Secondary Logo

Journal Logo

Technique of Internal Mammary Dissection Using Pectoralis Major Flap to Prevent Contour Deformities

Ramsey, Kelvin, F.R.C.S.(Plast.); Grinsell, Damien, F.R.A.C.S.(Plast.)

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 2192-2193
doi: 10.1097/PRS.0b013e3181bcf670
LETTERS
Free

Department of Plastic Surgery, St. Vincent's Hospital, Melbourne, Victoria, Australia

Correspondence to Dr. Ramsey, 14 Neville Street, Albert Park, Melbourne, Victoria 3206, Australia, kwdr@aol.com

Back to Top | Article Outline

Sir:

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.

Fig. 1.

Fig. 1.

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

Back to Top | Article Outline

REFERENCES

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. 2008;61:30–34.
3.Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg. 2009;123:1403–1407.
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. 2009;62:e73–e75.

Section Description

GUIDELINES

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons