BREAST

Lateral Thoracic Vessel as a Recipient Vessel in

Immediate Breast Reconstruction after Nipple/
Skin-Sparing Mastectomy: Experience with
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270 Flaps
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Mayu Muto, MD1

Background: The selection of recipient vessels for free-flap breast reconstruc-

Toshihiko Satake, MD2
Yui Tsunoda, MD1
Tomoyuki Koike, MD1
Kazutaka Narui, MD3
Takashi Ishikawa, MD4
Jiro Maegawa, MD5
Yokohama, Toyama, and Tokyo, Japan
tion is important for the success of the surgery and the aesthetics of the breast
mound. The thoracodorsal artery and vein (TDA/V) allow reconstruction with-
out noticeable scars from the anterior view, but TDA/V exposure is an inva-
sive and time-consuming process on sentinel node biopsy. This study aimed to
determine the effectiveness of the lateral thoracic artery and vein (LTA/V) as
recipient vessels by comparing them with the TDA/V.
Methods: This study included 270 flaps that underwent immediate free-flap
breast reconstruction after nipple/skin-sparing mastectomy by lateral incision.
The patients were categorized into two groups (LTA and TDA) based on the
recipient vessel selected.
Results: The LTA and TDA groups comprised 78 and 192 flaps, respectively.
Among the 131 short and small pedicle flaps, such as gluteal artery perforator
flap and profunda artery perforator flap, 65 (50%) used the LTA as the recipient
vessel. The external diameters of the LTA/LTV (median, 1.2 mm/1.5 mm) were
significantly lower than those of the TDA/TDV (median, 1.65 mm/2.0 mm).
The LTV was present in 94%, and the second vein was present in 49% of cases
with anastomosis. No significant differences in flap-related complications were
observed between the two groups.
Conclusions: The LTA/V can be used as recipient vessels for immediate free-
flap reconstruction. Because of their superficial location and small caliber, they
are easily accessible and suitable for short and small pedicle flaps.   (Plast.
Reconstr. Surg. 151: 1157, 2023.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

