Recipient vessel selection for microvascular chest wall reconstruction: A narrative review and decision support framework.

Background: Recipient vessel selection is a critical determinant of success in microvascular chest wall reconstruction. While the internal mammary and thoracodorsal vessels are most frequently used, prior surgery, radiotherapy, or flap design may necessitate alternative or salvage options. Despite its importance, no unified framework currently guides systematic vessel selection across reconstructive scenarios. Methods: A narrative review of the literature was conducted across PubMed, Medline, Embase, and Web of Science from database inception to August 2025. Studies reporting clinical outcomes, anatomical considerations, or vessel-specific complications in chest wall free flap reconstruction were included. Data were extracted from peer-reviewed studies, including case reports, case series, cohort studies, systematic reviews and meta-analyses. Results: Multiple recipient vessel systems are described, including the internal mammary, thoracodorsal, internal mammary perforator, thoracoacromial, lateral thoracic, circumflex scapular, intercostal, and cervical vessels, as well as vein grafts and arteriovenous loops. Each option demonstrates distinct advantages and limitations influenced by defect location, prior surgery or radiotherapy, pedicle requirements, preoperative assessment, and intraoperative vessel quality. Existing guidance on recipient vessel selection remains fragmented and is largely confined to breast reconstruction or institution-specific practice. Conclusion: This review summarises current evidence on recipient vessel selection in microvascular chest wall reconstruction and proposes a structured, evidence-informed decision-support framework. The framework is intended to aid preoperative planning and intraoperative strategy while recognising that final vessel choice must be tailored to individual patient factors and intraoperative findings.