Advertisement

Utilization of a partial rib-sparing procedure in microvascular breast reconstruction for preserving intercostal nerve and nipple reconstruction

Published:August 23, 2022DOI:https://doi.org/10.1016/j.bjps.2022.08.041

      Summary

      Background

      In microvascular breast reconstruction, internal mammary vessel (IMV) exposure has been performed. The preservation of intercostal nerve (ICN) is effective for preserving sensibility and decreasing postoperative pain. In nipple reconstruction, cartilage grafting is performed to provide additional support and projection. We considered that ICN preservation and costal cartilage banking could be performed simultaneously. This method was described as the “partial rib-sparing procedure.” The purpose of this study was to introduce this procedure.

      Methods

      Surgical technique of this procedure was as follows. The second intercostal space was used. The width of the trimmed cartilage was kept within the superior half of the third costal cartilage. Soft tissue within 5 mm of the inferior border of the second rib edge was preserved to save the second ICN. The length of IMVs in the partial rib-sparing procedure and that in the total rib-sparing procedure was compared.

      Results

      The number of patients in the partial rib-sparing and total rib-sparing groups was 137 procedures and 57 procedures, respectively. The length of IMVs was significantly longer in the partial rib-sparing procedure (median 20.5 mm vs. 17.6 mm, P < 0.001). In the partial rib-sparing group, no patient complained of prolonged local pain, and chest wall contour abnormalities were absent in all cases.

