Surgery Spotlight: Internal Mammary Vessel Exposure for Free Flap Breast Reconstruction-Surgery Spotlight: Internal Mammary Vessel Exposure for Free Flap Breast Reconstruction

Surgery Spotlight: Internal Mammary Vessel Exposure for Free Flap Breast Reconstruction

Video Transcription

This is a female patient with prior radiation therapy and a subsequent failed implant reconstruction who now presents for a delayed free flap reconstruction.  The old scar will be used and excised to access the pocket. The previously placed alloderm is either removed or scored, as in this case, to allow for lower pole expansion.  In many delayed reconstruction cases, the lower pole skin will need to be removed or significantly reconfigured to accommodate the flap and achieve a good shape.  The mastectomy defect is recreated. All scar tissue is removed. In cases of failed implant reconstruction where the pectoralis muscle has been elevated,  it is important to release the muscle from the skin. The flap should ultimately lay on top of the muscle and under the skin.  Next, fishhook retractors are placed to retract the skin and allow for adequate medial rib exposure.  For immediate cases and cases with small incisions, this is one of the most important steps. Without adequate exposure, the chances of success drop.  The third rib is palpated along the second and third rib inner space. A linear incision is made over the rib into the perichondrium with electrocautery.  The junction between the cartilage and the bony aspect of the rib can usually be palpated as a ridge about 5 cm from the sternum.  There is no need to remove the bony portion of the rib, and doing so will increase the chances of pleural injury.  A 2 by 3 cm portion of the pectoralis major muscle is typically removed and ensures that as the vessels traverse the muscle layer, they are not compressed.  In this particular case, only the capsule and intercostal muscles are at the base of the defect. We then begin to peel the perichondrium off the anterior surface of the rib.  The previous incision into the perichondrium is then extended into an H-shaped pattern to allow for it to be peeled adequately off the cartilaginous portion of the rib.  The perichondrium is elevated superiorly and inferiorly with a freer elevator until you reach both edges of the rib.  The dissection with the freer elevator is then continued to further dissect the posterior perichondrium off the rib.  A right-handed and left-handed doyen rib respiratory instrument is used to extend the posterior perichondrial elevation in medial and lateral motions.  The doyen retractors are used in the medial and lateral motions until the entire posterior perichondrium is elevated off the posterior rib.  The most lateral extent of the rib removal is again palpated as a ridge between the cartilage and bone junction. A portion of rib is then cut out using a rib cutter.  In some cases, there are large perforators that can be used as the primary recipient vessels. In some cases, the inner space between the ribs is relatively large.  When this occurs, there is no need to remove the rib for exposure. Additional medial portions of the rib are removed by using the Alexander rib elevator.  Once underneath the rib, gentle anterior pressure with the elevator will remove a portion of the medial cartilage.  The remainder of the dissection is performed with bipolar cautery and is completed from lateral to medial.  The vessels lie below the posterior layer of the perichondrium, directly above the parietal pleura. Care should be taken to not enter the pleural space during this dissection.  If this occurs, there is usually no need for placement of a chest tube unless there has been an injury to the lung with a resulting air leak.  The artery is typically lateral and the vein is medial. Sometimes there is a small secondary vein lateral to the artery.  If the vessels are injured, the dissection will proceed up to the second rib cartilage by removing the intervening intercostal muscle.  If there is still insufficient vessel length, then the second rib can be removed in a similar fashion.  The vessels are cleaned from surrounding tissue using bipolar cautery while keeping close attention to preserving significant intercostal perforators.  Vessel size is assessed in order to match with donor vessels. With the vessels grossly dissected, the operating microscope is brought in for final vessel preparation.

Video Summary

The video details a delayed free flap reconstruction procedure following prior radiation and failed implant reconstruction in a female patient. The process involves utilizing the old scar to access the pocket, removing old scar tissue, and scoring or removing previously placed alloderm to allow lower pole expansion. It emphasizes the importance of adequate exposure of the medial rib area for successful flap placement on the muscle. Careful dissection is conducted to avoid pleural injury, and suitable vessels are prepared for the flap using microscopes and precise surgical instruments, ensuring preservation of crucial intercostal perforators.

Asset Caption

A female patient presents with prior radiation therapy and subsequent failed implant reconstruction, and now presents for a delayed free flap reconstruction.

Surgeon Scott Hollenbeck, MD; Brett Phillips, MD, MBA

Source Duke University Duke Plastic, Maxillofacial and Oral Surgery 2016

Disclosure This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Breast

Scott Hollenbeck MD

Brett Phillips MD MBA; Memben

free flap reconstruction

radiation

scar tissue removal

microsurgery

intercostal perforators