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
