Secondary Logo

Journal Logo

Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction

The “1–2–3 Rule”

Moltaji, Syena, B.Sc., M.D.(c); Murphy, Jessica, M.Sc.; Thoma, Achilleas, M.D., M.Sc.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1120e–1121e
doi: 10.1097/PRS.0000000000005539

Michael G. DeGroote School of Medicine, McMaster University

Division of Plastic Surgery, Department of Surgery, McMaster University

Division of Plastic Surgery, Department of Surgery, Department of Health Research Methods, Evidence, and Impact, McMaster University., Hamilton, Ontario, Canada

Correspondence to Dr. Thoma, 101-206 James Street South, Hamilton, Ontario L8P 3A9, Canada, athoma@mcmaster.caTwitter: @achilleasthoma

Back to Top | Article Outline


It was with great interest that we read the article by Dr. Lee and colleagues on the location of the internal mammary vessels for microvascular autologous breast reconstruction.1 Knowledge of the anatomic variations of the internal mammary vessels is necessary for efficient operative dissection with minimal costal cartilage excision. For this reason, the senior author (A.T.) of this letter pursued a similar cadaveric study, albeit for another purpose, almost 30 years ago2: to delineate the internal mammary vessels, not as recipient vessels but as donor vessels, for the free vascularized anterior rib graft. Thoma et al.2 reported the pertinent anatomy of the internal mammary vessels, their diameters, and the distance from the sternal midline. Notably, the internal mammary vein was found to branch between the third and fifth ribs, most commonly in the fourth intercostal space.2 Lee et al.1 claimed that this finding had not been established prior to their study. The 1987 publication also delineated the costal blood supply from the inferior intercostal and supracostal vessels branching from the internal mammary vessels.2

The Lee et al.1 article bears fundamental similarities to the Thoma et al.2 article; however, we acknowledge, it entails a larger sample of cadavers, and a far more rigorous tabulation of findings. In the Lee et al.1 article, the costal level at which the internal mammary vein bifurcates is documented for the left and right of each cadaver. The authors also report the distance between the internal artery and vein, and the distance of the vessels from both the sternal border and the costochondral junction at each intercostal level.1 These precise findings allow a more detailed mapping of the vessels and represent an improvement in the standard of data reporting since the publication of the Thoma et al.2 article.

Despite its similarities, we do not believe Lee et al.1 had knowledge of our publication, as the branching of the internal mammary vein in the fourth intercostal was reported as novel information. A well-constructed literature search should be done before any project is undertaken to avoid the duplication of labor in research, and all similar papers should be appropriately cited. Readers can refer to the guide by Waltho et al.3 for step-by-step instructions on searching and synthesizing evidence. Use of the keywords “internal mammary vessel*” and “plastic surgery” identified the Thoma et al.2 article in Medline.

Given the significant improvement in reporting between the Lee et al.1 and Thoma et al.2 articles, we consider this article a new and valuable contribution to the literature. However, we would like to emphasize the importance of a thorough literature review before a study is begun. If the Thoma et al.2 findings had been reported more meticulously, it would be a redundant waste of research resources to conduct another cadaveric study of the internal mammary vessels. With an estimated $170 billion wasted on faulty and redundant research annually, overlooking simple steps of a literature search is a mistake we cannot afford.4 Nevertheless, we commend the thorough work done by Lee et al.,1 and we hope it will have a positive impact on dissection of the internal mammary vessels in the future.

Back to Top | Article Outline


The authors have no financial interest to declare in relation to the content of this communication. No funding was obtained for the production of this communication.

Syena Moltaji, B.Sc., M.D.(c)

Michael G. DeGroote School of Medicine

McMaster University

Jessica Murphy, M.Sc.

Division of Plastic Surgery

Department of Surgery

McMaster University

Achilleas Thoma, M.D., M.Sc.

Division of Plastic Surgery

Department of Surgery

Department of Health Research Methods, Evidence, and Impact

McMaster University.

Hamilton, Ontario, Canada

Back to Top | Article Outline


1. Lee CD, Butterworth J, Stephens RE, Wright B, Surek C. Location of the internal mammary vessels for microvascular autologous breast reconstruction: The “1-2-3 rule.” Plast Reconstr Surg. 2018;142:28–36.
2. Thoma A, Heddle S, Archibald S, Young JE. The free vascularized anterior rib graft. Plast Reconstr Surg. 1988;82:291–298.
3. Waltho D, Kaur MN, Haynes RB, Farrokhyar F, Thoma A. Users’ guide to the surgical literature: How to perform a high-quality literature search. Can J Surg. 2015;58:349–358.
4. Glasziou P, Chalmers I. Is 85% of health research really wasted? BMJ Opinion. 2016. Available at: Accessed May 12, 2018.
Back to Top | Article Outline


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.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at

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.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2019American Society of Plastic Surgeons