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Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap

Kim, Hyungsuk M.D.; Lim, So-Young M.D., Ph.D.; Pyon, Jai-Kyong M.D., Ph.D.; Bang, Sa-Ik M.D., Ph.D.; Oh, Kap Sung M.D., Ph.D.; Lee, Jeong Eon M.D., Ph.D.; Nam, Seok Jin M.D., Ph.D.; Mun, Goo-Hyun M.D., Ph.D.

Plastic and Reconstructive Surgery: March 2013 - Volume 131 - Issue 3 - p 327e–334e
doi: 10.1097/PRS.0b013e31827c6d38
Breast: Original Articles

Background: Using an internal mammary artery as the recipient vessel in a free flap autologous breast reconstruction is common practice, but this vessel is often sacrificed for end-to-end anastomosis and is typically assessed by removing a costal cartilage segment. The authors studied the reliability of the end-to-side arterial anastomosis using a rib-sparing approach by comparing it with end-to-end anastomosis.

Methods: The authors analyzed 100 consecutive medical records of patients who underwent autologous breast reconstruction with a free deep inferior epigastric artery perforator flap in which the internal mammary vessels were assessed using a rib-sparing technique. The study compared the complications between the two groups of end-to-side arterial anastomosis (50 cases) and end-to-end arterial anastomosis (50 cases).

Results: Exposure of the internal mammary artery using a rib-sparing technique was performed successfully in all 100 flaps. The second and third intercostal spaces were used in 46 and 54 cases, respectively. The mean width of the used intercostal space was 18.3 ± 2.4 mm in the end-to-side group and 18.3 ± 2.9 mm in the end-to-end group (p = 0.923). All flaps survived without partial or total necrosis. One case of venous insufficiency that required exploration occurred in the end-to-side group; the flap was totally saved with venous revision. There was no significant statistical difference between the end-to-side and end-to-end groups in all other variables, including mean flap ischemic time (p = 0.431) and fat necrosis (p = 0.339).

Conclusion: The rib-sparing and internal mammary artery–preserving free deep inferior epigastric artery perforator flap transfer is an efficient and safe technique for microsurgical breast reconstruction.



Seoul, South Korea

From the Departments of Plastic Surgery and Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine.

Received for publication April 23, 2012; accepted September 21, 2012.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Goo-Hyun Mun, M.D., Ph.D.; Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong 50, Gangnam-gu, Seoul, South Korea 135-710,

©2013American Society of Plastic Surgeons