T
he choice of the recipient vessel for free-
flap breast reconstruction is important for
successful surgery and the aesthetics of the
breast mound. The internal mammary artery and
vein (IMA/V) and thoracodorsal artery and vein
From the Departments of 1Plastic and Reconstructive Surgery
and 3Breast and Thyroid Surgery, Yokohama City University
Medical Center; 2Department of Plastic, Reconstructive, and
Aesthetic Surgery, Toyama University Hospital; 4Department
of Breast Oncology and Surgery, Tokyo Medical University
Hospital; and 5Department of Plastic and Reconstructive
Surgery, Yokohama City University Hospital.
Received for publication July 13, 2021; accepted May 26,
2022.
Presented at PRS Korea 2017, in Seoul, Korea, November
10 through 12, 2017.
Copyright © 2023 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000010128
(TDA/V) have been used as recipient vessels for
breast reconstruction, their clinical outcomes
have been discussed extensively,1–6 and they have
been considered safe and acceptable for use.
However, as the use of sentinel node biopsy (SNB)
has become widespread, the TDA/V is no longer
favored owing to its invasive nature and time-­
consuming process.7–9
Disclosure statements are at the end of this ­article,
following the correspondence information.
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The merits of the IMA/V include their stable
anatomy and the ease of breast-mound formation.4
The main disadvantage of these vessels for immedi-
ate reconstruction after nipple-sparing mastectomy
(NSM) is the need to extend the incision line to a
visually recognizable area from the front because
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of the anastomosis.10 It is possible to approach the
IMA/V without any incision during skin-sparing
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mastectomy (SSM), in which the areola size is large
and the breast skin is extensible. However, for
patients with a small areola size (<40 mm in diam-
eter) and poor breast skin extensibility, it is difficult
to approach the IMA/V without a skin incision.
Incisions from the inframammary fold to the axilla
can help create an inconspicuous surgical scar, but
could compromise blood flow to the lower lateral
area of the breast skin. The survival rate of the free
flap has improved substantially in recent years; it is
desirable to consider not only the survival rate but
also the aesthetics by creating a surgical scar that is
as inconspicuous as possible.
At our hospital, the lateral incision approach,
in which an inconspicuous surgical scar is created
from the front, leading to superior aesthetics, is
used for immediate free-flap reconstruction after
NSM and SSM in patients with small areolas. The
areola has to be resected in SSM, but it is possible
to reconstruct the nipple–areola complex (NAC)
in the second stage using a monitor flap at the
resected section. Poor blood flow to the lower lat-
eral area of the breast skin is rarely observed in
patients with small areolas. The TDA/V are suitable
options for recipient vessels in immediate recon-
struction by lateral incision. However, degradation
of the aesthetics is the major drawback in the case
of short and small pedicle flaps, such as the gluteal
artery perforator (GAP) flap or profunda artery
perforator (PAP) flap, because the TDA/V is posi-
tioned in the deep layer, causing the reconstructed
breast to have lateral fullness and deficient medial
fullness.1 To solve this problem, sufficient length
of the recipient vessel can be obtained by dissect-
ing the TDA/V from the distal to the proximal.
However, when dissecting the long vessel, the risk
of spasms and vessel damage must be considered.
In addition, GAP and PAP flaps often have a small
arterial caliber, which may cause vessel caliber mis-
match anastomosis with the TDA.
Therefore, the authors focused on numerous
cases in which the lateral thoracic artery (LTA) and
lateral thoracic vein (LTV) were preserved when
SNB was performed. The LTA/V are present at a
more superficial level than the TDA/V and can be
accessed easily, allowing for exposure with minimal
invasion and the aesthetics of the reconstructed
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Plastic and Reconstructive Surgery • June 2023
breast even in the case of short pedicle flaps. The
LTA/V are often suitable for small-caliber flaps.
The use of the LTA/V as recipient vessels for breast
reconstruction has been reported11–14; however, to
our knowledge, no large series report has com-
pared the LTA/V with other recipient vessels. This
study aimed to define the effectiveness and indica-
tions of the LTA/V for immediate free-flap breast
reconstruction after NSM/SSM by comparing the
details of the surgery, complications, and revision
surgery between the LTA and TDA groups.
PATIENTS AND METHODS
A total of 263 patients (270 flaps) who under-
went immediate free-flap breast reconstruction
after NSM/SSM by the lateral incision approach
at the Yokohama City University Medical Center
from October of 2005 to November of 2018 were
enrolled in this study. A total of 335 consecutive
patients underwent immediate free-flap breast
reconstruction during the same period. All the
patients provided informed consent, and all
data were acquired from a retrospective chart
review following approval by the institutional
review board. The LTA or TDA (main trunk, latis-
simus dorsi [LD] branch, or serratus anterior
[SA] branch) was used as the recipient artery.
Patients with large areolas (>40  mm in diame-
ter) and good skin extensibility who underwent
SSM were excluded because the lateral incision
approach was not used, and the IMA/V was used
as the recipient vessel in 76 patients (Fig. 1). The
patients were classified into two groups: the LTA
group, in which the LTA was selected as the recipi-
ent vessel (including cases where the accompany-
ing vein was not selected as the recipient vein);
and the TDA group, in which the main trunk, LD
branch, and SA branch of the TDA were selected.
Surgical Methods and Vessel Selection
The breast surgeons were required to identify
the LTA/V upon SNB or axillary lymph node dis-
section (ALND) and preserve them if possible.
Flaps with a short pedicle (<5 cm) and small arte-
rial caliber (<1.5  mm in diameter), such as the
GAP, PAP, or lumbar artery perforator (LAP) flap,
were collectively termed “short and small pedicle
flaps.” The LTA was selected as the primary choice
in cases where a short and small pedicle flap was
used for reconstruction. If the deep inferior epi-
gastric perforator (DIEP) flap or superficial infe-
rior epigastric artery (SIEA) flap was used, the LTA
was selected only when the caliber difference was
negligible; the final decision for selection was left
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Fig. 1. Flow chart algorithm for inclusion and exclusion criteria and selection of the recipient vessel. DIEP, deep infe-
rior perforator; GAP, gluteal artery perforator; LAP, lumbar artery perforator; LTA/V, lateral thoracic artery and vein;
NAC, nipple–areola complex; NSM, nipple-sparing mastectomy; PAP, profunda artery perforator; SIEA, superficial infe-
rior epigastric artery; SSM, skin-sparing mastectomy; TDA/V, thoracodorsal artery and vein.

