J Reconstr Microsurg 2022; 38(04): 263-269
DOI: 10.1055/s-0041-1731762
Original Article

Refining the Rib-sparing Approach in Microsurgical Breast Reconstruction: Keys to Success

Kristy Hamilton
1   Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
Dmitry Zavlin
2   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
Andres F. Doval
2   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
Aldona J. Spiegel
2   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
› Author Affiliations
Funding None of the authors, nor their close family members, have a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Furthermore, the authors declare that no commercial associations or financial disclosures exist that might pose or create a conflict of interest with information presented in this manuscript.


Background Free tissue transfer using microsurgical techniques is a popular option for breast reconstruction, and the internal mammary vessels remain the most popular recipient vessels for the anastomosis. Traditionally, ribs were resected for better access to these vessels in the intercostal space. However, rib resection has the potential for complications and adds a surgical step. Here, the authors evaluate and compare both techniques in a retrospective study as well as offer technical pearls.

Methods The 400 most recent consecutive patients who underwent microsurgical breast reconstruction by a single surgeon were retrospectively reviewed. 54 patients underwent the traditional rib-resecting approach. 346 patients underwent the rib-sparing approach, which was the preferred approach of the senior author, when possible. Patients requiring the rib-resecting approach were distributed evenly throughout the series. Primary outcomes were any immediate post-operative complications.

Results Between the two clinical groups, there was no difference between demographic or clinical details, the flap type, history of previous radiation, or timing of reconstruction. Complications of any kind as well as the subset of complications were significantly more frequent in the rib resection than in the rib-sparing group. Specifically, the rate of reanastomosis was higher in the rib resection group [10.6 vs 2.7%, p < 0.001] as was the frequency of return to the OR in the immediate post-operative setting [3.0 vs 0.3%, p < 0.001]. There is a 4.50 odds ratio of having a complication in a rib resection case versus rib sparing [CI: 1.97–10.30, p < 0.001]. All cases were initiated with the intent to perform a rib-sparing approach if possible, and they were converted to a rib-resection approach as needed.

Conclusion In the largest reported series to date, the rib-sparing approach is demonstrated to be both safe and efficacious in microsurgical breast reconstruction.

Ethical Considerations

The work described in this manuscript was approved by our institutional review board. The authors adhered to the Declaration of Helsinki at all time.

Publication History

Received: 31 December 2020

Accepted: 12 May 2021

Article published online:
17 August 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
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