When the recipient site is ready and the flap dissection completed, the pedicle is ligated and transected, and the flap is brought up to the chest. Hemostasis and closure of the donor site are then performed expeditiously. The beanbag is deflated and the patient brought into a more supine position for the microsurgical anastomoses.

RECIPIENT SITE

Preoperatively, the inframammary line is determined and marked with the patient in an erect position. Ignoring transverse mastectomy incisions, a curvilinear "hockey-stick" incision is made beginning at the anterior axillary fold and proceeding inferiorly to the inframammary crease and then curving up and medially. The skin flaps are raised superiorly and inferiorly. The third or fourth rib is identified, the perichondrium is incised, and the cartilage is resected subperichondrially. The back wall of the periochondrium is then incised, and the internal mammary vessels are identified about 1 cm lateral to the edge of sternum. These delicate vessels are dissected maintaining a thin cuff of investing tissues, branches are cauterized with the bipolar forceps or tied, and a 4 cm length of vessel is prepared for end-to-end anastomosis by division and ligation of the distal end of the internal mammary vessels.

The perichondrium is closed with care not to compress the pedicle. If the recipient veins are too small, as they are in one-third of the cases, an alternative must be sought. Several choices are available:

1. An interposition vein graft, harvested from the leg, may be used to anastomose to the axillary vein.

2. The cephalic vein may be dissected and turned down into position on the chest wall.

3. The external jugular vein, through two incisions, can be transposed over the clavicle to allow an anastomosis with or without interposition vein grafts.

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