Total ‘rib’-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video

Abstract

IntroductionThe total ‘rib’-preservation method of dissecting out the internal mammary vessels (IMV) during microvascular breast reconstruction aims to reduce free flap morbidity at the recipient site. We review our five-year experience with this technique.Patients & methodsAn analysis of a prospectively collected free flap data cohort was undertaken to determine the indications, operative details and reconstructive outcomes in all breast reconstruction patients undergoing IMV exposure using the total ‘rib’-preservation method by a single surgeon.Results178 consecutive breast free flaps (156 unilateral, 11 bilateral) were performed from 1st June 2008 to 31st May 2013 in 167 patients with a median age of 50 years (range 28–71). There were 154 DIEP flaps, 14 SIEA flaps, 7 muscle-sparing free TRAMs, 2 IGAP flaps and one free latissimus dorsi flap. 75% of the reconstructions (133/178) were immediate, 25% (45/178) were delayed. The mean inter-costal space distance was 20.9 mm (range 9–29). The mean time taken to expose and prepare the recipient IMV's was 54 min (range 17–131). The mean flap ischaemia time was 95 min (range 38–190). Free flap survival was 100%, although 2.2% (4 flaps) required a return to theatre for exploration and flap salvage. No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed.Discussion & conclusionThe total ‘rib’-preservation technique of IMV exposure is a safe, reliable and versatile method for microvascular breast reconstruction and should be considered as a valid alternative to the ‘rib’-sacrificing techniques.

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

“…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. Its advantages over the traditional rib-sacrificing methodwhereby the second and/or third rib is resected parasternally to facilitate exposure of the recipient vesselsinclude faster recovery times, reduced analgesic requirements post-operatively and better preservation of normal chest wall contour [11][12][13][14].…”

The effect of CT angiography and venous couplers on surgery duration in microvascular breast reconstruction: a single operator’s experience

“…Unlike previous reports (15), our study was confined to a single operator in order to eliminate inter-operator variability and also to standardise the recipient vessel exposure to the total rib preservation technique which has already been shown to reduce operative times with or without coupler use (29,33). Although trainee surgeons were also involved in the operations, the observations above relating to coupler use, CTA effect and combination still hold true.…”

A sequence of flaps and dissection exercises in the living model to improve the learning curve for perforator flap surgery

“…The former, traditionally used since its first description 12,13 has been described also in the swine model 11 Although the trans-chondral approach has been described in pigs, we decided to develop a new model for the training of the trans-muscular dissection technique (Figure 3), the one regularly used in humans, during microsurgical breast reconstruction that is considered to be safer. 14 This approach closely resembles the human situation and is therefore particularly useful to train the young surgeons to avoid or manage bleeding and pleural perforation. Anatomical differences in pigs are a more prominent anterior thoracic wall, a wider space between the thoracic wall and the vessels, where adipose tissue is less represented, larger veins with more resistant walls to surgical trauma.…”