Five Steps To Internal Mammary Vessel Preparation in Less Than 15 Minutes

VIDEO+
Five Steps to Internal Mammary Vessel

Preparation in Less than 15 Minutes
Nicholas T. Haddock, M.D.
Background: Modern breast reconstruction often involves microvascular recon-
Sumeet S. Teotia, M.D.
Dallas, Texas
struction. The most common recipient vessels are the internal mammary artery
and vein. Recently, there has been great focus on efficiency, but much of this em-
phasis has been directed to faster flap harvest or recovery protocols for expeditious
discharge. An equally important aspect is internal mammary vessel preparation.
Methods: Breast reconstruction was performed in 415 patients (715 breasts) using
autologous tissue (850 flaps) from 2012 to 2016. In 97.6 percent of these breast re-
constructions, the internal mammary vessels were used. The preparation of these
vessels was routinely performed using the five-step technique described here.
Results: Internal mammary preparation time ranged from 7 to 45 minutes
(median, 15 minutes). The procedure involves five simplified steps, as follows:
step 1, the rib is exposed by splitting the pectoralis major muscle; step 2, the
perichondrium anterior to the cartilage is incised and dissected away from
the cartilage; step 3, the cartilage is removed with a rongeur; step 4, laterally
the perichondrium is elevated and incised (under direct vision, this perichon-
drium is then split directly over the vessels and the cranial and caudal flaps are
resected); and step 5, careful dissection is performed on the artery and vein.
Conclusions: Safe preparation of recipient vessels in microvascular reconstruc-
tion is essential for success. In modern breast reconstruction, the internal
mammary artery and vein are typically used. Exposure of these vessels should
be predictable and efficient. The authors have found that a systematic ap-
proach using the above five steps accomplishes these goals. (Plast. Reconstr.
Surg. 140: 884, 2017.)
I
n modern breast reconstruction, autologous of the emphasis at scientific meetings and in the
tissue is offered to many patients and contin- literature is on how to harvest an individual flap
ues to grow in popularity. In most practices, faster2–4 or how enhanced recovery protocols5 will
the deep inferior epigastric perforator flap is lead to decreased length of stay. Although these
considered the gold standard, but other second- are key components of the overall care, the safe
ary alternatives continue to be presented. When and efficient preparation of the internal mam-
considering recipient vessels, there are two main mary artery and vein is equally important.
options. Historically, the subscapular system was
used; however, with the overall decrease in axillary
PATIENTS AND METHODS
node dissections, these vessels are typically not
exposed and are more distant from the primary Breast reconstruction was performed in 415
reconstructive field. Currently, the most common patients (715 breasts) using autologous tissue
choice is the internal mammary artery and vein.1
The internal mammary vessels typically match the
Disclosure: The authors have no disclosures.
deep inferior epigastric vessels in size very well.
There is great focus on efficiency and ulti-
mately cost savings in the operating room. Much Video Plus content is available for this article.
A direct URL citations appears in the text; sim-
From the Department of Plastic Surgery, University of Texas ply type the URL address into any Web browser
Southwestern. to access this content. Clickable links to the
Received for publication March 15, 2017; accepted May 30, material are provided in the HTML text of this
2017. article on the Journal’s website (www.PRSJour-
Copyright © 2017 by the American Society of Plastic Surgeons nal.com).
DOI: 10.1097/PRS.0000000000003774
884 www.PRSJournal.com
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 5 • Internal Mammary Vessel Preparation
(850 flaps) from 2012 to 2016. The majority of perichondrium is exposed, it is scored and two
these flaps were performed with a co-surgery self-retaining retractors are placed at 90 degrees to
model at a university hospital. In 97.6 percent of each other. A 2-0 Vicryl (Ethicon, Inc., Somerville,
these breast reconstructions, the internal mam- N.J.) suture is then placed to retract any overhang-
mary vessels were used. The internal mammary ing skin. (See Video, Supplemental Digital Con-
was avoided (no attempt at exposure was per- tent 1, which demonstrates the efficient five-step
formed) in secondary operations in which a pre- technique for internal mammary vessel prepara-
vious flap had been performed with the internal tion as a recipient site for breast reconstruction,
mammary vessels as the recipient site and failed. available in the “Related Videos” section of the
When exposed, the cranial internal mammary was full-text article on PRSJournal.com or, for Ovid
used 100 percent of the time. We experienced 10 users, available at http://links.lww.com/PRS/C390.)
flap losses (1.2 percent).
The dissection and preparation of these ves- Step 2: Perichondrial Incision
sels was routinely performed using the five-step The perichondrium anterior to the cartilage is
technique described here. The time required incised and a no. 9 elevator is used to sweep that
ranged from 7 to 45 minutes. The median time perichondrium off of the cartilage. This maneuver
was approximately 15 minutes. Longer times for develops the plane and is continued under the peri-
internal mammary harvest occurred in situations chondrium to develop this space as well. In primary
of significant inflammation and/or scarring, such immediate reconstructions, this usually occurs rap-
as following infection resulting in implant loss or idly. In situations with increased scarring, great care
radiation therapy. In these situations, the tissue must be taken to avoid puncturing the perichon-
planes are not always easily separated, resulting drium. This maneuver should always be performed
in the vessels being stuck to either the perichon- laterally away from the artery and vein.
drium or the pleura. Both must be carefully man- Step 3: Removal of Cartilage
aged to avoid damage to the vessels. The rongeur is then used to remove a small
segment of lateral cartilage. The rongeur should
Technique be large enough to take full-thickness cartilage
Step 1: Exposure and, on removing the lateral first centimeter, the
Exposure is the first critical step. After palpat- posterior perichondrium should be visible. Once
ing the third rib, a small incision (4 cm) is made confirmed to be intact, the subperichondrial
through the pectoralis major muscle using electro- plane is easily dissected with a combination of a
cautery. It is important to avoid lateral extension no. 9 elevator and a rongeur. The rongeur itself
of this incision to allow positioning of retrac- can often be used to create this plane, but if resis-
tors with adequate tension. Once the anterior tance is identified, a no. 9 elevator should be used
Video. Supplemental Digital Content 1 demonstrates the efficient

