The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation

Comparison of the second and third intercostal spaces regarding the use of internal mammary vessels as recipient vessels in DIEP flap breast reconstruction: An anatomical and clinical study

“…Microvascular anastomosis can be performed more comfortably at the second than at the third ICS given that the IMVs have larger diameters that are similar to those of the DIEA and DIEV, the ICS is wider, and the distance from the sternal border to the IMVs is greater. Similar to our findings, a recent study reported that the second ICS was wider and the diameter of the IMv prior to bifurcation was larger, so use of the second ICS was recommended [15].…”

An unusual “venous circle” of the internal mammary vein encountered during microvascular anastomosis and implications for practice

“…These findings are consistent with our in-vivo study of the IM vessels anatomy of the 2nd and 3rd ICS. We identified a single vein cranially to the 3rd rib in more than 80% of the cases which was almost always (92%) lying medial to the artery [8]. The rib-preservation method for vessel exposure, first described by Parrett et al in 2008 [9] and subsequently adopted and refined by the senior author [10], is widely seen as an easy, safe and reliable method of IMV exposure.…”

“…Internal mammary vein (IMV) anatomy has been widely studied by Rohrich and Arnez, and is highly variable [2,3,6,7]. We proved that the pertinent vessel anatomy of the 2nd ICS is much more predictable with a larger space and a single vein in more than 80% of the cases hence it is our preferred technique [8]. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle' encountered during microvascular dissection in the second ICS and discuss the surgical implications.…”

“…The vein, exposed between the second and third costal cartilages, exhibited unusual anatomy in the form of the single vein forming a 'bifurcation', quickly followed cranially by the two vessels converging back into a single vessel, thus creating a venous 'ring' (Figure 1(a-c)). The corresponding artery showed typical anatomy, being lateral to the vein, existing as a single vessel throughout the intercostal space [8]. Standard vessel anatomy was also displayed on the contralateral side for both artery and vein.…”

“…A 40-year old lady was undergoing bilateral riskreducing mastectomies and immediate breast reconstruction using bilateral deep inferior epigastric artery perforator (DIEP) flaps. A rib-preservation dissection technique [8][9][10] in the right second intercostal space (23 mm wide), was used to expose the recipient internal mammary vessels, with the vein found in a typical anatomical arrangement, running medial to the artery. The vein, exposed between the second and third costal cartilages, exhibited unusual anatomy in the form of the single vein forming a 'bifurcation', quickly followed cranially by the two vessels converging back into a single vessel, thus creating a venous 'ring' (Figure 1(a-c)).…”