Five steps to internal mammary vessel preparation in less than 15 minutes

Background: Modern breast reconstruction often involves microvascular reconstruction. The most common recipient vessels are the internal mammary artery and vein. Recently, there has been great focus on efficiency, but much of this emphasis 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 reconstructions, 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 perichondrium 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 reconstruction 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 approach using the above five steps accomplishes these goals.