We welcomed the comments noted by Drs. Malata et al. in their reply regarding our article1 that aimed at a successful and efficient method of internal mammary vessel exposure during free flap breast reconstruction. We took note of their approach and publications regarding a rib-preserving method that minimizes the potential morbidity of removing the costochondral cartilage.2–5 We also found that removing the peristernal cartilage at the second intercostal level would contribute to recipient morbidity. In addition, if the patient subsequently loses enough weight to lower their body mass index, the contour deformity may be subsequently exaggerated. We agree with the authors that correction of such contour depressions is challenging even with local techniques such as fat grafting.
To accommodate and prevent recipient-site deformity, our approach is geared toward harvest of a small section (1- to 2-cm curved chiseling) of fourth costal cartilage on the right and third costal cartilages on the left side, and never at the second level. It is well recognized that the anatomy of the right mammary vessels differs from the anatomy of the left mammary system, particularly with regard to mammary vein caliber. The higher a surgeon dissects superiorly, the larger the veins become, especially on the left side. To compensate for the lower caliber vein of the left side system because of harvest of third costal cartilage, we have adopted use of local vasodilators that adequately dilate the vein for anastomosis.6 As their article suggests, Dr. Malata et al. note a decrease in interspace width as one proceeds inferiorly. We do not believe that using the third or fourth interspace consistently would provide adequate exposure for anastomosis, especially if there is an injury during harvest.
Beyond the scope of our article and in our institutional experience, approximately one-third of our autologous breast reconstructions are stacked/multiple flaps (deep inferior epigastric artery perforator, profunda artery perforator, and/or lateral thigh perforator).7–9 In these circumstances, we use both the cranial and caudal systems of the internal mammary vessels and find that we need a length of at least 2 cm (or more) of mammary vessels to complete at least four anastomoses per side (eight or more in bilateral procedures), and this includes the potential for revision anastomosis because we rely on teaching our fellows and junior and senior level residents. We believe this cannot occur safely with a lower interspace approach at the third to fourth level. In addition, the presence of multiple anastomoses in this unique subset of patients requires gentle handling of several pedicles that overlie one another in various formations to prevent mechanical kinking and postoperative venous thrombosis.
Henceforth, we strongly believe that we must continue to not abandon traditional methods of partial rib resection, as the rib-preserving approach is not universal in application, and we attempted to show in our article that a safe five-step method can be a useful guide even to those who have successfully adopted the rib-preserving approach. The publication of our article should not be a surprise and does not necessarily promote the rib resection technique, but only serves to highlight efficient steps when a particular surgical team member chooses to access the mammary vessels by means of the traditional method.
The authors have no financial interest to declare in relation to the content of this communication.
Sumeet S. Teotia, M.D.Nicholas T. Haddock, M.D.Department of Plastic SurgeryUniversity of Texas SouthwesternDallas, Texas
1. Haddock NT, Teotia SS. Five steps to internal mammary vessel preparation in less than 15 minutes. Plast Reconstr Surg. 2017;140:884886.
2. 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.
3. 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.
4. 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.
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.
6. Vargas CR, Iorio ML, Lee BT. A systematic review of topical vasodilators for the treatment of intraoperative vasospasm in reconstructive microsurgery. Plast Reconstr Surg. 2015;136:411422.
7. Cho MJ, Haddock NT, Teotia SS. Multiple free flap breast reconstruction: An institutional experience when 1 flap for 1 side is not enough. ePoster presentation at: 2018 American Society for Reconstructive Microsurgery Annual Meeting; January 12–16, 2018; Phoenix, Ariz.
8. Cho MJ, Hembd AS, Venutolo CJ, Teotia SS, Haddock NT. Comparative analysis of single versus stacked free flap breast reconstruction: A single center experience. Paper presented at:63rd Annual Meeting of the Plastic Surgery Research Council; May 17–20, 2018; Birmingham, Ala.
9. Teotia SS, Kayfan S, Haddock NT. 4-flap breast reconstruction with DIEP and PAP flaps: When is it indicated and incorporated in one’s practice. Paper presented at: 9th Congress of World Society for Reconstructive Microsurgery; June 14–17, 2017; Seoul, Republic of Korea.