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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.
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Abstract

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.

Keywords

breast reconstruction - DIEP flap - rib resection - rib sparing - anastomosis - outcomes

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.

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  • References

  • 1 Shaw WW. Microvascular free flap breast reconstruction. Clin Plast Surg 1984; 11 (02) 333-341
    CrossrefPubMedGoogle Scholar
  • 2 Gill PS, Hunt JP, Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
    CrossrefPubMedGoogle Scholar
  • 3 Haywood RM, Raurell A, Perks AG, Sassoon EM, Logan AM, Phillips J. Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels. Br J Plast Surg 2003; 56 (07) 689-691
    CrossrefPubMedGoogle Scholar
  • 4 Moran SL, Nava G, Behnam AB, Serletti JM. An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg 2003; 111 (06) 1876-1882
    CrossrefPubMedGoogle Scholar
  • 5 Nejedlý A, Tvrdek M, Kletenský J, Pros Z. Internal mammary vessels as recipient vessels to the free TRAM flap. Acta Chir Plast 1995; 37 (01) 17-19
    PubMedGoogle Scholar
  • 6 Ninković M, Anderl H, Hefel L, Schwabegger A, Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction. Br J Plast Surg 1995; 48 (08) 533-539
    CrossrefPubMedGoogle Scholar
  • 7 Hefel L, Schwabegger A, Ninković M. et al. Internal mammary vessels: anatomical and clinical considerations. Br J Plast Surg 1995; 48 (08) 527-532
    CrossrefPubMedGoogle Scholar
  • 8 Arnez ZM, Valdatta L, Tyler MP, Planinsek F. Anatomy of the internal mammary veins and their use in free TRAM flap breast reconstruction. Br J Plast Surg 1995; 48 (08) 540-545
    CrossrefPubMedGoogle Scholar
  • 9 Dupin CL, Allen RJ, Glass CA, Bunch R. The internal mammary artery and vein as a recipient site for free-flap breast reconstruction: a report of 110 consecutive cases. Plast Reconstr Surg 1996; 98 (04) 685-689 , discussion 690–692
    CrossrefPubMedGoogle Scholar
  • 10 Conacher ID, Doig JC, Rivas L, Pridie AK. Intercostal neuralgia associated with internal mammary artery grafting. Anaesthesia 1993; 48 (12) 1070-1071
    CrossrefPubMedGoogle Scholar
  • 11 Knudsen FW, Andersen M, Niebuhr U, Nielsen PL, Krag C. The role of the internal thoracic artery in the sternal blood supply. Scand J Thorac Cardiovasc Surg 1993; 27 (01) 3-8
    CrossrefPubMedGoogle Scholar
  • 12 Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg 2008; 60 (03) 241-243
    CrossrefPubMedGoogle Scholar
  • 13 Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg 2009; 123 (05) 1403-1407
    CrossrefPubMedGoogle Scholar
  • 14 Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg 2011; 64 (01) 58-62
    CrossrefPubMedGoogle Scholar
  • 15 Kim H, Lim SY, Pyon JK. et al. Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruction with the free DIEP flap. Plast Reconstr Surg 2013; 131 (03) 327e-334e
    CrossrefPubMedGoogle Scholar
  • 16 Rosich-Medina A, Bouloumpasis S, Di Candia M, Malata CM. Total ‘rib’-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video. Ann Med Surg (Lond) 2015; 4 (03) 293-300
    CrossrefPubMedGoogle Scholar
  • 17 Mauch JT, Rhemtulla IA, Katzel EB, Hernandez JA, Broach RB, Serletti JM. Does size matter: evaluating the difference between the right and left internal mammary veins in free flap breast reconstruction. J Reconstr Microsurg 2019; 35 (09) 677-681
    Article in Thieme ConnectPubMedGoogle Scholar