to the discretion of the surgeon (Fig. 1). In uni-
lateral breast reconstructions using the bilateral
inferior GAP (IGAP) flaps, the flap was mounted
side by side in the vertical direction. The exterior
flap was anastomosed to the LTA or TDA and the
interior flap was anastomosed to the IMA. The
accompanying vein of the selected artery was fun-
damentally used as the recipient vein, but other
veins were used in cases such as a large caliber
difference. When two veins were present in the
flap, the fundamental approach was anastomosis
to either the accompanying vein or other veins.
The LTA/V, which run along the lateral bor-
der of the pectoralis minor, can be identified eas-
ily at the site where the sentinel node has been
excised by searching the posterior side from the
lateral border of the pectoralis major. Normally
there is only one LTA, but occasionally, there is
more than one. No surrounding vessels can be
mistaken for the LTA/V. We dissected the vessel
distally (several centimeters) and obtained a suit-
able recipient caliber for anastomosis and length
for the flap setting. Upon anastomosis of the ves-
sels, an emesis basin was turned inside out, laid on
the operating table, and affixed using a tape. The
flap was then set with the cutaneous side down on
a clean wet towel laid on the basin, affixing the
flap with a string to prevent it from falling. The
LTA/V lie within a more superficial layer than the
TDA/V, but this method (placing the towels in
layers to adjust the height) will allow even a short
pedicle flap to be positioned close to the recipient
vessel (Figs. 2 and 3).
We instructed the patients to avoid shoulder
exercises (eg, adduction, abduction) for the first
10 days postoperatively and to maintain space in
the axilla for 3 days.
Study Outcome
Age, body mass index (BMI), flap type, SNB
and ALND application, operative time, ischemic
interval of the flap, vessel size, vessel size dis-
crepancy, weight of the mastectomy specimen
and flap weight, microsurgical outcomes, com-
plications, and revision surgery necessitated by
lateral fullness after reconstruction were com-
pared between the LTA and TDA groups. The
external diameters of the vessels were measured
after anastomosis using a caliper. The external
diameter of vein 1 was measured after anasto-
mosis of each of the first recipient and donor,

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Fig. 2. View of microsurgical anastomosis conducted to the right LTA and LTV (above).
The LTA/V is located in the superficial layer; therefore, the flap is laid on an emesis
basin, which was turned inside out and placed on the operating table, and affixed
using tape to bring the flap closer to the vessel. Close-up view of the anastomosis to
the LTA/V (below). PAP, profunda artery perforator.

excluding vein 2, which was subsequently anasto-
mosed as the second vein. Vessel size discrepancy
was defined as anastomosis of the artery or vein 1
using methods such as gather or vein graft.
Statistical Analysis
The Student t test and Wilcoxon test were
performed for continuous variables. The chi-
square test and the Fisher exact test were per-
formed for categorical variables. P < 0.05 was
considered statistically significant. All data were
analyzed using JMP Pro software (version 15.0.0).
RESULTS
A total of 131 DIEP flaps, 59 PAP flaps, 38
superior GAP (SGAP) flaps, 33 IGAP flaps, 8 SIEA
flaps, and 1 LAP flap were encountered in this
study. The LTA group comprised 76 patients (78
flaps) and the TDA group comprised 187 patients
(192 flaps) (Table  1). Eight patients in the LTA

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Fig. 3. The LTA/V originate from the second part of the axillary artery, run along the lateral border
of the pectoralis minor, and pass along the deep surface of the pectoralis major. They can be
found when the lateral border of the pectoralis major is turned over. The TDA/V are located in the
deeper layers, whereas the LTA/V are located in the superficial layers. Therefore, it is easy to access
the LTA/V, and aesthetic breast mounds with no lateral fullness and no deficient medial fullness
can be reconstructed even using flaps with short pedicles.

Table 1. Comparison of Baseline Characteristics

LTA TDA Pa
Total no. of patients 76 187
Total no. of flaps 78 192
Mean age ± SD, yr 41.9 ± 7.4 44.4 ± 7.9 0.0192b
Median BMI (IQR), kg/m2 19.9 (18.6–21.3) 21.6 (19.9–23.4) <0.0001b
Smoking history, no. (%) 10 (13) 32 (17) 0.4275
Preoperative chemotherapy, no. (%) 11 (14) 45 (24) 0.0850
Preoperative radiotherapy, no. (%) 0 (0) 4 (2) 0.3273
BMI, body mass index; LTA, lateral thoracic arteries group; TDA, thoracodorsal arteries group.
a
The Student t test was used to compare age. The Wilcoxon test was used to compare BMI. The Fisher exact test was used to compare preopera-
tive radiotherapy. The chi-square test was used to compare the other characteristics.
b
Statistically significant.

group and 16 in the TDA group underwent bilat-
eral reconstruction. Three patients in the LTA
group and 10 in the TDA group underwent unilat-
eral reconstruction using bilateral IGAP flaps. The
mean age and median BMI in the LTA group were
significantly lower than those in the TDA group (P
= 0.0192 and P < 0.0001, respectively; Table 1). No
significant differences in smoking profile, preop-
erative chemotherapy, or preoperative radiother-
apy (in case of mastectomy for recurrence) were
observed between the groups (Table 1).
SNB was significantly prevalent in the LTA
group (P = 0.0001) and ALND in the TDA group
(P = 0.0002; Table 2). The operative time was sig-
nificantly shorter in the LTA group (P < 0.0001),
whereas no significant difference in the ischemic
interval was observed between the groups. The
LTA group had significantly lower mastectomy
sample weights (P = 0.001) and flap weights (P <
0.0001) than the TDA group (Table 2).
The LTA was selected for 29 of 59 (49%)
PAP flaps, 25 of 38 (66%) SGAP flaps, and 10

