Tips for successful microvascular abdominal flap breast reconstruction utilizing the "total rib preservation" technique for internal mammary vessel exposure.

ABSTRACT

INTRODUCTION: The internal mammary vessels (IMVs) are increasingly the recipients for free flap breast reconstruction (FFBR). Access traditionally entails removing a segment of the third costal cartilage. Despite excellent exposure, some authors have reported localized tenderness as well as a thoracic contour deformity. We introduced the "total rib preservation" technique for IMV exposure after specific request by a patient, and have used it for all subsequent reconstructions. METHODS: All patients who underwent FFBR with rib preservation by a single surgeon in the year beginning June 2008 were studied prospectively. Intraoperative measurements of the inter-rib space available for microvascular anastomosis were taken. Operative details and flap outcomes were compared with a cohort of earlier patients who underwent rib sacrifice. RESULTS: Over a 12-month period, 42 FFBRs in 37 patients (36 deep inferior epigastric perforator, five muscle-sparing transverse rectus abdominis myocutaneous, and one superficial inferior epigastric artery flap) were performed by a single operator. All flap transfers were successful. In the first 4 patients, the interspace between the third and fourth ribs was used; but for all subsequent patients the second and third rib interspace was used. The average distance between adjacent ribs was 21.3 mm (range, 9-28 mm) and the vessel preparation time decreased from an average of 93 to 49 minutes (first and last 5 cases). There was no significant difference in mean ischemia time between the rib preservation and the rib sacrifice groups (104.4 vs. 103.6 minutes). CONCLUSIONS: The total rib preservation method of IMV exposure is a viable, reproducible, and reliable option for microvascular breast reconstruction. It does not increase warm ischemia, which suggests time taken for anastomosis is not affected by rib preservation. There is a learning curve and care has to be taken to avoid possible pitfalls. We recommend the use of a higher rib interspace than originally described because of the greater vessel calibre, superior vessel exposure, and therefore, easier anastomosis.