Using the Venous Pectoral Branch from the Thoracoacromial System as a Lifeboat in Autologous Breast Reconstruction

The most common recipient vessels for autologous free flap breast reconstruction are the internal mammary vessels. At times, there are problems with the exposed internal mammary vein (IMV) that require other options such as using the contralateral IMV, superior rib resection to access proximal IMV, retrograde IMV use, and thoracodorsal vein access with or without a vein graft. This case demonstrates using the pectoral branch of the thoracoacromial venous system without a vein graft as a lifeboat option when the IMV is not suitable for anastomosis. C.W. was a 65-year-old female who underwent right-sided mastectomy with placement of a tissue expander. After adjuvant radiation therapy, C.W. underwent deep inferior epigastric perforator free flap breast reconstruction. During exposure of the internal mammary artery and IMV, an iatrogenic venotomy occurred that precluded the use of this vessel as a reliable recipient. The deep inferior epigastric perforator flap pedicle was then dissected proximal to isolate the artery and vein, and the vein was successfully anastomosed to the venous pectoral branch of the thoracoacromial system. The postoperative course was uneventful and patient was discharged home on postoperative day 4. Using the venous pectoral branch of the thoracoacromial is a safe and valuable option that can be considered in difficult situations when the IMV is not a suitable option.