RIB-SPARING TECHNIQUE FOR INTERNAL MAMMARY VESSELS EXPOSURE AND ANASTOMOSIS IN BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZENGAng , ZHULin , LIUZhifei ,  WANGXiaojun , ZHANGHailin , BAIMing , WANGZhi

Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, P. R. China;

Corresponding author：

WANGXiaojun, Email: xjwang100@hotmail.com

Keywords：

Rib-sparing technique for internal mammary vessels exposure and anastomosis; Deep inferior epigastric perforator flap; Breast reconstruction

DOI：

10.7507/1002-1892.20140298

Video：

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Objective To explore the feasibil ity and rel iabil ity of rib-sparing technique for internal mammary vessels exposure and anastomosis in breast reconstruction and thoracic wall repair with deep inferior epigastric perforator (DIEP) flaps. Methods Between November 2009 and September 2011, 11 female patients with post-mastectomy deformities were treated. The mean age was 42 years (range, 33-65 years). Of them, 10 patients underwent breast reconstruction with the DIEP flaps, and 1 patient received defect repair for chronic thoracic wall irradiated ulcer with the DIEP flap. The size of the flap ranged from 18 cm×9 cm to 28 cm×12 cm. Rib-sparing technique was applied in all these cases. The internal mammary vessels were exposed by dissection intercostal space and anastomosed with the deep inferior epigastric vessels. The donor sites were closed directly in all cases. Results In all cases, the rib-sparing technique for internal mammary vessels exposure and anastomosis was successfully performed. The mean time for internal mammary vessels exposure was 52 minutes (range, 38-65 minutes). The mean exposure length of the internal mammary vessels was 1.7 cm (range, 1.3-2.2 cm). All flaps survived completely postoperatively, and wounds and incisions at donor sites healed primarily. All patients were followed up 8-26 months (mean, 12 months). All patients were satisfied with the reconstructive outcomes. No collapse deformity or discomfort of the thoracic wall occurred. Conclusion The rib-sparing technique for internal mammary vessels exposure and anastomosis is a rel iable and reproducible approach to reconstruct the breast and repair the thoracic wall with DIEP flap, and it can reduce collapse deformity of the thoracic wall.

Citation： ZENGAng, ZHULin, LIUZhifei, WANGXiaojun, ZHANGHailin, BAIMing, WANGZhi. RIB-SPARING TECHNIQUE FOR INTERNAL MAMMARY VESSELS EXPOSURE AND ANASTOMOSIS IN BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP. Chinese Journal of Reparative and Reconstructive Surgery, 2014, 28(11): 1376-1379. doi: 10.7507/1002-1892.20140298 Copy

1.	Kropf N, Macadam SA, McCarthy C, et al. Influence of the reci pient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap. Scand J Plast Reconstr Surg Hand Surg, 2010, 44(2):96-101.
2.	Malata CM, Moses M, Mickute Z, et al. Ti ps for successful microvascular abdominal flap breast reconstruction util izing the "total rib preservation" technique for internal mammary vessel exposure. Ann Plast Surg, 2011, 66(1):36-42.
3.	Moran SL, Nava G, Behnam AB, et al. An outcome analysis comparing the thoracodorsal and internal mammary vessels as reci pient sites for microvascular breast reconstruction:a prospective study of 100 patients. Plast Reconstr Surg, 2003, 111(6):1876-1882.
4.	Srivastava A, Tripathi DM, Zaman W, et al. Subcostal versus transcostal mini donor nephrectomy:is rib resection responsible for pain related donor morbidity. J Urol, 2003, 170(3):738-740.
5.	Parrett BM, Caterson SA, Tobias AM, et al. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg, 2008, 60(3):241-243.
6.	Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg, 2009, 123(5):1403-1407.
7.	Darcy CM, Smit JM, Audolfsson T, et al. Surgical technique:The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg, 2011, 64(1):58-62.
8.	Kim H, Lim SY, Pyon JK, et al. Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruction with the free DIEP flap. Plast Reconstr Surg, 2013, 131(3):327e-334e.
9.	Tuinder SR, Dikmans R, Schi pper RJ, et al. Anatomical evaluation of the internal mammary vessels based on magnetic resonance imaging (MRI). J Plast Reconstr Aesthet Surg, 2012, 65(10):1363-1367.
10.	Khoo A, Rosich-Medina A, Woodham A, et al. The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure. Microsurgery, 2014, 34(6):448-453.
11.	Casares Santiago M, García-Tutor E, Rodríguez Caravaca G, et al. Optimising the preoperative planning of deep inferior epigastric perforator flaps for breast reconstruction. Eur Radiol, 2014, 24(9):2097-2108.
12.	Cina A, Barone-Adesi L, Rinaldi P, et al. Planning deep inferior epigastric perforator flaps for breast reconstruction:a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol, 2013, 23(8):2333-2343.
13.	Kim H, Lim SY, Pyon JK, et al. Preoperative computed tomographic angiography of both donor and reci pient sites for microsurgical breast reconstruction. Plast Reconstr Surg, 2012, 130(1):11e-20e.
14.	Demir A, Kucuker I, Keles MK, et al. The effect of learning curve on flap selection, re-exploration, and salvage rates in free flaps; A retrospective analysis of 155 cases. Microsurgery, 2013.[Epub ahead of print].
15.	Han S, Yoon SY, Park JM. The anatomical evaluation of internal mammary vessels using sonography and 2-dimensional computed tomography in Asians. Br J Plast Surg, 2003, 56(7):684-688.
16.	Bourget A, Chang JT, Wu DB, et al. Free flap reconstruction in the head and neck region following radiotherapy:a cohort study identifying negative outcome predictors. Plast Reconstr Surg, 2011, 127(5): 1901-1908.
17.	Fosnot J, Fischer JP, Smartt JM Jr, et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction? Plast Reconstr Surg, 2011, 127(2):496-504.
18.	Galanis C, Nguyen P, Koh J, et al. Microvascular lifeboats:a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg, 2014, 134(1):20-27.

