title: Total 'rib'-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video.
abstract: BACKGROUND
  The total 'rib'-preservation method of dissecting out the internal mammary vessels (IMV) during microvascular breast reconstruction aims to reduce free flap morbidity at the recipient site. We review our five-year experience with this technique.
  
  
  METHODS
  An analysis of a prospectively collected free flap data cohort was undertaken to determine the indications, operative details and reconstructive outcomes in all breast reconstruction patients undergoing IMV exposure using the total 'rib'-preservation method by a single surgeon.
  
  
  RESULTS
  178 consecutive breast free flaps (156 unilateral, 11 bilateral) were performed from 1st June 2008 to 31st May 2013 in 167 patients with a median age of 50 years (range 28-71). There were 154 DIEP flaps, 14 SIEA flaps, 7 muscle-sparing free TRAMs, 2 IGAP flaps and one free latissimus dorsi flap. 75% of the reconstructions (133/178) were immediate, 25% (45/178) were delayed. The mean inter-costal space distance was 20.9 mm (range 9-29). The mean time taken to expose and prepare the recipient IMV's was 54 min (range 17-131). The mean flap ischaemia time was 95 min (range 38-190). Free flap survival was 100%, although 2.2% (4 flaps) required a return to theatre for exploration and flap salvage. No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed.
  
  
  CONCLUSIONS
  The total 'rib'-preservation technique of IMV exposure is a safe, reliable and versatile method for microvascular breast reconstruction and should be considered as a valid alternative to the 'rib'-sacrificing techniques.
authors.affiliation: Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK.
authors.forename: Anais
authors.initials: A
authors.lastname: Rosich-Medina
authors.affiliation: Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK.
authors.forename: Serafeim
authors.initials: S
authors.lastname: Bouloumpasis
authors.affiliation: Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK.
authors.forename: Michele
authors.initials: M
authors.lastname: Di Candia
authors.affiliation: Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK ; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge & Chelmsford, UK ; The Cambridge Breast Unit at Addenbrooke's Hospital, UK.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Malata
keywords: Breast free flaps; Breast reconstruction; Intercostal space distance; Internal mammary vessels; Rib-sparing vessel exposure; Total rib preservation