title: Tips for successful microvascular abdominal flap breast reconstruction utilizing the "total rib preservation" technique for internal mammary vessel exposure.
abstract: BACKGROUND
  The internal mammary vessels (IMVs) are increasingly the recipients for free flap breast reconstruction (FFBR). Access traditionally entails removing a segment of the third costal cartilage. Despite excellent exposure, some authors have reported localized tenderness as well as a thoracic contour deformity. We introduced the "total rib preservation" technique for IMV exposure after specific request by a patient, and have used it for all subsequent reconstructions.
  
  
  METHODS
  All patients who underwent FFBR with rib preservation by a single surgeon in the year beginning June 2008 were studied prospectively. Intraoperative measurements of the inter-rib space available for microvascular anastomosis were taken. Operative details and flap outcomes were compared with a cohort of earlier patients who underwent rib sacrifice.
  
  
  RESULTS
  Over a 12-month period, 42 FFBRs in 37 patients (36 deep inferior epigastric perforator, five muscle-sparing transverse rectus abdominis myocutaneous, and one superficial inferior epigastric artery flap) were performed by a single operator. All flap transfers were successful. In the first 4 patients, the interspace between the third and fourth ribs was used; but for all subsequent patients the second and third rib interspace was used. The average distance between adjacent ribs was 21.3 mm (range, 9-28 mm) and the vessel preparation time decreased from an average of 93 to 49 minutes (first and last 5 cases). There was no significant difference in mean ischemia time between the rib preservation and the rib sacrifice groups (104.4 vs. 103.6 minutes).
  
  
  CONCLUSIONS
  The total rib preservation method of IMV exposure is a viable, reproducible, and reliable option for microvascular breast reconstruction. It does not increase warm ischemia, which suggests time taken for anastomosis is not affected by rib preservation. There is a learning curve and care has to be taken to avoid possible pitfalls. We recommend the use of a higher rib interspace than originally described because of the greater vessel calibre, superior vessel exposure, and therefore, easier anastomosis.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge, United Kingdom. cmalata@hotmail.com
authors.forename: Charles M
authors.initials: CM
authors.lastname: Malata
authors.forename: Michael
authors.initials: M
authors.lastname: Moses
authors.forename: Zita
authors.initials: Z
authors.lastname: Mickute
authors.forename: Michele
authors.initials: M
authors.lastname: Di Candia
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008323:Mammary Arteries / Q000601:surgery*; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D011446:Prospective Studies; D012272:Ribs / Q000601:surgery; D013524:Surgical Flaps / Q000098:blood supply*