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Autologous breast reconstruction using abdominally based perforator flaps has become increasingly popular following mastectomy for breast cancer. Of these, the deep inferior epigastric artery perforator (DIEP) flap represents one of the most popular techniques. However, surgeons must remain cognizant of anatomic variations in the abdominal wall vasculature that could complicate or preclude planned DIEP flaps. In this case, a 64-year-old female with a history of prior tubal ligations and caesarean sections underwent preoperative computed tomographic angiography (CTA) for planned autologous breast reconstruction with a DIEP flap. CTA revealed complete absence of the left deep inferior epigastric artery, with a sizeable left abdominal wall perforator visualized receiving retrograde flow from a crossing midline branch originating from the contralateral right deep inferior epigastric system. This vessel traversed the midline in a superficial plane in the subcutaneous tissue. Despite this aberrant anatomy, the surgical team successfully raised a unilateral DIEP flap based on the right pedicle. This case represents a unique anatomical variation of the abdominal wall and emphasises the importance of preoperative imaging when planning abdominally based free flaps. [ABSTRACT FROM AUTHOR]

The deep inferior epigastric perforator flap (DIEP) has become the gold standard method of autologous breast reconstruction by simultaneously maximising aesthetics of the breasts and abdomen, and maximising the function of the abdominal wall. While the anatomical variability of the DIEP flap perforators have been well characterised, there has been less attention paid to the hierarchy of DIEP perforators in terms of limiting abdominal dysfunction post-operatively. In this paper, we seek to draw attention to what is, in our opinion, the ideal scenario in DIEP flap harvest. Where present, a medial paramuscular cutaneous vessel (MPCV) may be harvested using the pyramidalis separation technique enabling a complete rectus abdominis muscle-sparing and abdominal motor nerve-sparing approach. Herein, we describe the pyramidalis separation technique and the results in representative cases. In our experience, this technique enables an expeditious surgical procedure, and dramatically reduces damage to both muscles and nerves. Level of evidence: Level V, therapeutic study [ABSTRACT FROM AUTHOR]

Purpose: Matching the diameter of the deep inferior epigastric artery (DIEA) and perforating branch (PB) of the internal thoracic artery (ITA) is important for arterial anastomosis during breast reconstruction using the DIEA flap. An anatomic investigation of these arteries was performed using multidetector row computed tomography (MDCT). Patients and methods: Contrast-enhanced MDCT data of 50 women (aged 18–90 years) covering the neck to the groin were analyzed. The diameter of the PBs of the ITA at their origins from the first to the sixth intercostal space and of the DIEA 20 mm from the bifurcation of the external iliac artery were measured. Results: The mean diameters of the right and left DIEAs were 1.53 ± 0.263 mm and 1.53 ± 0.306 mm, respectively. The diameter of the PBs in the second and third intercoastal spaces was the same as the diameter of the DIEA, bilaterally. Conclusion: It is suggested that anastomosis of the DIEA with PBs of the ITA in the second and third intercoastal spaces is optimal for DIEA flap grafting. Our results could contribute to making vascular anastomosis easier, thereby reducing the burden on both surgeons and patients. [ABSTRACT FROM AUTHOR]

Background: Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption. Methods: A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators. Results: A total of 959 perforators were identified, with 319 perforators identified in the 'Pfannenstiel scar' group and 640 perforators in the 'no abdominal scar' group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p = 0.2819); however, perforators of the 'Pfannenstiel scar' group were of larger mean diameter than the 'no abdominal scar' group (0.96 vs 0.85 mm ( p = 0.0027). Conclusions: The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes. Level of Evidence: Level III, risk / prognostic study. [ABSTRACT FROM AUTHOR]

Autologous breast reconstruction can often provide a more aesthetic outcome than other options for breast reconstruction because breast volume and shape can be extensively modified based on individual need, the texture of the reconstructed breast is a closer match to the native breast, and complications such as capsular contracture are avoided. However, with these benefits come the potential for complications unique to autologous tissue transfer. While overall complications are low, there are ways to maximize operative success and minimize the risk of complications. Deep inferior epigastric artery perforator (DIEP) flaps, the current mainstay in choice of autologous reconstruction, provide generally good outcomes. However, improvements in outcomes can still be achieved with a better understanding of individual anatomy. Perforator size, location, intramuscular and subcutaneous course, and association with motor nerves are all factors that can significantly affect operative technique, length of operation, and operative outcomes. With significant variation between individuals, preoperative imaging has become an essential element of DIEP flap surgery. Computed tomography angiography (CTA) is currently the gold standard but evolving techniques such as magnetic resonance angiography (MRA) and image-guided stereotaxy are rapidly contributing to improved outcomes. [ABSTRACT FROM AUTHOR]

Free flaps based on the deep inferior epigastric artery are known to be easily raised and offer a long and reliable vascular pedicle. According to the defect size and consistency, they can be raised as muscular, myocutaneous and as a sandwich flap, including the peritoneum [5]. A free flap consisting of only the peritoneum has been speculated on. Seventeen dissections on fresh cadavers were performed. The visualization of the vascular pedicle was obtained by blue dye coloration, contrast medium angiography, and intravascular silicone latex injections. It was found that the parietal peritoneum of the lower abdomen was constantly supplied by an axial branch of the deep inferior epigastric artery and not by muscle perforators. [ABSTRACT FROM AUTHOR]

The aim of this study was to provide an anatomic basis for the transversus and rectus abdominis musculoperitoneal (TRAMP) flap, recently successfully introduced for vulvovaginal reconstruction. In 25 cadavers the width and length of the portions of rectus and transversus abdominis muscles suitable for the TRAMP flap as well as the length and diameter of the inferior epigastric artery were assessed. The mean length of the rectus abdominis muscle was 32.42±0.48 cm and its width 6.15±0.12 cm. The suitable part of the transversus abdominis muscle measured 19.08±0.3 cm mean length with a mean width of 18.62±0.19 cm. No significant left-right differences were observed. The resulting area of the rectus abdominis muscle was 197.78±5.09 cm2 and that of the transversus abdominis muscle 356.20±7.87 cm2. The mean extramuscular course of the deep inferior epigastric artery (DIEA) was 4.97±0.09 cm with a mean diameter of 0.29±0.01 cm. This offers numerous possibilities for an anastomosis of the DIEA when the TRAMP flap is desired as a free flap. Because of its dimensions and flexibility the TRAMP offers several possibilities in reconstructive surgery. [ABSTRACT FROM AUTHOR]