five-step technique for internal mammary vessel preparation as a
recipient site for breast reconstruction, available in the “Related Vid-
eos” section of the full-text article on PRSJournal.com or, for Ovid
users, available at http://links.lww.com/PRS/C390.
885
Plastic and Reconstructive Surgery • November 2017
to avoid damage to the posterior perichondrium. CONCLUSIONS

The most common mistake is to not remove Safe preparation of recipient vessels in micro-
enough cartilage medially. Usually, the dark hue vascular reconstruction is essential for success. In
of the vein can be visualized through the peri- modern breast reconstruction, the most common
chondrium and will verify adequate exposure. vessels used are the internal mammary artery and
Step 4: Removal of Posterior Perichondrium vein. Exposure of these vessels should be predict-
and Muscle able and efficient. We have found that a systematic
Laterally, the muscle and perichondrium are approach using the above five steps accomplishes
elevated and incised. This is usually done by start- these goals.
ing in the caudal intercostal muscle and proceed- Nicholas T. Haddock, M.D.
ing cranially through the perichondrium with Department of Plastic Surgery
electrocautery on a low setting. If the plane is not University of Texas Southwestern
easily separated, scissors or bipolar cautery can be 1801 Inwood Road
Dallas, Texas 75390
used. Care should be taken just cranial and cau- nicholas.haddock@utsouthwestern.edu
dal to the perichondrium, as there are typically
intercostal branches. Once elevated, a retroperi-
chondrial dissection is performed and the vessels REFERENCES
are identified. A moist cottonoid is placed superfi- 1. Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical tech-
cial to the vessels. The perichondrium is then split nique: The intercostal space approach to the internal mam-
with electrocautery, exposing the vessels. The cra- mary vessels in 463 microvascular breast reconstructions.
nial and caudal flaps are then resected with great J Plast Reconstr Aesthet Surg. 2011;64:58–62.
2. Smit JM, Dimopoulou A, Liss AG, et al. Preoperative CT
care to clip perforators around the already visual- angiography reduces surgery time in perforator flap recon-
ized artery and vein. struction. J Plast Reconstr Aesthet Surg. 2009;62:1112–1117.
3. Marsh D, Patel NG, Rozen WM, Chowdhry M, Sharma H,
Step 5: Vessel Dissection Ramakrishnan VV. Three routine free flaps per day in a single
Standard dissection is then performed on the operating theatre: Principles of a process mapping approach
artery and vein. Usually, the majority of the dis- to improving surgical efficiency. Gland Surg. 2016;5:107–114.
section is performed on the artery with minimal 4. Acosta R, Enajat M, Rozen WM, et al. Performing two DIEP
touch to the vein. This is especially important in flaps in a working day: An achievable and reproducible prac-
tice. J Plast Reconstr Aesthet Surg. 2010;63:648–654.
scarred fields, such as following radiation therapy. 5. Afonso A, Oskar S, Tan KS, et al. Is enhanced recovery the
Lymph nodes are often encountered and can be new standard of care in microsurgical breast reconstruction?
easily harvested if required. Plast Reconstr Surg. 2017;139:1053–1061.
886

Five Steps To Internal Mammary Vessel Preparation in Less Than 15 Minutes

Uploaded by

Copyright:

Available Formats

Five Steps To Internal Mammary Vessel Preparation in Less Than 15 Minutes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Five Steps To Internal Mammary Vessel Preparation in Less Than 15 Minutes

Uploaded by

Copyright:

Available Formats

VIDEO+

Five Steps to Internal Mammary Vessel

Video. Supplemental Digital Content 1 demonstrates the efficient

to avoid damage to the posterior perichondrium. CONCLUSIONS

You might also like