Although vascular pedicle avulsion in breast reconstruction is an extremely rare complication, pedicle damage in free flap surgery is well documented,[11] while TD pedicle injury during axillary lymph nodes dissection is still poorly debated in literature. The most common causes of intra-operative pedicled flap failure are coupled to errors in surgical dissection, or excessive tension or torsion to the pedicle that

could give rise to flap ischemia and necrosis.[12, 13] Some new techniques for LD harvest might be effective for sparing muscle functions and achieving better aesthetic outcomes in recipient and donor sites, although increasing the chance of pedicle damage by the plastic surgeons.[14-16] In all reported five cases, the general surgeon injured Antiinfection Compound Library the TD pedicle during axillary lymph-node dissection prior to complete breast reconstruction, damages occurring at different anatomical sites requiring different types of microsurgical repair. In two cases, an end-to-end anastomosis between the distal TDV stump and CSV was adopted as best option to flap salvage since the previously experienced shortening of the TD vein stumps after refreshing the edges could produce an unsafe primary anastomosis

limiting the flap’s arch of rotation. No doubt raised on case where a sharp, longitudinal laceration of TDV without tissue loss required a simple microsurgical repair. In case of TDV injury from previous surgery, where the scarring around TD pedicle made also CSV dissection difficult and unreliable, Cell Cycle inhibitor surgeon was skilled enough to suddenly convert the pre-operative plan, considering the integrity of TD pedicle, from a pedicled to a free flap. In one case, the partial flap

loss probably occurred because of the shortening of arterial before stumps that may have led to unsafe anastomosis under tension; moreover the strain on the vessel followed by implant positioning under the muscle may have caused arterial vasospasm, flap ischaemia and consequently occlusive clot of the vein. To salvage a LD flap from a pedicle injury, few points should be addressed. Feasibility of primary anastomosis should be always assessed, but depending on type of injury (sharp laceration, cauterization, avulsion) including or not a vessel tissue loss, as the stumps revisions may result in too short vessels contraindicating a direct under tension anastomosis. Time of injury is also important, as long lasting damage from previous surgery can severely obstruct vessels, wrapped in scar tissue not suitable for anastomosis. Finally, according to the anatomical level of injury different salvage options are available and should be preferred. For better understanding, the TD pedicle can be converted into a vascular path along a line extending from the apex of axilla to the anterior border of the muscle, where it provides two terminal branches, a horizontal and a descending.