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REVIEWEuropean Journal of Plastic Surgery (2026) 49:148 https://doi.org/10.1007/s00238-026-02526-3Mahmut Öztürk, Tobias Niederegger and Thomas Schaschinger contributed equally to this work. Adriana C. Panayiadriana.panayi@icloud.com Gabriel Hundeshagengabrielhundeshagen@gmail.com1 Department of Hand, Plastic, and Reconstructive Surgery, Burn Center at Heidelberg University, BG Klinik Ludwigshafen, Ludwigshafen, Germany2 Medical Faculty, Heidelberg University, Heidelberg, Germany3 Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Klinikum Kassel, Kassel, Germany4 Department of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, Rämistrasse 100, Zurich 8091, Switzerland5 Institute for Molecular and Cellular Anatomy, University of Regensburg, Universitätsstraße 31, Regensburg D-93053, Germany6 Institute for Medical Science & Engineering (IMSE), Deggendorf Institute of Technology, Deggendorf 94469, Germany7 Department of Plastic Surgery, Kliniken am Goldenen Steig, Freyung, GermanyAbstractBackground The internal mammary artery (IMA) is a critical vessel for both autologous breast reconstruction (ABR) and coronary artery bypass grafting (CABG), creating potential conf l ict when both procedures are needed. This review evalu-ates evidence on the feasibility, safety, and vascular consequences of using the IMA in ABR while preserving future CABG options.Methods A PRISMA-2020 aligned systematic review assessed IMA use in ABR and implications for future CABG. PubMed, EMBASE, and Web of Science were searched through March 10, 2025, using terms related to ABR and CABG.Results Ten studies (2004–2025) met inclusion criteria, involving female patients aged 24–77 years. Most studies used the deep inferior epigastric perforator fl ap for ABR, with the IMA as the predominant recipient vessel. Notably, end-to-side arterial anastomosis and dissection at or below the fourth intercostal space were frequently applied to preserve IMA length and integrity for future CABG. Myocardial complication rates after ABR were comparable to fl ap loss rates, and one patient subsequently underwent CABG using an alternative graft due to prior IMA harvest. Importantly, one cohort study introduced the Breast Reconstruction and Internal Mammary Artery Assessment (BRIMA) score, a cardiovascular risk-stratif i cation tool designed to guide IMA selection in reconstructive planning.Conclusions The IMA may be used in selected ABR cases without signif i cantly limiting future CABG if end-to-side anasto-moses or internal mammary artery perforators preserve conduit integrity. Because the IMA is the primary CABG graft, care-ful surgical planning and cardiovascular risk assessment are crucial. Further prospective data are needed to guide long-term management as the population ages. Level of Evidence: no gradable.Keywords Autologous breast reconstruction · Breast reconstruction · CABG · Coronary artery bypass · Cardiac surgeryReceived: 1 April 2026 / Accepted: 24 July 2026© The Author(s) 2026The internal mammary artery in autologous breast reconstruction and coronary artery bypass graftingMahmut Öztürk 5,6,7  · Tobias Niederegger 2  · Thomas Schaschinger 2  · Jule Brandt 2  · Oliver Didzun 3  · Adriana C. Panayi 4  · Valentin Haug 1  · Emre Gazyakan 1  · Amir Bigdeli 3  · Ulrich Kneser 1  · Gabriel Hundeshagen 1