Rib-sparing, Intrathoracic Preparation of Internal Mammary Vessels for Free Flap Reconstruction of Chest Wall Defect

We present a case of a 68-year-old male patient who initially underwent forequarter amputation for the surgical treatment of locally aggressive metastatic squamous cell carcinoma to the axilla. The patient's course was complicated by recurrent cancer at the operative site, which was invasive into the adjacent chest wall. The patient subsequently underwent wide local excision of the squamous cell carcinoma, requiring resection of an 18 × 20 cm portion of the chest wall, including soft tissue, ribs (portions of the second to fifth), and lung tissue. Soft tissue coverage with an expanded polytetrafluoroethylene mesh reconstruction was planned, using a free anterolateral thigh flap to the internal mammary (IM) vessels. Standard dissection of the IM vessels for free flap reconstruction includes an anterior approach with rib removal. Given concerns that additional rib resection could further threaten the structure and function of the postreconstruction thoracic wall, we used a rib-sparing, posterior, intrathoracic approach to the IM vessels. This approach used the patient's thoracic wall defect to prepare the IM vessels before mesh reconstruction. Once prepared, the vessels were passed through a small intercostal window for anastomosis anterior to the thoracic wall after the mesh reconstruction had been performed. The patient underwent an uneventful postoperative course, highlighted by aggressive pulmonary rehabilitation. The patient's flap healed without wound healing complications and provided stable coverage over his chest wall reconstruction. Our case demonstrated a rib-sparing, posterior, intrathoracic approach to the IM vessels, which minimized further disruption of the patient's respiratory mechanics.