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 Plastic and Reconstructive Surgery • June 2023

Table 2. Comparison of Surgical Details

LTA TDA Pa
Total no. of flaps (%) 78 (100) 192 (100)
Flap type, no. (%)
 PAP 29 (37) 30 (16)
 SGAP 25 (32) 13 (7)
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 IGAP 10 (13) 23 (12)

 DIEP 10 (13) 121 (63)
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 SIEA 3 (4) 5 (3)

 LAP 1 (1) 0
Treatment of axillary lymph nodes, no. (%)
 Sentinel node biopsy 66 (85) 116 (60) 0.0001b
 ALND 10 (13) 69 (36) 0.0002b
 Previous ALND 2 (3) 7 (4) 1.0000
Mean total operative time ± SD, minutes (unilateral only) 452 ± 114 519 ± 106 <0.0001b
Median ischemia time (IQR), minutes (unilateral only) 103(59–139) 85(66–121) 0.3587
Median weight of mastectomy specimen (IQR), g 204(148–295) 272(182–357) 0.0010b
Median flap-used weight (IQR), g 256(200–316) 342(248–428) <0.0001b
Postoperative radiotherapy 1 (1.3) 16 (8.3) 0.0285b
ALND, axillary lymph node dissection; DIEP, deep inferior perforator; IGAP, inferior gluteal artery perforator; LAP, lumbar artery perfora-
tor; LTA, lateral thoracic arteries group; PAP, profunda artery perforator; SGAP, superior gluteal artery perforator; SIEA, superficial inferior
epigastric artery; TDA, thoracodorsal arteries group.
a
The chi-square test was used to compare the sentinel node biopsy and the ALND. The Fisher exact test was used to compare the previous
ALND and the postoperative radiotherapy. The Student t test was used to compare the total operative time. The Wilcoxon test was used to
compare other characteristics.
b
Statistically significant.

Table 3. Comparison of Vessel Details

LTA TDA/SA br (109 Cases, 113 Flaps) Pa
Median external diameter of artery (IQR), mm 1.2 (1.0–1.5) 1.65 (1.2–2.0)/1.5 (1.2–1.8) <0.0001 /<0.0001b
b

Median external diameter of vein 1 (IQR), mm 1.5 (1.1–2.0) 2.0 (1.35–2.2)/2.0 (1.35–2.2) 0.0007b/0.0013b
Vessel size discrepancy of artery, no. (%) 8 (10) 29 (15)/19 (16.8) 0.2938/0.2010
Vessel size discrepancy of vein 1 4 (5%; n = 73) 11 (6%; n = 189)/7 (6%; n = 111) 1.0000/1.0000
Reanastomosis of artery, no. (%) 21 (27) 41 (21) 0.3349
Reanastomosis of vein 1 7 (10%, n = 73) 12 (6%, n = 189) 0.3647
LTA, lateral thoracic arteries group; SA br, serratus anterior branch of thoracodorsal arteries group; TDA, thoracodorsal arteries group.
a
The chi-square test was used to compare the vessel size discrepancy of artery and reanastomosis. The Fisher exact test was used to compare the
vessel size discrepancy of vein 1. The Wilcoxon test was used to compare the other characteristics.
b
Statistically significant.

of 33 (30%) IGAP flaps. The LTA was selected
in 65 of 131 (50%) short and small pedicle flaps
(Table  2). In the LTA group, the first vein was
anastomosed to LTV1 in 73 flaps (94%). Two
accompanying veins (LTV1 and LTV2) were
identified in 38 flaps (49%) and anastomosed
to LTV2 as the second vein. In the TDA group,
except for the two flaps (1%) in which the vein
was anastomosed to the LTV, the first vein was
anastomosed to either of the main trunks, SA
branches, or LD branches of the TDV (99%).
The second vein was anastomosed to the main
trunk, SA branch, or LD branch of the TDV in
122 flaps (64%).
The external diameters of the LTA and LTV
(median, 1.2 mm and 1.5 mm, respectively) were
significantly lower (P < 0.0001 and P = 0.0007,
respectively) than those of the TDA and TDV
(median, 1.65  mm and 2.0  mm, respectively;
Table 3). The external diameters of the LTA and
LTV were also significantly lower (P < 0.0001 and
P = 0.0013, respectively) than those of the SA
branch of the TDA and TDV (median, 1.5  mm
and 2.0  mm, respectively; Table  3). A compari-
son of the external diameters of the recipient
vessels and those of each flap pedicle is shown
in Fig. 4. No significant differences in artery and
vein size discrepancy or required reanastomo-
sis of the artery and vein during surgery were
observed between the groups (Table  3). Vein
grafts for short and small pedicle flaps were used
in four cases in the LTA group (LTA4 and LTV0)
and three cases in the TDA group (TDA2 and
TDV1). No significant differences in flap-related

