title: To Resect or Not to Resect: The Effects of Rib-Sparing Harvest of the Internal Mammary Vessels in Microsurgical Breast Reconstruction.
abstract: BACKGROUND
  The internal mammary vessels are the most commonly used recipients for microsurgical breast reconstructions. Often, the costal cartilage is sacrificed to obtain improved vessel exposure. In an effort to reduce adverse effects associated with traditional rib sacrifice, recent studies have described less-invasive, rib-sparing strategies.
  
  
  METHODS
  After obtaining institutional review board's approval, a retrospective review of all patients undergoing microsurgical breast reconstruction at a single institution between November 2007 and December 2013 was conducted. Patients were divided into two cohorts for comparison: rib-sacrificing and rib-sparing internal mammary vessel harvests.
  
  
  RESULTS
  A total of 547 reconstructions (344 patients) met inclusion criteria for this study. A total of 64.9% (n = 355) underwent rib-sacrificing internal mammary vessel harvest. Cohorts were similar in baseline patient characteristics, indications for surgery, and cancer therapies. However, patients undergoing rib-sparing reconstructions had significantly shorter operative times (440 vs. 476 minutes; p < 0.01), and significantly less postoperative pain on postoperative day (POD) 1 (2.8/10 vs. 3.4/10; p = 0.033) and POD2 (2.4/10 vs. 3.0/10; p = 0.037). Furthermore, patients undergoing rib-sparing techniques had greater incidence of fat necrosis requiring excision (12.5 vs. 2.8%; p < 0.01) and a trend toward higher incidence of hematoma, venous thrombosis, and arterial thrombosis when compared with rib-sacrificing patients.
  
  
  CONCLUSIONS
  Rib-sparing harvest of internal mammary vessels is a feasible technique in microsurgical breast reconstruction. However, given the significant increase in fat necrosis requiring surgical excision, the trend toward increased postoperative complications, and no significant difference in postoperative revision rates, the purported benefits of this technique may fail to outweigh the possible risks.
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Stelios
authors.initials: S
authors.lastname: Wilson
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Katie
authors.initials: K
authors.lastname: Weichman
authors.affiliation: Teaching Hospital Technical University, Klinikum Bogenhausen, Munich, Germany.
authors.forename: P Niclas
authors.initials: PN
authors.lastname: Broer
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Christina Y
authors.initials: CY
authors.lastname: Ahn
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Allen
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Pierre B
authors.initials: PB
authors.lastname: Saadeh
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Nolan S
authors.initials: NS
authors.lastname: Karp
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Mihye
authors.initials: M
authors.lastname: Choi
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Jamie P
authors.initials: JP
authors.lastname: Levine
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York.
authors.forename: Vishal D
authors.initials: VD
authors.lastname: Thanik
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods; D001940:Breast / Q000098:blood supply* / Q000601:surgery*; D001943:Breast Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods; D008323:Mammary Arteries / Q000637:transplantation*; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D012272:Ribs / Q000601:surgery*; D018570:Risk Assessment; D013524:Surgical Flaps; D016896:Treatment Outcome