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. 2019 Oct;8(5):477-485.
doi: 10.21037/gs.2019.08.08.

Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases

Qi Zhang  1   2 , Qin Xiao  2   3 , Rong Guo  1   2 , Bingqiu Xiu  1   2 , Lun Li  1   2 , Weiru Chi  1   2 , Yajia Gu  2   3 , Jiong Wu  1   2   4
Affiliations

Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases

Qi Zhang et al. Gland Surg. 2019 Oct.

Abstract

Background: Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction.

Methods: Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed.

Results: Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612).

Conclusions: IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.

Keywords: Abdominal free flap; breast cancer; breast reconstruction; rib sparing.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Measurement of intercostal space. (A,B) The internal mammary vessels were marked in sagittal reconstructed images (red arrow), parallel to the position recorded in the operation. The width of ICS (blue line) was measured between the costal cartilage (blue arrow) and the depth (green line) was measured from the surface of the pectoralis major muscle to the IMVs; (C,D) distance (yellow line) was measured between the parasternal line and IMVs in transverse reconstruction images. White arrow: the rib; green arrow: locating clips in breast tumor; yellow arrow: the sternum; red arrows in (C,D): internal mammary vessel. ICS, intercostal space; IMV, internal mammary vessel.
Figure 2
Figure 2
The numbers of abdominal free flap reconstruction surgeries and rib sparing rate in FUSCC each year. FUSCC, Fudan University Shanghai Cancer Center.
See this image and copyright information in PMC

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