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Fig. 4. Comparison of diameters of the recipient and donor vessels. DIEA, deep inferior artery perforator; IGAP, inferior gluteal
artery perforator; LT, lateral thoracic; PAP, profunda artery perforator; SA br, serratus anterior branch; SGAP, superior gluteal artery
perforator; SIEA, superficial inferior epigastric artery; TD, thoracodorsal.

Table 4. Flap-Related Complications Based on the of the reconstructed breast was significantly (P =
Selection of the Recipient Vessel 0.0068) lower in the LTA group (n = 8; 10.3%)
LTA, No. (%) TDA, No. (%) Pa than in the TDA group (n = 48; 25%). Among
Takeback 5 (6) 13 (7) 0.9143 the short and small pedicle flaps (except in the
operation case of unilateral reconstruction using bilateral
Total flap loss 1 (1) 4 (2) 1.0000 IGAP flaps), there were four (n = 62; 6.5%) in
Partial flap 2 (3) 3 (2) 0.6285 the LTA group and eight (n = 56; 14.3%) in the
loss
TDA group, although no significant difference
Fat necrosis 3 (4) 12 (6) 0.5653
was noted (Table 5).
Arterial 0 1 (0.5) 1.0000
thrombosis Figure  5 shows the preoperative view of a
Venous 2 (3) 6 (3) 1.0000 47-year-old patient with right breast cancer. She
thrombosis underwent immediate reconstruction by NSM
Hematoma 2 (3) 5 (3) 1.0000 with lateral incision, SNB, and a PAP flap. The
Mastectomy 6 (8) 20 (10) 0.4916 lateral incision followed the line from the axilla
skin necro-
sis through the anterior axillary line to the lateral end
NAC necrosis 5 (9; n = 58) 21 (14; n = 153) 0.3138 of the inframammary line (the red line in Fig. 5).
(NSM only) The LTA/V were selected as the recipient vessels.
LTA, lateral thoracic arteries group; NAC, nipple–areola complex; Postoperative radiation therapy was not required.
NSM, nipple-sparing mastectomy; TDA, thoracodorsal arteries The reconstructed breast had excellent aesthetic
group.
a
The chi-square test was used to compare the takeback operation, results, with no lateral fullness and no deficient
mastectomy skin necrosis, and NAC necrosis. The Fisher exact test medial fullness, and there was no requirement for
was used to compare the other characteristics. revision surgery (Fig. 6).

complications, such as takeback operation, total

or partial necrosis, fat necrosis, arterial or venous
thrombosis, hematoma, mastectomy skin necro-
sis, or NAC necrosis, were noted between the
two groups (Table 4). The number of flaps that
underwent revision surgery for lateral fullness
DISCUSSION
The IMA/V and TDA/V have long been
subjected to comparisons as recipient vessels
for breast reconstruction. The IMA/V has no
previous exposure in delayed reconstruction, is

