Preparation of Internal Mammary Vessels Using Ultrasonic Energy: A Technical Note

Autologous breast reconstruction is commonly performed after mastectomy, with internal mammary vessels being the preferred recipient vessels due to their proximity to the mastectomy site, consistent anatomy, and favorable vessel caliber.1 Safe and efficient preparation of these vessels is crucial to ensure optimal surgical outcomes and minimize complications. Various tools have been used for the dissection of the pectoralis major and intercostal muscles, including scalpels; monopolar and bipolar cautery;2,3 and, more recently, ultrasonic energy devices. Ultrasonic instruments enable simultaneous cutting and coagulation with minimal thermal spread, which may reduce operative time and limit collateral tissue damage.4,5 Traditionally, internal mammary vessel exposure involves partial or total removal of costal cartilage using electrocautery, especially in narrow intercostal spaces.6,7 However, with proper technique, it is often possible to preserve the rib. Ultrasonic devices have been reported to aid in flap elevation,5 but their specific role in internal mammary vessel preparation remains underreported. This article presented a technical description of internal mammary vessel preparation using an ultrasonic device. The accompanying video outlined the procedural steps and highlighted key anatomical and surgical considerations. SURGICAL TECHNIQUE The internal mammary vessels are typically accessed through the second or third intercostal space, depending on anatomical width. After marking the appropriate intercostal space, the pectoralis major muscle is split along its fibers using electrocautery, extending laterally from the sternum. A flexible retractor is used to enhance exposure. To expand the working space, muscle fibers are released from their origin using an ultrasonic dissection device (Harmonic Focus, Ethicon Endo-Surgery). This instrument also aids in separating the muscle from the anterior surface of the costal cartilage. Hemostasis is maintained throughout using bipolar cautery. A curved mosquito clamp is used to initiate lateral dissection of the intercostal muscle. The ultrasonic device is then used to release the intercostal muscle medially, taking care to avoid the perivascular fat surrounding the internal mammary vessels. Dissection proceeds until the upper edge of the lower costal cartilage is reached. If the intercostal space measures more than 1.5 cm, rib preservation is generally feasible. If narrower, partial removal of the costal cartilage is performed. This begins with an incision of the anterior perichondrium using cautery, followed by subperichondrial dissection with a periosteal elevator. Approximately 30%–50% of the cartilage is removed, depending on exposure needs, using a rongeur. All procedural steps described here are demonstrated in detail in the video. (See Video [online], which displays the steps of the technique for preparing the internal mammary vessels as recipient vessels using ultrasonic energy devices.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"The steps of the technique for preparing internal mammary vessels as recipient vessels using ultrasonic energy devices.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_tkwngank"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The remaining soft tissues overlying the internal mammary vessels are carefully dissected with bipolar cautery. The ultrasonic device facilitates precise dissection, and this stepwise process can typically be completed within 10 minutes. Subsequent microvascular procedures are performed under magnification. OUTCOME Between January 1 and December 12, 2023, 125 internal mammary vessel dissections were performed in 113 patients. The mean patient age was 47.8 years (SD: 7.8 y). The average time for recipient vessel preparation was 16.5 minutes (SD: 6.3 min). In 10 cases, the vessel caliber was insufficient, and alternative recipient sites were used; all occurred on the left side. There were no dissection-related complications that prevented the use of the internal mammary vessels. This was a retrospective review of consecutive cases performed within a 1-year period to ensure a uniform study time frame and minimize selection bias. DISCUSSION Preparation of the internal mammary vessels requires careful dissection of the intercostal space to ensure safe exposure, especially given the high arterial pressure and the potential for vessel retraction.6,7 Although the procedure itself is routine for experienced surgeons, it can be challenging in patients with prior radiation or dense tissue adhesions. In this technique, an ultrasonic energy device was used during selected steps of the dissection, including the separation of muscle fibers and intercostal muscle release. Additional tools, such as bipolar and monopolar electrocautery, were also used as appropriate. This approach reflects a practical combination of instruments based on the surgical field and tissue characteristics. The ultrasonic device facilitated controlled dissection and hemostasis in a limited operative field.4,5 Although this report did not compare outcomes between energy devices, the method was feasible and reproducible in our series. The accompanying video aimed to support surgeons unfamiliar with this technique by providing a step-by-step visual guide. Future studies may help evaluate comparative efficacy, cost implications, and long-term outcomes associated with different vessel preparation tools. Given the relatively large number of cases performed within a short time frame, further hypothesis-driven or comparative studies would be feasible and may provide additional insights beyond this descriptive video report. CONCLUSIONS The internal mammary vessels remain the most reliable recipient site for autologous breast reconstruction. This report described a standardized technique for vessel preparation using an ultrasonic energy device. When appropriately applied, this method allowed precise dissection, effective hemostasis, and streamlined exposure, even in challenging cases. The protocol was reproducible and efficient, and the accompanying video provided detailed visual guidance for practical adoption. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT The patient provided written informed consent for the use of her video.