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Background: The deep inferior epigastric artery perforator (DIEP) free flap is the optimal autogenous reconstructive technique in many patients undergoing postmastectomy. Our aim was to evaluate the standard DIEP free flap design in relation to the dominant perforating vessels using computed tomography angiography (CTA)., Methods: We retrospectively reviewed CTAs from 75 patients who had undergone perforator flap reconstruction within the past year. Locations of the largest perforator with a minimum diameter of 2.0 mm piercing the anterior rectus fascia were recorded., Results: Of 150 hemiabdomens reviewed, 146 (97.3%) had a dominant perforator. The median location for the dominant perforator was 3.3 cm lateral and 0.9 cm below the umbilicus. One hundred twenty-one (83%) of the dominant perforators arose within 3 cm of the umbilicus. One hundred one (69%) arose at or below the level of the umbilicus. Forty-five (31%) arose above the level of the umbilicus. Thirteen (9%) arose more than 2 cm above the umbilicus., Conclusions: The standard DIEP flap design incorporates most of the dominant perforating vessels. However, a significant number of perforators arise at or above the umbilicus, which would be near the edge or out of the standard design of the DIEP. Our findings support the use of preoperative CTA in the evaluation of patients undergoing DIEP free flap reconstruction. Modification of flap design to include the dominant perforating vessels should be considered when the dominant vessel is outside the standard design of the DIEP.

Patient: A 37-year-old woman presented with Mondor's thrombophlebitis 13 years after augmentation mammaplasty with subpectoral saline implants. She presented complaining of 1 week of "band-like" cords and pain involving the thoracoepigastric and lateral thoracic vessels. She was evaluated and ruled out for other etiologies of her breast symptoms., Background: Mondor's disease is a benign and self-limiting disease characterized by thrombophlebitis of the subcutaneous veins of the chest and abdominal wall. The inflammation causes painful superficial cords manifesting as skin retraction. Mondor's disease has been described in aesthetic breast surgery literature, but most cases occur within the first few postoperative weeks., Conclusions: Mondor's disease may be idiopathic, iatrogenic, or a manifestation of underlying pathology such as breast cancer. The diagnosis of iatrogenic Mondor's disease can be made with high clinical certainty when following aesthetic breast surgery in the early postoperative period. However, in late presentations that are not immediately related to surgery, Mondor's disease remains a diagnosis of exclusion, and other underlying pathologic etiologies must be ruled out.

The anatomy of the anterior abdominal wall is highly variable and leads to uncertainty when harvesting a deep inferior epigastric artery perforator flap. Presurgical imaging has been shown to reduce the operating time, as well as reduce the rates of flap and donor site complications. The importance of imaging of the venous system has also been recognized for reducing the risk of venous congestion. The modalities currently available for presurgical imaging include handheld Doppler ultrasound, duplex ultrasound, computed tomographic angiography (CTA), and contrast-enhanced magnetic resonance angiography (CE-MRA). Of these, the most promising are CTA and CE-MRA, and advantages and disadvantages exist for both modalities. In this article, we review the use of CE-MRA for preoperative flap imaging and report our experience with its use in deep inferior epigastric artery perforator flap harvest, as well as compare it with CTA. We also explore the future directions for presurgical flap imaging.

Abdominal wall computed tomography angiography (CTA) is used to guide preoperative planning and intraoperative technique for deep inferior epigastric artery perforator free flap breast reconstructive surgery. This study considers the amount of radiation delivered to the patient, outlining how scan parameters can be optimized to minimize the radiation exposure whilst maintaining image quality. Results of scan parameters and dose reports for 34 patients undergoing abdominal wall CTA are compared with those patients undergoing routine abdominal computed tomography. The links between computed tomography dose quantities are explained, including their conversion to effective dose (in mSv) and risk as the probability for inducing deterministic effects (eg, skin burns) and stochastic effects (ie, cancer induction). The mean effective dose by using our technique for routine abdominal computed tomography is 9.9 and for abdominal wall CTA is 6.0 mSv. All doses are far below the thresholds for deterministic effects to the skin. Abdominal wall CTA can be justified before major reconstructive surgery if the surgeon believes that the very low estimated risk of fatal radiation-induced cancer (1 in 4270 for 6 mSv) is outweighed by the benefits.

With the increasing use of preoperative imaging of the abdominal vasculature prior to free flaps based on the abdominal wall, the identification of a previously undescribed anatomic structure has, that of large-vessel (macroscopic) arteriovenous communications, has emerged. These macrovascular arteriovenous shunts are observed in most patients, and provide a communication between the arterial perforators of the deep inferior epigastric artery and the superficial inferior epigastric vein. These communications provide vascular shunting occurring prior to capillary filling and have potentially profound clinical implications and therapeutic possibilities in a range of medical and surgical conditions. Although these have been demonstrated previously on computed tomographic angiography imaging, their macroscopic and microscopic anatomy has not been described. We present images in vivo, ex vivo, and histologically to highlight their anatomic features.