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Fig. 5. Preoperative images of a 47-year-old patient with right breast cancer. Preoperative design of the
nipple-sparing mastectomy and immediate breast reconstruction with lateral incision (right).
Table 5. Revision Surgery Because of Lateral Bulki-
ness after Breast Reconstruction
LTA, No. (%) TDA, No. (%) Pa
Total 8 (10.3) (n = 78) 48 (25) (n = 192) 0.0068b
Short and 4 (6.5) (n = 62) 8 (14.3) (n = 56) 0.2244
small
pedicle
LTA, lateral thoracic arteries group; TDA, thoracodorsal arteries
group.
a
The chi-square test was used to compare the total flaps. The Fisher
exact test was used to compare the short and small pedicle flaps.
b
Statistically significant.
minimally influenced by irradiation, and allows
for the use of short pedicle flaps to be centrally
set, with good aesthetic outcomes.4 Disadvantages
of the IMA/V include the small diameter of the
left IMV, extension of the scar to the internal side
of the chest because of the anastomosis, contour
deformity4,15,16 and pain16 caused by excision of
the costal cartilage, and a possibility of disabling
the use of the IMA/V for coronary artery bypass
transplantation.17–19 In contrast, the TDA/V offers
advantages such as short operative time in the case
of ALND,4 scar-free inner side of the chest (excel-
lent aesthetics),10 and availability of more options
for the recipient vein. One of the drawbacks of
using the TDA/V is that they may not be used in
delayed reconstruction because of previous scars
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Plastic and Reconstructive Surgery • June 2023
in the surrounding area. When using the LD
branch, the LD flap cannot be used as a lifeboat
in case of a free-flap failure. In the case of bilateral
reconstruction using the DIEP flap or if a short
pedicle flap is used, the external side becomes
bulky and prohibits the flap from reaching the
internal side, resulting in poor aesthetics.1 As SNB
has become commonly used, the TDA/V are not
favored because of the invasive and time-consum-
ing process.7–9 In contrast, the IMA/V have gained
popularity following reports on the use of the rib-
sparing technique,16,20 end-to-side anastomosis,18,21
anastomosis to internal mammary vessel perfora-
tor,22–24 and flow-through anastomosis25 to address
problems. However, axillary vessels such as the
TDA/V are important because reconstruction can
be performed with only a lateral incision without
creating a conspicuous anterior scar. Thus, we
suggest the LTA/V as a new option to compensate
for the shortcomings of the TDA/V.
The LTA/V originate from the second part
of the axillary artery, descend the lateral margin
of the pectoralis minor, run through the back of
the pectoralis major, spread out over the serratus
anterior muscle, and supply the axillary lymph
node, serratus anterior, pectoralis major, pecto-
ral minor, subscapular muscle, and the mammary
gland.26 Loukas et al.26 investigated the anatomy
 Volume 151, Number 6 • Lateral Thoracic Vessel in Reconstruction
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Fig. 6. Postoperative view of the patient 1 year after reconstruction using a profunda artery perforator
flap. The reconstructed breast had an excellent aesthetic outcome with no lateral fullness and no defi-
cient medial fullness. There was no need for revision surgery.

of the LTA using 420 cadavers and reported its
presence in 96.7% of the cases; the origins of the
LTA varied widely (six types), but the ultimate tis-
sue distribution remained typical, with 90.4% of
the LTAs running along the lateral margin of the
pectoralis minor and subsequently supplying it;
no significant differences were observed based
on age and sex.26 In the current study, LTVs were
detected in 94% of the cases; the presence of the
second vein was detected in 49% of the cases.
Although the LTA/V have various origins, the
anatomy at the level that we identified and anasto-
mosed was consistent.
In this study, although the external diameters
of the LTA/V were significantly lower than those
of the TDA/V, no significant differences in ves-
sel size discrepancy, number of reanastomoses, or
flap-related complications were noted between
the groups. These results support the validity of
the authors’ policy of selecting the LTA as a pri-
mary option for short and small pedicle flaps, and
in the case of DIEP flap or SIEA flaps, the LTA was
selected only when the caliber difference was neg-
ligible. The LTA was selected in approximately
50% of PAP flaps and 66% of SGAP flaps but only
30% of IGAP flaps. This was because cases involv-
ing the unilateral reconstruction using bilateral
IGAP flaps were included in this study; it was easy
to select the TDA because a short flap pedicle was
not an issue because of anastomosis to only the
vessel of the mounted flap on the outer side.
The differences in age, BMI, mastectomy
specimen weight, flap-used weight, and total
operative time between the two groups might
have been caused by factors such as the large
percentage of short and small pedicle flaps in
the LTA group, the large percentage of DIEP
flaps in the TDA group, and the flap selec-
tion criteria established at our department. At
our department, the DIEP flap is selected for
patients with large breasts, no desire for future
pregnancy, and middle-sized body with a good
amount of fat in the abdominal region, whereas
the SGAP flap or IGAP flap ×2 is selected for
patients with large breasts, having a desire for
pregnancy, or without much fat in the abdomen;
the PAP flap is selected for patients with small
breasts.11,27 As for total operative time, the short
time required for the exposure of the recipient
vessel in the LTA group had some effect on the
results. However, other factors, such as the dif-
ference in the time required for flap harvesting
or the short time required for breast-mound
formulation in those with a short pedicle flap,
might have contributed to the difference in the
operative time.

