Analgesia requirements in patients undergoing DIEP flap breast reconstructions: rib preservation versus rib sacrifice.

Figure 1 Intraoperative photograph of a right 2nd intercostal space showing the IMVs successfully anastomosed to the deep inferior epigastric vessels. The distance between the two ribs and thus the space available for the microvascular anastomoses was 19 mm. Internal mammary vessel (IMV) exposure for free-flap breast reconstruction (BR) traditionally entails removal of a segment of the 3rd costal cartilage, but has been reportedly associated with early local pain and long term tenderness. The technique of total rib-preservation exposes the IMV’s between adjacent ribs and allows adequate space for microvascular anastomosis, thereby avoiding rib-sacrifice (Figure 1). It has been suggested that such a rib-sparing technique may reduce postoperative pain, but this has never been objectively assessed. The senior author (CMM) adopted total rib-preservation of IMV preparation following a specific patient request in May 2008 and has exclusively used it for all subsequent patients. We decided to test the hypothesis that patients undergoing deep inferior epigastric perforator (DIEP) flap BR’s with rib-preservation experienced less postoperative pain compared to those with segmental rib cartilage resection.