      Conclusions

      The partial rib-sparing procedure is superior, especially for patients with narrow intercostal spaces and/or patients who decide to undergo nipple reconstruction with costal cartilage. This procedure could be performed to preserve the soft tissues around the ICN and decrease the postoperative pain.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bostwick 3rd, J.
        • Vasconez L.O.
        • Jurkiewicz M.J
        Breast reconstruction after a radical mastectomy.
        Plast Reconstr Surg. 1978; 61: 682-693
        • Feller A.M.
        • Hörl H.W.
        • Biemer E.
        The transverse rectus abdominis musculocutaneous free flap: A reliable alternative for delayed autologous tissue breast reconstruction.
        Ann Plast Surg. 1990; 25: 425-434
        • Arnez Z.M.
        • Smith R.W.
        • Kersnic M.
        • et al.
        Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap.
        Br J Plast Surg. 1988; 41: 500-505
        • Coroneos C.J.
        • Heller A.M.
        • Avram R.
        • et al.
        SIEA versus DIEP arterial complications: A cohort study.
        Plast Reconstr Surg. 2015; 135: 802-807
        • Holm C.
        • Mayr M.
        • Ninkovic M.
        • et al.
        Perfusion zones of the DIEP flap revisited: A clinical study.
        Plast Reconstr Surg. 2006; 117: 37-43
        • Lee K.T.
        • Mun G.H.
        Perfusion of the diep flaps: A systematic review with meta-analysis.
        Microsurgery. 2018; 38: 98-108
        • Tuinder S.
        • Baetens T.
        • Lataster A.
        • et al.
        Septocutaneous tensor fasciae latae perforator flap for breast reconstruction: Radiological considerations and clinical cases.
        J Plast Reconstr Aesthet Surg. 2014; 67: 1248-1256
        • Tuinder S.M.H.
        • Beugels J.
        • Allen R.J.
        • et al.
        The lateral thigh perforator flap for autologous breast reconstruction: A prospective analysis of 138 flaps.
        Plast Reconstr Surg. 2018; 141: 257-268
        • Zoccali G.
        • Mughal M.
        • Farhadi J.
        • et al.
        Breast reconstruction with Superior Gluteal Artery Perforator free flap: 8 Years of experience.
        J Plast Reconstr Aesthet Surg. 2019; 72: 1623-1631
        • O'Neill A.C.
        • Hayward V.
        • Hofer S.O.
        • et al.
        Usability of the internal mammary recipient vessels in microvascular breast reconstruction.
        J Plast Reconstr Aesthet Surg. 2016; 69: 907-911
        • Chang E.I.
        • Chang E.I.
        • Chang D.W.
        • et al.
        Demystifying the use of internal mammary vessels as recipient vessels in free flap breast reconstruction.
        Plast Reconstr Surg. 2013; 132: 763-768
        • Sacks J.M.
        • Chang D.W.
        Rib-sparing internal mammary vessel harvest for microvascular breast reconstruction in 100 consecutive cases.
        Plast Reconstr Surg. 2009; 123: 1403-1407
        • Parrett B.M.
        • Caterson S.A.
        • Lee B.T.
        • et al.
        The rib-sparing technique for internal mammary vessel exposure in microsurgical breast reconstruction.
        Ann Plast Surg. 2008; 60: 241-243
        • Oni G.
        • Malata C.M.
        New surgical technique: Simultaneous use of contiguous intercostal spaces during total rib preservation exposure of the internal mammary vessels in microvascular breast reconstruction.
        J Plast Reconstr Aesthet Surg. 2019; 72: 1525-1529
        • Guerra A.B.
        • Khoobehi K.
        • Allen R.J.
        • et al.
        New technique for nipple areola reconstruction: Arrow flap and rib cartilage graft for long-lasting nipple projection.
        Ann Plast Surg. 2003; 50: 31-37
        • Heitland A.
        • Markowicz M.
        • Pallua N.
        • et al.
        Long-term nipple shrinkage following augmentation by an autologous rib cartilage transplant in free DIEP-flaps.
        J Plast Reconstr Aesthet Surg. 2006; 59: 1063-1067
        • Mihara R.
        • Mori H.
        • Okazaki M.
        Nipple reconstruction with dorsal skin provides better projection than reconstruction with abdominal or breast skin with cartilage grafting.
        Aesth Plast Surg. 2017; 41: 31-35
        • van der Graaf T.
        • Verhagen P.C.
        • Kleinrensink G.J.
        • et al.
        Surgical anatomy of the 10th and 11th intercostal, and subcostal nerves: Prevention of damage during lumbotomy.
        J Urol. 2011; 186: 579-583
        • Ueshima H.
        • Hara E.
        • Otake H.
        • et al.
        The ultrasound-guided transversus thoracic muscle plane block is effective for the median sternotomy.
        J Clin Anesth. 2016; 29: 83
        • Bijkerk E.
        • Cornelissen A.J.M.
        • Tuinder S.M.H.
        • et al.
        Intercostal nerve block of the anterior cutaneous branches and the sensibility of the female breast.
        Clin Anat. 2020; 33: 1025-1032
        • Schlenz I.
        • Kuzbari R.
        • Holle J.
        • et al.
        The sensitivity of the nipple-areola complex: An anatomic study.
        Plast Reconstr Surg. 2000; 105 (2000): 905-909
        • Mickute Z.
        • Di Candia M.
        • Malata C.M.
        • et al.
        Analgesia requirements in patients undergoing DIEP flap breast reconstructions: Rib preservation versus rib sacrifice.
        J Plast Reconstr Aesthet Surg. 2010; 63: 837-839
        • Mailis A.
        • Umana M.
        • Feindel C.M.
        Anterior intercostal nerve damage after coronary artery bypass graft surgery with use of internal thoracic artery graft.
        Ann Thorac Surg. 2000; 69: 1455-1458
        • Arnez Z.M.
        • Valdatta L.
        • Planinsek F.
        • et al.
        Anatomy of the internal mammary veins and their use in free TRAM flap breast reconstruction.
        Br J Plast Surg. 1995; 48: 540-545
        • Tokumoto H.
        • Akita S.
        • Mitsukawa N.
        • et al.
        Utility of autologous fibrin glue in the donor site of free abdominal flap for breast reconstruction: A randomized controlled study.
        J Plast Reconstr Aesthet Surg. 2021; 74: 2870-2875
        • Vartanian E.D.
        • Lo A.Y.
        • Patel K.M.
        • et al.
        The role of neurotization in autologous breast reconstruction: Can reconstruction restore breast sensation?.
        J Surg Oncol. 2021; 123: 1215-1231
        • Schoeller T.
        • Schubert H.M.
        • Wechselberger G
        Rib cartilage replacement to prevent contour deformity after internal mammary vessel access.
        J Plast Reconstr Aesthet Surg. 2008; 61: 464-466
        • Kavouni A.
        • Shibu M.
        Problems associated with the use of internal mammary vessels as recipients for free flap breast reconstruction.
        Br J Plast Surg. 1995; 52: 597
        • Moran S.L.
        • Nava G.
        • Serletti J.M.
        • et al.
        An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: A prospective study of 100 patients.
        Plast Reconstr Surg. 2003; 111: 1876-1882
        • Darcy C.M.
        • Smit J.M.
        • Acosta R.
        • 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: 58-62
        • Rosich-Medina A.
        • Bouloumpasis S.
        • Malata C.M.
        • et al.
        Total 'rib'-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video.
        Ann Med Surg. 2015; 22: 293-300
        • Clark C.P.
        • Rohrich R.J.
        • Robinson J.
        • et al.
        An anatomic study of the internal mammary veins: Clinical implications for free-tissue transfer breast reconstruction.
        Plast Reconstr Surg. 1997; 99: 400-404
        • Kim H.
        • Lim S.Y.
        • Pyon J.K.
        • et al.
        Rib-sparing and internal mammary arterypreserving microsurgical breast reconstruction with the free DIEP flap.
        Plast Reconstr Surg. 2013; 131: 327-334
        • Khoo A.
        • Rosich-Medina A.
        • Malata C.M.
        • 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: 448-453
        • Sasaki Y.
        • Madada-Nyakaurub R.N.
        • Malata C.M.
        • et al.
        The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.
        J Plast Reconstr Aesthet Surg. 2019; 72: 1000-1006
        • Liliav B.
        • Loeb J.
        • Antony A.K.
        • et al.
        Single-stage nipple areolar complex reconstruction technique, outcomes, and patient satisfaction.
        Ann Plast Surg. 2014; 73: 492-497
        • Wolfa O.
        • Liub J.
        • Kronowitzd S.J.
        • et al.
        The spare-parts technique: A safe and efficient single-stage nipple and areola reconstruction.
        J Plast Reconstr Aesthet Surg. 2020; 73: 1871-1878
        • Srivastava A.
        • Tripathi D.M.
        • Zaman W.
        • et al.
        Subcostal versus transcostal mini donor nephrectomy: Is rib resection responsible for pain related donor morbidity.
        J Urol. 2003; 170: 738-740