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Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

There was no significant difference in the
intraoperative reanastomosis rate between the
two groups, although it was high in arteries (27%
in the LTA group and 21% in the TDA group).
For each flap, reanastomosis with the GAP flap
was particularly common in the LTA (34.3%) and
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TDA (30.6%) groups, with the PAP flap more
common in the TDA group (36.7%). The reanas-
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tomosis rate of the IMA was 15.8% during the
same period, and the rates for the GAP and PAP
flaps were also high. The GAP flap is particularly
difficult to anastomose given its short pedicle,
small arterial caliber, and thick and firm fat tissue,
making it difficult to achieve a good position for
anastomosis. The high reanastomosis rate could
be attributed to the use of not only the DIEP flap
but also other flaps. However, arterial thrombosis
was associated with very few complications, and
should not cause postoperative problems if han-
dled properly intraoperatively.
There were fewer revision procedures due to
lateral fullness after reconstruction in the LTA
group. However, it is possible that the ratio of the
different flap types affected the results because
the DIEP flap is characteristically large and soft
and tends to become laterally bulky. Therefore,
the results of the short and small pedicle flaps
alone were compared in this study; fewer cases of
lateral fullness tended to be observed in the LTA
group.
The main advantage of the LTA/V is their
superficial position, which allows for ease of dis-
section and minimal invasiveness, and that an aes-
thetic breast mound with no lateral fullness and
no deficient medial fullness is possible even using
flaps with short pedicles. The external diameter
of the LTA/V is significantly smaller than that
of the TDA/V, but it is suitable for small-caliber
flaps. Another major advantage is that pedicled
LD flaps are a viable option in case of flap failure.
The shortcomings include the need for preserva-
tion by the breast surgeon on SNB or ALND, the
possibility of ligation in case of ALND, and the
possibility of not being used because of a previ-
ous scar in the surrounding region in delayed
reconstruction.
A limitation of this study is the inclusion of only
thin, Asian patients. The average BMI in Japan is
lower than that in some Western countries. No sig-
nificant difference in fat necrosis was noted between
the LTA and TDA groups, although the external
diameters of the LTA/V were significantly lower than
those of the TDA/V and may have had less inflow
and outflow. However, the median flap weight was
also low. This study included three patients in the
1166
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2023
LTA group in whom the flap weight was greater than
500 g, none of whom developed flap-related compli-
cations such as fat necrosis. However, the number of
cases was insufficient to prove that the LTA/V can
supply enough blood inflow and outflow to a flap
weighing more than 500 g, and the possibility of an
increase in the fat necrosis rate cannot be ruled out.
Additional research in a higher-BMI population is
needed to confirm these aspects.
CONCLUSIONS
Both LTA/V and TDA/V were used success-
fully in this study. Because of the superficial
positioning of the LTA/V, it is easy to dissect for
identification, is less invasive, and the formation
of the breast mound with good aesthetics is pos-
sible even using short pedicle flaps. In addition,
due to its small caliber, it is suitable for use as a
recipient vessel for small-caliber flaps. The ability
to preserve the LD branch is another advantage.
This study demonstrated that the LTA/V can com-
pensate for the shortcomings of the TDA/V and
offers a new option, apart from the traditional
IMA/V and TDA/V, for use as a recipient vessel in
breast reconstruction.
Toshihiko Satake, MD
Toyama University Hospital
2630, Sugitani
Toyama 930-0194, Japan
toshi@med.u-toyama.ac.jp
DISCLOSURE
None of the authors has a financial interest in any
of the products or drugs mentioned in this article.
REFERENCES
1. Feng LJ. Recipient vessels in free-flap breast reconstruction:
a study of the internal mammary and thoracodorsal vessels.
Plast Reconstr Surg. 1997;99:405–416.
2. Dupin CL, Allen RJ, Glass CA, Bunch R. The internal mam-
mary artery and vein as a recipient site for free-flap breast
reconstruction: a report of 110 consecutive cases. Plast
Reconstr Surg. 1996;98:685–689.
3. Ninković MM, Schwabegger AH, Anderl H. Internal
mammary vessels as a recipient site. Clin Plast Surg.
1998;25:213–221.
4. Moran SL, Nava G, Behnam AB, Serletti JM. An outcome
analysis comparing the thoracodorsal and internal mam-
mary vessels as recipient sites for microvascular breast recon-
struction: a prospective study of 100 patients. Plast Reconstr
Surg. 2003;111:1876–1882.
5. Di Santanelli PF, Longo B, Sorotos M, Pagnoni M, Laporta