1. Kropf N, Macadam SA, McCarthy C, et al. Influence of the reci pient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap. Scand J Plast Reconstr Surg Hand Surg, 2010, 44(2):96-101.
2. Malata CM, Moses M, Mickute Z, et al. Ti ps for successful microvascular abdominal flap breast reconstruction util izing the "total rib preservation" technique for internal mammary vessel exposure. Ann Plast Surg, 2011, 66(1):36-42.
3. Moran SL, Nava G, Behnam AB, et al. An outcome analysis comparing the thoracodorsal and internal mammary vessels as reci pient sites for microvascular breast reconstruction:a prospective study of 100 patients. Plast Reconstr Surg, 2003, 111(6):1876-1882.
4. Srivastava A, Tripathi DM, Zaman W, et al. Subcostal versus transcostal mini donor nephrectomy:is rib resection responsible for pain related donor morbidity. J Urol, 2003, 170(3):738-740.
5. Parrett BM, Caterson SA, Tobias AM, et al. The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction. Ann Plast Surg, 2008, 60(3):241-243.
6. Sacks JM, Chang DW. Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases. Plast Reconstr Surg, 2009, 123(5):1403-1407.
7. Darcy CM, Smit JM, Audolfsson T, et al. Surgical technique:The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions. J Plast Reconstr Aesthet Surg, 2011, 64(1):58-62.
8. Kim H, Lim SY, Pyon JK, et al. Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruction with the free DIEP flap. Plast Reconstr Surg, 2013, 131(3):327e-334e.
9. Tuinder SR, Dikmans R, Schi pper RJ, et al. Anatomical evaluation of the internal mammary vessels based on magnetic resonance imaging (MRI). J Plast Reconstr Aesthet Surg, 2012, 65(10):1363-1367.
10. Khoo A, Rosich-Medina A, Woodham A, et al. The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure. Microsurgery, 2014, 34(6):448-453.
11. Casares Santiago M, García-Tutor E, Rodríguez Caravaca G, et al. Optimising the preoperative planning of deep inferior epigastric perforator flaps for breast reconstruction. Eur Radiol, 2014, 24(9):2097-2108.
12. Cina A, Barone-Adesi L, Rinaldi P, et al. Planning deep inferior epigastric perforator flaps for breast reconstruction:a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol, 2013, 23(8):2333-2343.
13. Kim H, Lim SY, Pyon JK, et al. Preoperative computed tomographic angiography of both donor and reci pient sites for microsurgical breast reconstruction. Plast Reconstr Surg, 2012, 130(1):11e-20e.
14. Demir A, Kucuker I, Keles MK, et al. The effect of learning curve on flap selection, re-exploration, and salvage rates in free flaps; A retrospective analysis of 155 cases. Microsurgery, 2013.[Epub ahead of print].
15. Han S, Yoon SY, Park JM. The anatomical evaluation of internal mammary vessels using sonography and 2-dimensional computed tomography in Asians. Br J Plast Surg, 2003, 56(7):684-688.
16. Bourget A, Chang JT, Wu DB, et al. Free flap reconstruction in the head and neck region following radiotherapy:a cohort study identifying negative outcome predictors. Plast Reconstr Surg, 2011, 127(5): 1901-1908.
17. Fosnot J, Fischer JP, Smartt JM Jr, et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction? Plast Reconstr Surg, 2011, 127(2):496-504.
18. Galanis C, Nguyen P, Koh J, et al. Microvascular lifeboats:a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg, 2014, 134(1):20-27.

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RIB-SPARING TECHNIQUE FOR INTERNAL MAMMARY VESSELS EXPOSURE AND ANASTOMOSIS IN BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP

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