Recipient vessel selection in autologous breast reconstruction: a narrative review of strategies and clinical implications

Background and Objective: Autologous breast reconstruction most commonly utilizes free tissue transfer to create a natural-appearing and aesthetically pleasing breast. A critical component of flap-based reconstruction is the selection of recipient vessels, yet the optimal choice, exposure, and technical utilization can vary. This study reviews the different options for recipient vessel selection along with the critical factors that influence decision-making and surgical technique in these cases. Methods: A literature review of PubMed/MEDLINE databases was performed from inception to June 2025 to identify recipient vessels utilized in autologous breast reconstruction. Key words included "recipient vessels", "breast reconstruction", "autologous reconstruction", and "microsurgery". Original and review articles in English were included. Studies were analyzed for discussion of indications, advantages, and drawbacks of one or more recipient options. Key Content and Findings: A multitude of factors influence decision-making in recipient selection and technique including flap choice, mastectomy type, prior operations and surgeon preference. Internal mammary (IM) vessels are the first-line choice. Internal mammary perforators (IMPs) have been explored to reduce morbidity but lack reliability. Thoracodorsal (TD) vessels and other axillary selections can be utilized in appropriately selected patients, typically as second-line options. Conclusions: Advancements in reconstructive techniques have changed the landscape for optimal recipient vessel selection from TD vessels to IM vessels. Options for free flap breast reconstruction continue to evolve toward improving aesthetic outcomes, increasing efficiency, and minimizing recipient site morbidity. Currently, IMP techniques are the forefront of continued innovation, but alternative recipient vessels may be appropriate in select individuals after considering patient factors and surgeon experience.