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Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction

The “1–2–3 Rule”

Lee, Christina Dami, M.S.; Butterworth, James, M.B.B.Ch.; Stephens, Robert, Ph.D.; Wright, Barth, Ph.D.; Surek, Christopher, D.O.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1121e–1122e
doi: 10.1097/PRS.0000000000005540
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Division of Clinical Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Mo.

Department of Plastics and Reconstructive Surgery, University of Kansas Medical Center, Kansas City, Kansas

Kansas City University of Medicine and Biosciences, Kansas City, Mo.

Department of Plastics and Reconstructive Surgery, University of Kansas Medical Center, Kansas City, Kans.

Correspondence to Ms. Lee, 1750 Independence Avenue, Kansas City, Mo. 64106, leecdami@gmail.com

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Sir:

We would like to thank Dr. Thoma and colleagues for taking the time to comment on our article.1 It is known that the dissection of the internal mammary vessels for microvascular autologous breast reconstruction has a steep learning curve, especially for young surgeons. Our intention was to conduct a cadaveric project specifically relating to the autologous breast reconstruction using the internal mammary vessels to provide surgeons with a reliable and relatively safe zone of dissection for locating the vessels intraoperatively for recipient vessel exposure.1

In the process of developing our method, we looked at various measurements and descriptive data points. In our study design, we elected to include the venous bifurcation pattern initially to confirm the commonly accepted pattern site of the fourth intercostal space.2 Incidentally, our data indicated otherwise, and we found that the internal mammary vein bifurcated most commonly in the third intercostal space.1 Dr. Thoma et al. suggest that we claimed that the vein bifurcated most commonly in the fourth intercostal space.2 Our sentiment is that the variance within the laterality is more significant and valuable for aiding in intraoperative dissections than the most common pattern without indicating specific side.

We regret that the 1988 publication for the free vascularized anterior rib graft3 was not a part of our references. We acknowledge that there is always a possibility of small but pertinent pieces of information not surfacing as readily for review, especially with a large number of studies conducted globally. A careful literature review is an important factor for successful projects. With the continuing advancement of technology, we are fortunate to have search engines such as Medline/PubMed, with which we can delineate relevant and irrelevant resources by reviewing title, abstract, and keywords. Although we must be thorough in our search, we must also be efficient. With that, we relied heavily on the title and the abstract for the process of eliminating what we considered to be inconsequential for our topic. In addition to the Medline/PubMed search, we depended on the select references with relevant information to take us to the resources that are more focused to our specific project.

With great respect, we disagree that our cadaveric internal mammary vessel research and contribution would have been a redundant waste of resources even with more careful reporting of Thoma et al.’s findings, as the authors suggest.2 In addition, the reference they cited suggests that the estimated $170 billion wasted on research is based on the three factors: accessible publication, complete and accurate reporting, and good design without significant flaw.4 Had the sole purpose of our project been to describe the venous bifurcation pattern, indeed we might have contributed to redundancy and potential waste of resources. Although both studies involve the anterior chest wall and the same major vessels (i.e., the internal mammary vessels), harvesting an anterior rib graft, as opposed to dissecting the internal mammary vessels for recipient vessels for microvascular autologous breast reconstruction, does not particularly share the same techniques. Other fundamental differences include that we do not encourage causing iatrogenic pneumothorax3 and, as a principle, a smaller segment of anterior chest wall to be removed with dissection for autologous breast reconstruction.

The venous bifurcation pattern was an incidental finding rather than the primary. Furthermore, designating the costochondral junction to be the more reliable intraoperative marker1 than the lateral sternal border deems the venous bifurcation less relevant for the main purpose of our study, but it was included for the completeness of the cadaveric study. Although Thoma et al.’s publication was neither the stem nor the origin of our study, it should be encouraged rather than not to continue to explore and revisit projects in the past few decades or more as the field of medicine overwhelmingly depends and flourishes on new technologies and research, contributing to its advancement.

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DISCLOSURE

None of the authors has a financial interest to declare in relation to the content of this communication.

Christina Dami Lee, M.S.

Division of Clinical Anatomy

Kansas City University of Medicine and Biosciences

Kansas City, Mo.

James Butterworth, M.B.B.Ch.

Department of Plastics and Reconstructive Surgery

University of Kansas Medical Center

Kansas City, Kansas

Robert Stephens, Ph.D.

Barth Wright, Ph.D.

Kansas City University of Medicine and Biosciences

Kansas City, Mo.

Christopher Surek, D.O.

Department of Plastics and Reconstructive Surgery

University of Kansas Medical Center

Kansas City, Kans.

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REFERENCES

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. Moltaji S, Murphy J, Thoma A. Location of the internal mammary vessels for microvascular autologous breast reconstruction: The “1–2–3 rule” (Letter). Plast Reconstr Surg. 2019;143:1120e–1121e.
3. Thoma A, Heddle S, Archibald S, Young JE. The free vascularized anterior rib graft. Plast Reconstr Surg. 1988;82:291–298.
4. Glasziou P, Chalmers I. Is 85% of health research really wasted? BMJ Opinion. 2016. Available at: https://blogs.bmj.com/bmj/2016/01/14/paul-glasziou-and-iain-chalmers-is-85-of-healthresearch-really-wasted. Accessed August 26, 2018.
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