In 2009, 86,424 breast reconstructions were performed in the United States, with 76% being implant-based procedures. Capsular contracture and infection are the 2 most cited indications for implant explantation, resulting in a reconstruction failure. However, several patients are dissatisfied with implant reconstruction even without the aforementioned complications. We hypothesize that microvascular autologous tissue transfer with perforator free-flap breast reconstruction provides an excellent salvage modality in the face of an unsatisfactory implant reconstruction, resulting in an improved cosmetic and functional outcome, with low risk of complications. We retrospectively reviewed the charts of patients in the senior author's practice who underwent perforator flap breast reconstruction between the years 1998 through 2008, and identified all patients who had prior implant reconstruction. Indications for implant explantation, medical history, operative procedure, and postoperative complications were reviewed. During the study period, 1846 perforator flaps were performed. We found 191 patients who underwent autologous breast reconstruction after implant reconstruction with a total of 284 flaps (15.4%). The most frequent patient complaint was unnatural appearance and feel of the implants (Baker I or Baker II), and the majority of patients had not undergone radiation. Most patients were reconstructed using abdominal flaps with 164 deep inferior epigastric perforators, 50 superior gluteal artery perforators, 30 superficial inferior epigastric arteries, 35 inferior gluteal artery perforators, and 5 transverse upper gracilis. The total complication rate was 7.4%, with most complications related to wound healing at the donor site. There were 3 flap losses (1%), all of which were later successfully reconstructed with another perforator flap. Implant failures are traditionally thought to be in patients with Baker grade III/IV capsular contractures and in patients status post radiation therapy. However, in our study, the majority of patients seeking perforator flap reconstruction after implant reconstruction complained of an unnatural feel and appearance of their breasts, and did not have a severe capsular contracture deformity (Baker III/IV), nor had they undergone radiation. This suggests that implant reconstruction can lead to patient dissatisfaction severe enough to warrant removal even with Baker I/II results, and not in the setting of postradiation changes.

The computed tomography microangiography revolutionized the planning of abdominal flaps, and enabled us to identify perforators from the deep inferior epigastric system with a medial extramuscular or minimal medial intramuscular trajectory. We define these perforators as paramuscular and paraneural, since their main course is retromuscular and they emerge medial to the medial border of rectus muscle or medial to its motor nerve supply, respectively. Studying the different perforator distributions in the abdomen of 58 patients who underwent breast reconstruction with deep inferior epigastric artery perforator flap, we have recorded that 46.4% of the abdominal walls have a dominant paramuscular/paraneural perforator (25.8% paramuscular and 20.6% paraneural) with an average diameter 1.56 +/- 0.2 mm. Although, the comparison of the rectus muscle morbidity following deep inferior epigastric artery perforator flap dissection based on paramuscular/paraneural and based on other perforator patterns, did not reveal significant differences, paraneural/paramuscular type perforators are not related anatomically to the motor nerves, and the donor site morbidity should be negligible in any operator's hands.

Suction-assisted lipectomy (SAL) in association with abdominoplasty has been regarded with trepidation, with ischemia of the apron flap, skin loss, and open wounds among the potential dire consequences. Leaving midabdominal and epigastric fatty excess, however, confers suboptimal contour and often a mediocre cosmetic result. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated. Forty-two patients were treated with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised. The dissection then proceeds in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Excess skin and fat are excised from the inferior aspect of the flap, and the flap is inset. Wetting solution is instilled, and SAL of the entire flap, particularly in the midline and in the region of the neoumbilicus, is performed. Data were reviewed retrospectively. Twenty-seven anterior and 15 circumferential procedures were performed. There were 36 females and 6 males. There was one hematoma (3%) requiring re-exploration (male, circumferential), and 3 seromas (7%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Contrary to classic abdominoplasty undermining to the costal margins, the maintenance of a broad subcostal blood supply allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.

A preoperative abdominal wall study was conducted using a multidetector scanner in 162 women who had undergone breast reconstruction with abdominal perforator flaps. A map of the abdominal perforator vessels dependent on the deep inferior epigastric artery was created. In the first 36 cases, anatomic dissection of all perforators was performed during surgery. The outcome was then compared with the radiologic findings. In the following 126 cases, the perforator vessel chosen preoperatively by the multidetector scanner was located and dissected directly. In the first 36 cases, an absolute correlation was observed between the radiologic information and intraoperative findings. In the following 126 cases, surgery time and the rate of postoperative complications decreased significantly. The multidetector scanner provides valuable preoperative information enabling identification of the most suitable perforator in view of its caliber, location, course, and anatomic relationships. Once located, we can proceed directly to its dissection during surgery, making it a faster and safer technique.

Coronary artery bypass grafting is a common surgical procedure for myocardial revascularization. This operation usually involves the use of the left internal mammary artery to bypass the left anterior descending coronary artery. The internal mammary artery and its perforators are also an important blood supply to the female breast, though not considered a critical blood supply. Due to an abundant blood supply from multiple sources, complications of the female breast are rare. We present a case report of a patient who developed necrosis of the entire medial left breast and superior abdominal wall following coronary artery bypass grafting which used the left internal mammary artery.

Fat necrosis is a common postoperative complication in transverse rectus abdominis muscle flap breast reconstruction. A histological quantification of the blood supply to the lower abdominal fat was undertaken to define this problem further. One hundred eighty sections, 1.5 cm(2) in size, were studied from one half of the lower abdomen in 10 fresh cadavers. These represent three different depths of fat (superficial, middle, deep) and six different anatomic areas (upper, middle, and lower sectors of the medial and lateral parts of the hemiabdomen). The average diameter, number of blood vessels, and the total vascular area were measured in each section. The average diameter of the blood vessels was greater in the superficial compared with the mid fat layer (p = 0.02). The total vascular area was greater in the deep compared with the mid fat layer (p = 0.01) and the superficial fat layer (p = 0.05). The number of blood vessels was also significantly higher in the deep fat layer compared with the mid fat layer (p = 0.001) and the superficial fat layer (p = 0.01). The lower medial area of the lower anterior abdominal wall contained the largest number and average diameter of blood vessels whereas the mid lateral area contained the smallest number and average diameter; however, this did not reach significance (p = 0.1 and 0.2). The results of this study are in keeping with the bimodal vascular supply to the subcutaneous fat of the anterior abdominal wall. The deep and the superficial fat layers are supplied more richly with vessels with a larger diameter whereas the intermediate fat layer is supplied from the terminal branches of these vessels.