Anatomical evaluation of the internal mammary vessels based on Magnetic Resonance Imaging (MRI) anastomosis than in either of the two veins when two venous anastomoses are performed.13 The diameter of the artery is mean 0.2 mm (18%) and of the vein mean 0.2 mm (18%) larger in the second than in the third intercostals space. The surface and than the mean diameter of the vessels were calculated only for patients with Schwabegger classification II because statistical analysis had to be performed. The number of patients with Scwabegger classification I, III, IV and V are not enough to perform a statistical analysis for each group. On the other hand the inclusion of cases with classification I and III will only support our data more because the 2 veins in the intercostal space 3 singularly always have a smaller diameter than the single vein in the intercostal space 2 but this can be considered as a confounding element in the statistical analysis. To determine the best approach to the mammary vessels more details have to be clinically considered. First of all the use of mammary vessels as recipient vessels is widely accepted, although they will not be always suitable anymore in the future for coronary bypass surgery. Greer-Bayramoglu et al.14 demonstrated that only by using the left mammary artery in the fourth intercostal space of distally, the length of the mammary artery preserved will be enough for future bypass surgery. However, at the fourth intercostal space level of distally the mammary vein is often not suitable for adequate anastomosis.1,2,4 As a consequence the use of the second or third intercostal space will not change the suitability of the vessels for future bypass surgery. Second, if the flap selected for breast reconstruction has a short pedicle like a TMG (transverse myocutaneous gracilis) flap or a sc-GAP (septocutaneous gluteal artery perforator) flap, the second intercostal space can be too proxi- mal to put the flap at the right height to obtain a well-shaped breast without tension on the pedicle. Third, the second intercostal space can be difficult to reach in a prophylactic, nipple-sparing mastectomy with an incision at the inframammary fold. In those cases we will advise to select the third intercostal space sacrificing only a part of the second rib to have better exposure to the mammary vessels. Preoperative MRI evaluation might help in the planning of the procedure. CONCLUSION We conclude that in most of the cases the second intercostal space, from an anatomical point of view, is the most suitable for a rib-sparing approach of the mammary vessels for micro-anastomosis because it is significantly wider 160
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