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During microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain.All patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain.In the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m2. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30.The majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m2, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.