The “periosteal anchor stitch”: Opening up the surgical field

Abstract

Recent trends in autologous breast reconstruction have moved away from use of the thoracodorsal vessels to use of the internal mammary vessels as the first-choice recipient site.1 The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction as they allow medial placement of a flap. However their main disadvantage is the limited exposure of the vessels provided by removal of a segment of the rib cartilage.2 Clinical 3 and anatomical 4 studies of the internal mammary vessels suggest that the most appropriate sized portion of the recipient artery and vein for microanastomosis are located at the third intercostal space. Most surgeons therefore resect a segment of the third costal cartilage and rib. This is the basis of our practice.Where possible mastectomy scars are periareolar, or positioned as a transverse incision across the breast at the level of the nipple. In the male, the nipple is located over the 4th intercostal space, 5 however this position is not reliable in women and may be considerably lower. 6As a result the edge of the upper, medial skin flap of a mastectomy overlaps the operative site, and thus requires retraction. This is especially so in immediate reconstructions. The fibers of the pectoralis major muscle are split to expose the third costal cartilage and also require retraction.One of the keys to maximize microsurgical efficiency is to create a wide, clear stable operative field. This means minimizing instrumentation including the number of retractors and pairs of hands. This can be achieved by the use of self-retaining retractors.The design of self-retainers such as the West's and Travers' is such that both limbs open outwards at equal distance from the central hinge-point. To provide adequate exposure of the third intercostal space a greater force for retraction is required on the upper, medial skin flap than on the lower skin flap. If both claws are positioned solely on the skin flaps or pectoralis major muscle, the self-retainer drifts caudally and laterally. The muscle is torn and the upper medial skin flap obscures the operative site.To overcome these problems, we use an anchoring suture for the lateral arm of our self-retaining retractor. Using a round bodied needle, a loose, double suture of 0 nylon is placed in the third costal cartilage 1 to 2 cm lateral to the planned cartilage excision. A double suture is used to spread the load and prevent tearing out. Silk was used initially, but this does not glide through the cartilage as easily as a monofilament suture. Once the first quarter of the needle is in the cartilage, the rest of the needle is ''pushed'' through, thus allowing the curve of the needle to come through the firm cartilage. The claw of the lateral arm of the self-retaining retractor is hooked into the loops of this suture, thereby providing an anchor point for retraction laterally (see Fig. 1). The retractor is opened with the medial claw retracting the upper medial portion of the mastectomy flap and split pect...