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Background: A caudal limb of the internal mammary vein (IMV) is used as an additional venous drainage route.There, however, remains an undeniable possibility that unrecognized occlusion of the retrograde IMV occurs in the early postoperative period due to non-physiologic flow, and lacks its efficacy as a backup venous drainage route.However, no reports are available regarding the postoperative patency of the anastomosed retrograde IMV.Patients and Methods: We performed a hospital-based prospective case series study to clarify the efficacy of the retrograde IMV anastomosis as an additional venous drainage route in the case of two-vein anastomosis in free flap transfer.Both the antegrade and the retrograde IMVs anastomoses were performed in patients who underwent free flap transfer using IMV as a recipient vein.The postoperative flow vector and peak blood velocity of the retrograde IMV anastomosis were examined using 2D phase contrast MRI and color Doppler imaging.Result: A total of five retrograde IMV anastomoses in five patients were performed in the study period.The postoperative patency rate of the retrograde IMV was 60%.in patent group, the postoperative peak venous blood velocity of the retrograde IMV was significantly slower than that of the antegrade IMV (4.6 ± 0.5 vs 7.2 ± 0.8 cm/s, P < 0.05).Conclusion: The postoperative patency rate of the retrograde IMV anastomosis in two-vein anastomosis case was studied for the first time.Further study is needed to evaluate the reliability of the retrograde IMV as an additional venous drainage route.