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Mehrara, Babak Joseph, M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 2193
doi: 10.1097/PRS.0b013e3181bcf804

Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, N.Y. 10021,

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I thank Dr. Ramsey and Dr. Grinsell for their comments. As my colleagues and I stated previously, there are many ways to expose the internal mammary vessels for microsurgical anastomosis. The method we have demonstrated works well in our hands and has not been associated with any of the risks outlined by Dr. Ramsey and Dr. Grinsell. Even in patients who have undergone previous chest wall irradiation, we have not found that the perichondrium is adherent to the underlying vessels. In fact, in these cases it is often easier to dissect the perichondrium off of the rib, since it is usually somewhat thickened. Once dissected, the perichondrium is incised at a location lateral to the vessels and then dissected off under direct vision so as to avoid tearing the thin walled internal mammary vein. Similarly, as my colleagues and I have previously reported, this technique is not associated with kinking or distortion of the vessels resulting in microvascular thrombosis.1 We agree that, when feasible, the vessels can be dissected safely without removing the rib. In those circumstances, raising a small pectoralis major flap, as demonstrated in our video (, is still easily and safely performed and results in excellent exposure of the vessels. Splitting the muscle is a perfectly reasonable approach; however, we feel that this approach makes the microsurgery more difficult, as the vessels are located in a deeper “hole,” with the edges of the muscle requiring retraction. As we have previously published and demonstrated in this video, the combination of the pectoralis flap and the use of the pediatric Omni retractor provides excellent exposure, with the vessels located at an optimum level for microsurgery.2 We believe that these factors contribute to our low published rates of microvascular thrombosis.1–4

Babak Joseph Mehrara, M.D.

Department of Surgery

Memorial Sloan-Kettering Cancer Center

1275 York Avenue

New York, N.Y. 10021

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1. Mosahebi A, Da Lio A, Mehrara B. The use of a pectoralis major flap to improve internal mammary vessels exposure and reduce contour deformity in microvascular free flap breast reconstruction. Ann Plast Surg. 2008;61:30–34.
2. Mehrara BJ, Santoro T, Smith A, Watson JP, Shaw WW, Da Lio AL. Improving recipient vessel exposure during microvascular breast reconstruction. Ann Plast Surg. 2003;51:361–365.
3. Chen CM, Halvorson EG, Disa JJ, et al. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg. 2007;120:1477–1482.
4. Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: Experience with 1195 flaps. Plast Reconstr Surg. 2006;118:1100–1109; discussion 1110–1111.

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