Five Steps to Internal Mammary Vessel Preparation in Less than 15 Minutes

Abstract

Sir: We commend the authors on describing steps to improve efficiency in rib harvest for deep inferior epigastric perforator breast reconstruction.1 Their video demonstrates rapid dissection of the internal mammary vessels with a rib removal technique. The case appears to be a nonirradiated chest with virgin tissues. We would like to highlight some points of the technique described that may save time and avoid serious complications. This is particularly the case in an irradiated or previously infected wound bed. We start by splitting the pectoralis major in line with its fibers; however, we raise the muscle both inferiorly and superiorly in a subpectoral plane, taking care to preserve internal mammary artery perforators. In some cases, if a sizable internal mammary artery perforator is present, there is no need to perform a rib removal, and this should save precious surgical time. Another approach that we have used—particularly if there is a large rib space—is the rib-preserving approach (Fig. 1); careful lateral-to-medial dissection with bipolar cautery can be used to identify the vessels. This technique has a learning curve but has potential advantages, such as reduced pain, lower chance of chest wall contour deformity, and faster dissection.2Fig. 1.: Rib-preserving approach.Once the third rib is exposed, the pectoralis major muscle is dissected superiorly and inferiorly. Good exposure is achieved with a deep retractor, stay sutures,3 or fish hook retractors. Like the authors, we split the perichondrium and start dissection with an Obwegeser elevator; if the plane is not clear because of irradiation or previous infection, we use a finer instrument such as a Mitchell trimmer to develop a clear plane and release the adherent posterior perichondrium. This helps develop a natural plane behind the rib, avoiding bleeding and subsequent loss of time (Fig. 2).Fig. 2.: Careful dissection of irradiated scarred tissues of posterior perichondrium with a Mitchell trimmer.Right- and left-handed cardiac Doyen rib elevators are also useful in speeding up rib removal, but care must be taken to first remove all of the posterior perichondrium. Once the rib is dissected free, it is cut on the lateral side with protection from the Doyen rib elevator. If this has been performed carefully, one can disarticulate rib from the sternal joint in one go. We would caution (particularly the less experienced) against use of rongeurs to remove the rib piecemeal in the irradiated chest. The pulling motion to remove the rib can cause avulsion of underlying adherent scarred tissues, which may in turn lead to a hole in the recipient vessels. We use rongeurs only if the disarticulation is incomplete medially. Finally, we must highlight that care must be taken around the dissection of the vein, as it can easily become attenuated, with damage to the vessel wall. We would advise the use of bipolar cautery rather than monopolar that was demonstrated in the video when close to the vessels. In the many units where we have trained, two microsurgical reconstructions are still possible using the additional techniques described. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mohammed Farid, M.R.C.S., M.Sc.Onur Gilleard, F.R.C.S.(Plast.)Dariush Nikkhah, M.Sc., F.R.C.S.(Plast.)Barts Health NHS TrustThe Royal London HospitalWhitechapel, London, United Kingdom