The Northeastern Society of Plastic Surgeons

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Revisiting the Role of the Internal Mammary in Breast Reconstruction: Considerations in Current Practice
Steven M. Sultan, M.D., Amanda M. Rizzo, B.A., Tessa J. Campbell, MD, Lawrence Draper, MD, Heather A. Erhard, MD, Teresa Benacquista, MD, Katie E. Weichman, MD.
Montefiore Medical Center, New York, NY, USA.

Background
The internal mammary artery (IMA) has gradually replaced the thoracodorsal as the primary recipient vessel in autologous breast reconstruction because of its ease of harvest, medial location within the breast pocket and beneficial geometry for microsurgery. Despite the widespread use of the IMA in this application there is growing concern in our center that current trends in reconstruction may demand a review of the safety of IMA harvest given the possibility that our patients may go on to require coronary artery bypass grafting (CABG) in the future.
Methods
A retrospective review of all patients who underwent autologous breast reconstruction at Montefiore Medical Center in the past nine years was conducted. Patients treated in 2009-2011 were compared to those treated in 2017. The groups were compared on the basis of demographic data (age, race, BMI), comorbidities (hypertension, diabetes, hyperlipidemia, smoking) and operative characteristics (laterality, indications). The patients in each group were further risk-stratified for 10-year risk of major cardiovascular events using the American College of Cardiology’s (ACC) cardiovascular risk calculator.
Results
There was a large increase in the number of free flaps for breast reconstruction performed at our center over the study period (2009-2011 n=55, 2017 n=75). There were no significant differences between groups in age (2009-2011=51.2±9.8 years, 2017=51.1±9.4 years; p=0.98) or BMI (2009-2011=29.9±4.4, 2017=30.9±4.6; p=0.20). There were significantly more hypertensive patients in the 2009-2011 group (2009-2011=32 (58.2%), 2017=27 (36.0%); p=0.13). There were no other significant differences in medical comorbidities between groups. There were a significantly greater number of bilateral reconstructions performed in 2017 (2009-2011=18 (32.7%), 2017=38 (50.7%); p=0.04). There was no significant difference in 10-year risk of cardiovascular events between groups (2009-2011=7.2±6.9%, 2017=5.0±5.8%; p=0.17). The highest individual 10-year risk of cardiovascular events was 28.1% in 2009-2011 and 28.9% in 2017.
Conclusions
The rate of autologous reconstruction at our center is significantly higher in current practice than it was nine years ago. Though most of our patients remain at low 10-year risk for cardiovascular events, there are patients in whom it would be prudent to avoid bilateral IMA harvest in anticipation of a possible future need for CABG. This is especially important to consider in underserved populations, as such patients can be expected to experience worse outcomes of chronic diseases than those with greater access to healthcare. For these reasons the authors recommend cardiac risk stratification of patients preoperatively, especially those scheduled for bilateral reconstruction in an otherwise underserved area.


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