there is no suitable alternative flap with a longer pedicle, the surgeon must consider using vein grafts to reach distant recipient vessels. The need for vein grafts should be anticipated early so that they can be harvested and prepared before the free flap is harvested. The greater and lesser saphenous veins are long, large-caliber, readily accessible veins that can be harvested in a 2-team approach.
All the aforementioned decisions must be made before beginning the procedure in the operating room. Once in the operating theater, it has been our practice to surgically explore the patient's neck systematically to identify potential recipient vessels that are still present and healthy enough to be used in a microvascular procedure. In general, we attempt to find vessels within the ipsilateral and then the contralateral part of the neck before we proceed with harvesting the internal mammary vessels.
If the reconstruction is to be performed cephalad to the inferior border of the mandible, then the superficial temporal artery, facial artery, and superior thyroid arteries are our first-choice recipient arteries. If all these vessels have been depleted or rendered unusable, then vein grafts are used to reach more remote vessels (low in the neck or in the contralateral part of the neck). Once a suitable recipient artery is identified, the next step is to identify a viable recipient vein. In general, we consider the superficial temporal, facial, and external and internal jugular veins as our first-choice veins.
If the defect to be reconstructed is caudal to the mandible, our first-choice recipient vessels are the transverse cervical artery and vein, superior thyroid artery and vein, facial artery and vein, and external or internal jugular vein. If these vessels are unusable, it becomes important to consider alternative recipient vessels outside the neck, such as the thoracoacromial artery, cephalic vein, or IMA and IMV.
When identifying a recipient vein, it is often tempting to consider using the anterior jugular veins. Unfortunately, most patients undergoing head and neck reconstructive surgery will have or have had a tracheostomy. Iatrogenic injury to the anterior jugular veins during a tracheotomy or the inflammation associated with the stoma make these veins very unfavorable; therefore, we do not consider these as potential recipient veins.
Although the experience using the IMA and IMV in breast reconstruction is far more extensive, our small case series shows that these vessels can be successfully used to achieve a microvascular anastomosis in the head and neck. Because these reconstructions are often dependent on the IMA and IMV as a last resort to achieve a microvascular reconstruction, it is important to harvest these recipient vessels before the free flap to determine that they are healthy and usable. Unfortunately, we did experience a case in which the IMA was not suitable for free-tissue transfer owing to severe atherosclerosis, which caused insufficient flow. In general, however, we have found the IMA to be an excellent recipient artery with a generous caliber and high-pressure arterial flow. The IMV may be quite thin walled. We found no significant differences between male and female patients in the harvest of these recipient vessels. The use of a venous coupler (Synovis) is frequently noted in the breast reconstruction literature and facilitates coaptation of thin-walled veins and veins of different calibers. Using the conventional technique for harvesting these vessels will significantly increase the available length.
The disadvantages of harvesting the internal mammary vessels are the fragility of the veins, potential anatomic variants,22 potential for pneumothorax, intercostal nerve injury or neuralgia, cosmetic deformity of the donor site, and reduced blood supply to the sternum.23,24 A life-threatening case of cardiac tamponade has been reported.25 Furthermore, the use of these vessels precludes their future use in coronary artery bypass surgery.26
There is emerging research on the robotic harvesting of the internal mammary vessels; these studies have been discussed in the plastics literature.27 We have not added this technique to our algorithm because of concerns about increasing the length of an already extensive and lengthy procedure.
In conclusion, the IMA and IMV provide excellent recipient vessels for use in head and neck reconstruction. These vessels are harvested from a location remote from both prior neck procedures and conventional head and neck radiation fields and therefore provide reconstructive surgeons with healthy, accessible vessels for use in challenging reconstructive cases. These vessels can be harvested quickly and efficiently with little donor site morbidity.
Correspondence: Adam S. Jacobson, MD, Department of Otolaryngology–Head and Neck Surgery, Beth Israel Medical Center, 10 Union Square E, Ste 5B, New York, NY 10003 (firstname.lastname@example.org).
Submitted for Publication: January 7, 2013; final revision received February 21, 2013; accepted March 26, 2013.
Author Contributions:Study concept and design: All authors. Acquisition of data: Smith. Analysis and interpretation of data: Jacobson. Drafting of the manuscript: Jacobson and Smith. Critical revision of the manuscript for important intellectual content: Urken. Administrative, technical, and material support: Jacobson.
Conflict of Interest Disclosures: None reported.