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Total 'rib'-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video.

Rosich-Medina A, Bouloumpasis S, Di Candia M, Malata CM - Ann Med Surg (Lond) (2015)

Bottom Line: 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).No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK.

ABSTRACT

Introduction: 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.

Patients & 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.

Discussion & conclusion: 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.

No MeSH data available.


Related in: MedlinePlus

Temporal change in digging time for exposure of the internal mammary vessels over the five year study period.
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fig3: Temporal change in digging time for exposure of the internal mammary vessels over the five year study period.

Mentions: The mean intercostal space distance (ICD) available for the microanastomoses was 20.9 mm ± 3.4 with a range of 9–29 mm. Fig. 2 depicts the mean ICD for all 178 patients and compares the mean ICDs of patients who did not require re-explorations versus those that had on-table revisions of anastomoses and/or a return to theatre. It demonstrates that there was no statistically significant difference between these parameters (p = 0.31). The mean time taken for exposure of the IMV's (the so called “digging time”) was 54 min ± 29.6. Overall, over the five year period, there was a trend towards a shorter “digging time” of the IMV's as demonstrated in Fig. 3. The flap ischaemia time also varied widely but had a mean of 95 min ± 24.2 (range = 38–190 min) (Table 2). The arterial microanastamoses were always performed end-to-end using interrupted 9.0 monofilament nylon sutures. In contrast the venous anastomoses were either sutured (9/0 continuous nylon sutures) or with a venous coupler. The venous anastomotic couplers, of varying sizes (2.0–4.5 mm), were used in the last 95 cases (53%) all in the latter part of the study (2010–2013). One vein was anastomosed in 78% (125/161) of cases, two in 35/161 (22%), three in 1/161 (0.6%). The number of venous anastomoses was not specified in 17/161 (11%) cases.


Total 'rib'-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video.

Rosich-Medina A, Bouloumpasis S, Di Candia M, Malata CM - Ann Med Surg (Lond) (2015)

Temporal change in digging time for exposure of the internal mammary vessels over the five year study period.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4556813&req=5

fig3: Temporal change in digging time for exposure of the internal mammary vessels over the five year study period.
Mentions: The mean intercostal space distance (ICD) available for the microanastomoses was 20.9 mm ± 3.4 with a range of 9–29 mm. Fig. 2 depicts the mean ICD for all 178 patients and compares the mean ICDs of patients who did not require re-explorations versus those that had on-table revisions of anastomoses and/or a return to theatre. It demonstrates that there was no statistically significant difference between these parameters (p = 0.31). The mean time taken for exposure of the IMV's (the so called “digging time”) was 54 min ± 29.6. Overall, over the five year period, there was a trend towards a shorter “digging time” of the IMV's as demonstrated in Fig. 3. The flap ischaemia time also varied widely but had a mean of 95 min ± 24.2 (range = 38–190 min) (Table 2). The arterial microanastamoses were always performed end-to-end using interrupted 9.0 monofilament nylon sutures. In contrast the venous anastomoses were either sutured (9/0 continuous nylon sutures) or with a venous coupler. The venous anastomotic couplers, of varying sizes (2.0–4.5 mm), were used in the last 95 cases (53%) all in the latter part of the study (2010–2013). One vein was anastomosed in 78% (125/161) of cases, two in 35/161 (22%), three in 1/161 (0.6%). The number of venous anastomoses was not specified in 17/161 (11%) cases.

Bottom Line: 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).No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic & Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK.

ABSTRACT

Introduction: 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.

Patients & 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.

Discussion & conclusion: 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.

No MeSH data available.


Related in: MedlinePlus