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Page 2 of 11 Leach et al. Plast Aesthet Res 2023;10:39 https://dx.doi.org/10.20517/2347-9264.2023.32

experience.

CHEST WALL DEFORMITY AND PAIN ASSOCIATED WITH RIB RESECTION
Use of the internal mammary artery and vein as the flap recipient site traditionally includes the removal of
rib cartilage for exposure of the vessels . With excision of the rib cartilage, two main primary concerns
[1,2]
[3-7]
include chronic pain and chest wall deformity . Several techniques have been subsequently described to
[16]
try to alleviate these issues, including rib-sparing [3,8-15] , simultaneous rib-sparing , and anastomosis to
intercostal perforator vessels [14,17,18] to avoid or minimize rib resection. Additionally, consideration can be
given to the utilization of alternative recipient vessels, such as the thoracodorsal vessels. With removal of the
rib cartilage, techniques to reduce the chest wall deformity include the use of a pectoralis flap [19,20] , placement
[5]
of the medial portion of the flap over the defect , and replacement of the cartilage .
[4]
First described in 2008 by Parrett, the rib-sparing technique involves resection of the intercostal muscles as
well as the perichondrium on either side of the third intercostal space (ICS), allowing for 2 to 2.5 cm of
internal mammary vessel pedicle length . Rosich-Medina et al. reported results of 178 free flaps in 167
[3]
patients with no postoperative chest wall pain or concerns over chest wall contour after rib-sparing
[13]
exposure of the internal mammary vessels . Sacks et al. reported the results of 100 microvascular
reconstructive cases using the rib-sparing technique with no noted contour deformities . Mickute et al.
[12]
looked at patient-controlled anesthesia (PCA) morphine use postoperatively in 12 rib-sparing versus 12 rib
removal patients and found significantly less morphine use (mean 11.0 mg vs. 28.6 mg) in the rib-sparing
[21]
group, which held true when accounting for patient weight .

Computed tomography (CT) has been used to measure intercostal spaces preoperatively, with the finding
[8]
that increased patient height correlated to increased ICS width . In the patients with preoperative CT scan,
the mean ICS width was 2.65 ± 0.54 cm in rib-sparing patients compared to 2.25 ± 0.38 cm in a rib resection
group . Khoo et al. published results of intra-operative clinical measurement of the second ICS width
[8]
performed with a surgical ruler in 95 patients/109 breasts, and found a mean of 2.03 ± 0.331 cm, and a very
weak positive correlation with patient height . Sasaki et al. found similar measurements of 2.06 ± 0.359 cm
[9]
[10]
for the second ICS (290 evaluated) and 1.40 ± 0.420 cm for the third ICS (30 evaluated) . A retrospective
chart review of 400 patients performed by Hamilton et al. found conversion to or initial attempt with rib
[11]
resection for patients when the ICS was less than 12 mm .

If ICS dissection does not provide adequate space for anastomosis, the ribs may be trimmed with a rongeur
and the microscope can be tilted to visualize the vessels as they pass under the rib for continued
dissection [8,10,12,14] . Darcy et al. described resection of the posterior portion of the cartilage to improve
exposure while leaving the anterior surface intact 30% of the time after increased experience with this
technique . Another technique includes the exposure of two contiguous ICSs (second and third) without
[14]
rib resection as described by Oni et al. . This method provided for additional exposure of the internal
[16]
mammary vessels in cases such as bipedicled flaps, stacked free flaps, anastomotic redo, and salvage.
Successful completion of this technique provided for antegrade and retrograde anastomoses in 15 patients
[16]
with no flap failure. They noted mean second ICS width of 2.07 cm and third ICS width of 1.20 cm .

Consideration should also be given to the ICS that is selected. One concern with rib-sparing techniques
when the second ICS is utilized is shorter cephalad vessel length if revision of the anastomosis is
required [13,15] .