“Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction: The “1–2–3 Rule”

Background: Postmastectomy breast reconstruction provides psychosocial benefits in self-esteem, sexuality, and quality of life. Autologous procedures yield the highest overall patient satisfaction compared to implant-based breast reconstruction as the gold standard. The internal mammary vessels (IMA/V) are the preferred recipient vessels for free flap breast reconstruction. The study's purpose is to provide surgeons with a reliable method to locate the vessels intraoperatively. Methods: The IMA/V were dissected bilaterally on 30 cadaveric specimens. Distances from the lateral sternal borders (LSBs) and the costochondral junctions (CCJs) to the IMA/V at the 2nd, 3rd and 4th costal levels were recorded. Descriptive bifurcation patterns were recorded. Initial dissection practicums were performed utilizing the proposed safer dissection zone per quantitative data. Results: 60 IMAs and 120 IMVs were studied at 3 costal levels resulting in 180 sets of measurements. Distances from LSB to medial IMV were 6.12 mm, 9.04 mm, and 10.45 mm at costal levels two, three, and four, respectively. Mean distances between CCJs and IMAs were 12.80 mm, 24.78 mm, and 33.28 mm at costal levels two, three, and four, respectively. Most IMV bifurcated at 3rd costal level, and left side bifurcated higher than right. Dissection practicums revealed that the proposed dissection zone was consistently reliable in locating the vessels. Conclusions: This study provides mean measurements from common bony landmarks to the IMA/V, equipping surgeons with a reliable zone of dissection for recipient vessel exposure. This may decrease morbidity and improve outcomes in autologous breast reconstructions. Financial Disclosure Statement: None of the authors has a financial interest to declare in relation to the content of this manuscript. Acknowledgements: The authors would like to thank the Kansas City University of Medicine and Biosciences Division of Clinical Anatomy and the University of Nebraska Medical Center for faculties, equipment, and specimens for this study. Corresponding Author: Christina Dami Lee, MS, 1750 Independence Avenue, Kansas City, MO 64106, Dami.lee4@gmail.com ©2018American Society of Plastic Surgeons

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