We thank Dr. Antony and colleagues for their excellent video presentation entitled “Technique of Internal Mammary Dissection Using Pectoralis Major Flap to Prevent Contour Deformities,”1 illustrating the recently published explanation of their technique.2
They describe raising a medially based flap of pectoralis major before resection of costal cartilage to gain access to the internal mammary vessels. This is subsequently replaced to cover the potential space at the site of rib resection once the anastomosis has been performed, to obviate any contour deformity.
We should like to recommend a technique that would make this excellent suggestion both safer and easier. First, the rib-sparing technique has already been described for internal mammary access as being a reliable and safe option.3 We believe that this technique should always be initially attempted, rather than costal cartilage resection, thus removing the problem of contour deformity altogether. Intercostal space selection is a patient-tailored decision based on ergonomics for microsurgery planning, ideally aiming for the second or third space to access a single large-diameter vessel.
Therefore, the procedure is started by either splitting the pectoralis major muscle in the line of its fibers, or raising a medially based flap as in the case of the video presentation (assuming that any perforators are of insufficient size for anastomosis). Once through the intercostal muscles, within the interspace, progress can be made both quickly and safely in a medial direction, until the vessels are displayed (Fig. 1). The dissection proceeds in a distal-to-proximal direction so that, were there to be an accidental injury to the vessel, proximal control can always be achieved. If more length of vessel is needed, which we believe is a rare occurrence, a portion of costal cartilage can be taken out at this stage. This, we believe, is safer than the technique described in the video. The reason for this is that the vessels can be followed under the perichondrium of the rib cartilage and freed from below under direct vision. In patients who have had radiotherapy, the internal mammary vessels may well be adherent to the deep surface of the perichondrium. If the technique in the video is used for these patients, it is possible to tear the vessels while removing the cartilage, with potentially serious and rarely catastrophic consequences.4 This risk can be avoided by safely dissecting the vessels away from the underside of the rib before resection of the costal cartilage.
Once the vessels are exposed and anastomoses have been performed, the split pectoralis fibers are redraped around the vessels, or the medially based flap as recommended by Antony et al.1 can be reattached. Kinking of the vessels must be a concern, however, if the flap technique is used.
We believe that there is a sequence of surgical maneuvers that should be used for internal mammary access that can be followed each time reliably and safely. If this technique is carried out in the order described, safe and plentiful access can be achieved in a reproducible manner.
Kelvin Ramsey, F.R.C.S.(Plast.)
Damien Grinsell, F.R.A.C.S.(Plast.)
Department of Plastic Surgery
St. Vincent's Hospital
Melbourne, Victoria, Australia
1.Antony AK, Kamdar M, Da Lio A, Mehrara BJ. Technique of internal mammary dissection using pectoralis major flap to prevent contour deformities. Plast Reconstr Surg
. 2009;123: 1674–1675.
2.Mosahebi A, Da Lio A, Mehrara BM. 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
3.Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg
4.Pratt GF, Faris JG, Lethbridge M, Teh LG. Breast reconstruction with a free DIEP (TRAM) flap complicated by cardiac tamponade and arrest: A case report. J Plast Reconstr Aesthet Surg
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