R. The axillary versus internal mammary recipient vessel
sites for breast reconstruction with DIEP flaps: a retrospec-
tive study of 256 consecutive cases. Microsurgery 2015;35:
34–38.
 Volume 151, Number 6 • Lateral Thoracic Vessel in Reconstruction
6. Samargandi OA, Winter J, Corkum JP, Al Youha S, Frank
S, Williams J. Comparing the thoracodorsal and internal
mammary vessels as recipients for microsurgical autologous
breast reconstruction: a systematic review and meta-analysis.
Microsurgery 2017;37:937–946.
7. Temple CL, Strom EA, Youssef A, Langstein HN. Choice of
recipient vessels in delayed TRAM flap breast reconstruction
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0
after radiotherapy. Plast Reconstr Surg. 2005;115:105–113.
8. Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW.
hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 06/04/2023
Changing trends in recipient vessel selection for microvas-
cular autologous breast reconstruction: an analysis of 1483
consecutive cases. Plast Reconstr Surg. 2007;119:1993–2000.
9. O’Neill AC, Hayward V, Zhong T, Hofer SO. Usability of the
internal mammary recipient vessels in microvascular breast
reconstruction. J Plast Reconstr Aesthet Surg. 2016;69:907–911.
10. Ho OA, Lin YL, Pappalardo M, Cheng MH. Nipple-sparing
mastectomy and breast reconstruction with a deep inferior
epigastric perforator flap using thoracodorsal recipient ves-
sels and a low lateral incision. J Surg Oncol. 2018;118:621–629.
11. Satake T, Muto M, Ko S, Yasumura K, Ishikawa T, Maegawa
J. Breast reconstruction using free posterior medial thigh
perforator flaps: intraoperative anatomical study and clinical
results. Plast Reconstr Surg. 2014;134:880–891.
12. Fong HC, Goh T, Chui CHK, Rasheed MZ, Ong YS. The lat-
eral thoracic vessels: a useful recipient in immediate breast
reconstruction. J Reconst Microsurg Open 2016;1:2–7.
13. Satake T, Nakasone R, Kobayashi S, Maegawa J. Immediate
breast reconstruction using the free lumbar artery perforator
flap and lateral thoracic vein interposition graft for recipi-
ent lateral thoracic artery anastomosis. Indian J Plast Surg.
2016;49:91–94.
14. Yang L, Long J, Li Z, et al. The lateral thoracic vessels: a novel
recipient site for breast reconstruction with DIEP flap. J Plast
Reconstr Aesthet Surg. 2019;72:1530–1536.
15. Schoeller T, Schubert HM, Wechselberger G. Rip carti-
lage replacement to prevent contour deformity after inter-
nal mammary vessel access. J Plast Reconstr Aesthet Surg.
2008;61:464–466.
16. Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing
technique for internal mammary vessel exposure in microsur-
gical breast reconstruction. Ann Plast Surg. 2008;60:241–243.
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
17. Al-Benna S, Steinstraesser L, Patani N. Free flap breast recon-
struction consent forms should warn against the potential
loss of the internal thoracic artery for coronary artery bypass
grafting. Plast Reconstr Surg. 2012;129:867e–868e.
18. Maher JL, Mahabir RC, Roehl KR. Addressing the potential
need for coronary artery bypass grafting after free tissue
transfer for breast reconstruction: an algorithmic approach.
Ann Plast Surg. 2015;75:140–143.
19. Sultan SM, Rizzo AM, Erhard HA, Benacquista T, Weichman
KE. Revisiting the internal mammaries as recipient vessels
in breast reconstruction: considerations in current practice.
Breast Cancer Res Treat. 2020;184:255–264.
20. Rosich-Medina A, Bouloumpasis S, Di Candia M, Malata CM.
Total “rib”-preservation technique of internal mammary ves-
sel exposure for free flap breast reconstruction: a 5-year pro-
spective cohort study and instructional video. Ann Med Surg
(Lond). 2015;4:293–300.
21. Apostolides JG, Magarakis M, Rosson GD. Preserving the
internal mammary artery: end-to-side microvascular arterial
anastomosis for DIEP and SIEA flap breast reconstruction.
Plast Reconstr Surg. 2011;128:225e–232e.
22. Guzzetti T, Thione A. Successful breast reconstruction with
a perforator to deep inferior epigastric perforator flap. Ann
Plast Surg. 2001;46:641–643.
23. Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internal
mammary perforator recipient vessels for breast reconstruc-
tion using free TRAM, DIEP, and SIEA flaps. Plast Reconstr
Surg. 2007;120:1769–1773.
24. Park MC, Lee JH, Chung J, Lee SH. Use of internal mam-
mary vessel perforator as a recipient vessel for free TRAM
breast reconstruction. Ann Plast Surg. 2003;50:132–137.
25. Satake T, Sugawara J, Yasumura K, Mikami T, Kobayashi S,
Maegawa J. “Mini-flow-through” deep inferior epigastric per-
forator flap for breast reconstruction with preservation of
both internal mammary and deep inferior epigastric vessels.
Arch Plast Surg. 2015;42:783–787.
26. Loukas M, du Plessis M, Owens DG, et al. The lateral thoracic
artery revisited. Surg Radiol Anat. 2014;36:543–549.
27. Satake T, Muto M, Ogawa M, et al. Unilateral breast recon-
struction using bilateral inferior gluteal artery perforator
flaps. Plast Reconstr Surg Glob Open 2015;3:e314.
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