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
tissue is offered to many patients and contin-
ues to grow in popularity. In most practices,
the deep inferior epigastric perforator flap is
considered the gold standard, but other second-
ary alternatives continue to be presented. When
considering recipient vessels, there are two main
options. Historically, the subscapular system was
used; however, with the overall decrease in axillary
node dissections, these vessels are typically not
exposed and are more distant from the primary
reconstructive field. Currently, the most common
choice is the internal mammary artery and vein.1
The internal mammary vessels typically match the
deep inferior epigastric vessels in size very well.
There is great focus on efficiency and ulti-
mately cost savings in the operating room. Much
From the Department of Plastic Surgery, University of Texas
Southwestern.
Received for publication March 15, 2017; accepted May 30,
2017.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003774
of the emphasis at scientific meetings and in the
literature is on how to harvest an individual flap
faster2–4 or how enhanced recovery protocols5 will
lead to decreased length of stay. Although these
are key components of the overall care, the safe
and efficient preparation of the internal mam-
mary artery and vein is equally important.
PATIENTS AND METHODS
Breast reconstruction was performed in 415
patients (715 breasts) using autologous tissue
Disclosure: The authors have no disclosures.
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 Volume 140, Number 5 • Internal Mammary Vessel Preparation

(850 flaps) from 2012 to 2016. The majority of
these flaps were performed with a co-surgery
model at a university hospital. In 97.6 percent of
these breast reconstructions, the internal mam-
mary vessels were used. The internal mammary
was avoided (no attempt at exposure was per-
formed) in secondary operations in which a pre-
vious flap had been performed with the internal
mammary vessels as the recipient site and failed.
When exposed, the cranial internal mammary was
used 100 percent of the time. We experienced 10
flap losses (1.2 percent).
The dissection and preparation of these ves-
sels was routinely performed using the five-step
technique described here. The time required
ranged from 7 to 45 minutes. The median time
was approximately 15 minutes. Longer times for
internal mammary harvest occurred in situations
of significant inflammation and/or scarring, such
as following infection resulting in implant loss or
radiation therapy. In these situations, the tissue
planes are not always easily separated, resulting
in the vessels being stuck to either the perichon-
drium or the pleura. Both must be carefully man-
aged to avoid damage to the vessels.
Technique
Step 1: Exposure
Exposure is the first critical step. After palpat-
ing the third rib, a small incision (4 cm) is made
through the pectoralis major muscle using electro-
cautery. It is important to avoid lateral extension
of this incision to allow positioning of retrac-
tors with adequate tension. Once the anterior
perichondrium is exposed, it is scored and two
self-retaining retractors are placed at 90 degrees to
each other. A 2-0 Vicryl (Ethicon, Inc., Somerville,
N.J.) suture is then placed to retract any overhang-
ing skin. (See Video, Supplemental Digital Con-
tent 1, which demonstrates the efficient five-step
technique for internal mammary vessel prepara-
tion as a recipient site for breast reconstruction,
available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid
users, available at http://links.lww.com/PRS/C390.)
Step 2: Perichondrial Incision
The perichondrium anterior to the cartilage is
incised and a no. 9 elevator is used to sweep that
perichondrium off of the cartilage. This maneuver
develops the plane and is continued under the peri-
chondrium to develop this space as well. In primary
immediate reconstructions, this usually occurs rap-
idly. In situations with increased scarring, great care
must be taken to avoid puncturing the perichon-
drium. This maneuver should always be performed
laterally away from the artery and vein.
Step 3: Removal of Cartilage
The rongeur is then used to remove a small
segment of lateral cartilage. The rongeur should
be large enough to take full-thickness cartilage
and, on removing the lateral first centimeter, the
posterior perichondrium should be visible. Once
confirmed to be intact, the subperichondrial
plane is easily dissected with a combination of a
no. 9 elevator and a rongeur. The rongeur itself
can often be used to create this plane, but if resis-
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
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • November 2017
to avoid damage to the posterior perichondrium.
The most common mistake is to not remove
enough cartilage medially. Usually, the dark hue
of the vein can be visualized through the peri-
chondrium and will verify adequate exposure.
Step 4: Removal of Posterior Perichondrium
and Muscle
Laterally, the muscle and perichondrium are
elevated and incised. This is usually done by start-
ing in the caudal intercostal muscle and proceed-
ing cranially through the perichondrium with
electrocautery on a low setting. If the plane is not
easily separated, scissors or bipolar cautery can be
used. Care should be taken just cranial and cau-
dal to the perichondrium, as there are typically
intercostal branches. Once elevated, a retroperi-
chondrial dissection is performed and the vessels
are identified. A moist cottonoid is placed superfi-
cial to the vessels. The perichondrium is then split
with electrocautery, exposing the vessels. The cra-
nial and caudal flaps are then resected with great
care to clip perforators around the already visual-
ized artery and vein.
Step 5: Vessel Dissection
Standard dissection is then performed on the
artery and vein. Usually, the majority of the dis-
section is performed on the artery with minimal
touch to the vein. This is especially important in
scarred fields, such as following radiation therapy.
Lymph nodes are often encountered and can be
easily harvested if required.
886
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
CONCLUSIONS
Safe preparation of recipient vessels in micro-
vascular reconstruction is essential for success. In
modern breast reconstruction, the most common
vessels used are the internal mammary artery and
vein. Exposure of these vessels should be predict-
able and efficient. We have found that a systematic
approach using the above five steps accomplishes
these goals.
Nicholas T. Haddock, M.D.
Department of Plastic Surgery
University of Texas Southwestern
1801 Inwood Road
Dallas, Texas 75390
nicholas.haddock@utsouthwestern.edu
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