Chapter 9 INTRODUCTION In 1983 Shaw described the use of the mammary artery and vein(s) as recipient vessels in breast reconstruction1. He utilized the vessels in the fifth intercostal space reporting that the internal mammary vein was very small. He could use it as a recipient vessel in only 3 of the 8 cases. In 1994 Feller advised not to use the mammary vessels because the vein is often not suitable for microanastomosis2. In 1996 Dupin reported a series of 110 consecutive cases of breast reconstruction with a successful flap transfer in 99 percent3 using the internal mammary artery and vein. Based on clinical experience and the data reported by Clark4, Dupin advised to isolate the mammary vessels under the third rib3. Despite the excellent and reliable exposure, the removal of part of the rib has been associated with postoper- ative local pain, long-term tenderness and sometimes contour deformities of the chest wall8,9. Although perforators of the mammary artery and vein as recipient vessels are an alternative, this is not always possible10,11. In 2008 Parrett5 described a series of 74 flaps for breast reconstruction using the rib sparing technique for internal mammary vessel exposure without increasing the complication rate. The vessels were exposed in the third intercostal space. In 2009 Sacks6 presented 100 consecutive cases of breast reconstruction with the rib-sparing technique: also in these cases the third intercostal space was used. In 90 percent no rib cartilage was removed. In 2011 Malata7 suggests several advices for successful microvascular abdominal flap breast reconstruction utilizing the total rib preservation technique for exposure of the internal mammary vessels. He switches from the exposure of the vessels in the third and fourth intercostal space to the second one because easier clinically. With this study we would like to objectively describe the intercostal spaces to expose the internal mammary vessels with a rib-sparing technique and to identify the advantages and dis- advantages in selecting the second or the third intercostal space. MATERIALS AND METHODS In the period August-November 2010, 294 breast MRIs were performed in 289 patients in our institution. Criteria that was excluded was male sex, history of breast surgery, neo-adjuvant chemotherapy, and patients with bilateral breast cancer. In cases where there multiple MRIs in one patient, only the first MRI was included. 153
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