Background:
Free tissue transfers are the gold standard for post-mastectomy autologous breast reconstruction. Such flaps are generally anastomosed to the internal mammary vessels (IMVs) which are traditionally exposed by sacrificing the 3rd costal cartilage. This can be associated with complications such as pain, chest wall deformity and late local tenderness. Total rib preservation aims to reduce morbidity at the recipient site. This technique was adopted by a single surgeon in June 2008, and has since been used exclusively in all microvascular free flap breast reconstructions.

Material and Methods:
Prospectively collected free flap data were analysed to determine the indications, surgical details and outcomes for this technique in breast reconstruction.

Result:
204 breast free flaps (172 unilateral:27 bilateral; 159 immediate:45 delayed) were performed by a single surgeon over 51⁄2 years. Patient ages ranged from 28 to 71. There were 178 DIEP flaps, 16 SIEA flaps, 7 muscle-sparing free TRAM, 2 IGAPs and one free LD flap. (Of the abdominal free flaps 21 were bipedicled). The mean inter-costal space distance was 21.1 mm (range 13-29). The mean IMV preparation time was 56 minutes (range 17–192). The mean ischemia time was 95 minutes (range 38-190). Free flap survival was 100%, although 5 flaps (1.7%) required a return to theatre for exploration (haematomas and venous congestion). They were all successfully salvaged. There have been no complaints of localised chest wall pain and no contour deformity has been observed.

Conclusion:
Total rib sparing technique for IMV exposure is safe, reliable and versatile.