We read with interest the article by Drs. Haddock and Teotia regarding the exposure of the internal mammary vessels for microvascular breast reconstruction in 15 minutes.1 We would like to congratulate them on their superb results and eloquent five-step technique. We agree with the authors that the internal mammary recipient site is now the preeminent site for breast free flaps and, as is the case in their series, it is used almost exclusively in our practice. We also agree with the importance that must be attached to the “safe and efficient preparation of the internal mammary artery and vein.” Uncontrollable bleeding from the internal mammary vessels can be catastrophic; thus, careful controlled exposure is always recommended over speed.
It is also, however, important to take steps aimed at reducing morbidity at the recipient site. We therefore continue to be surprised by articles that persist in sacrificing the rib costal cartilage for internal mammary vessel exposure when there have been numerous publications extolling the virtues of rib-preservation techniques for well over 10 years. These publications include written and visual aids to assist with learning the technique.2–4 The second intercostal space is our preferred space and provides adequate room for unipedicled and bipedicled flap reconstructions in the vast majority of cases. In an analysis performed by our group, the second space was on average 20 mm wide compared with the third, which was 14 mm; thus, our preferred practice is to use the second space.
We have looked at 296 of our rib-sparing cases and found that the total rib-preservation technique has a very short learning curve. In our experience, even the most junior residents can learn to perform this technique expediently. The time taken for vessel exposure by our residents declined steeply with each case, and they quickly become comfortable with this technique after approximately four cases. For the senior author, the median vessel exposure times were 27 minutes for the second intercostal space and 25 minutes for the third intercostal space. Our figures were for the total time to prepare the vessels ready for anastomosis and not just exposure of the vessels. What should be noted is that we use a two-team approach so that internal mammary vessel exposure occurs simultaneously with flap raising and therefore does not impact on overall surgical time.
In addition to adequate access and a short learning curve, the rib-preservation technique has several other benefits, including less pain and deformity at the recipient site.5 Deformity can be an issue particularly in slim women undergoing unilateral reconstruction to match contralateral breasts with natural upper pole volume deficiency because of ptosis. In some of these cases, additional procedures may be required to address the defect following cartilage excision. We believe, therefore, that the rib-preservation technique is important to the reduction of recipient-site morbidity, just as the development of deep inferior epigastric perforator flaps evolved to reduce abdominal donor-site morbidity.
None of the authors has a financial interest to declare in relation to the content of this communication.
Charles Malata, F.R.C.S.(Plast.)Department of Plastic and Reconstructive Surgery, and Cambridge Breast UnitAddenbrooke’s HospitalCambridge University Hospitals NHS Foundation TrustCambridge, United KingdomAnglia Ruskin University School of MedicineCambridge and Chelmsford, United Kingdom
Yoshie Sasaki, M.D.Georgette Oni, Ph.D., F.R.C.S.(Plast.)Department of Plastic and Reconstructive SurgeryAddenbrooke’s HospitalCambridge University Hospitals NHS Foundation TrustCambridge, United Kingdom
1. Haddock NT, Teotia SS. Five steps to internal mammary vessel preparation in less than 15 minutes. Plast Reconstr Surg. 2017;140:884886.
2. Parrett BM, Caterson SA, Tobias AM, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg. 2008;60:241243.
3. Malata CM, Moses M, Mickute Z, Di Candia M. Tips for successful microvascular abdominal flap breast reconstruction utilizing the “total rib preservation” technique for internal mammary vessel exposure. Ann Plast Surg. 2011;66:3642.
4. Rosich-Medina A, Bouloumpasis S, Di Candia M, Malata CM. Total ‘rib’-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video. Ann Med Surg (Lond.) 2015;4:293300.
5. Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg. 2011;64:5862.