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Perioperative blood loss during and following breast reconstruction surgery can have substantial impact on free flap survival and patient morbidity. Transfusion rates of up to 95% have been reported following transverse rectus abdominis myocutaneous flap breast reconstruction, with blood loss described as significant in most cases. However, there has been little reported of such requirements in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. We present the transfusion requirements of 152 consecutive patients who underwent DIEP flap breast reconstruction, with a view to quantifying transfusion requirements and identifying risk factors for such loss. In this cohort, 80.3% of patients required blood transfusion, with a mean volume of 3.9 U per patient. There was a statistically significant correlation for increased transfusion requirement in patients with preoperative anemia ( P < 0.001) and in bilateral cases ( P < 0.001), but not for cases of immediate reconstruction ( P = 0.72). Although blood loss in breast reconstructive surgery is rarely large enough to be life-threatening, relative anemia does have significant effect on flap survival and patient morbidity. With risk factors for increased transfusion requirements identified in the current study, high-risk patients can be predicted preoperatively.

Background:The fascial system of the breast has, to date, only been described in general terms. This anatomical study has developed two distinct methods for better defining existing breast structures such as the inframammary fold, as well as defining previously unnamed ligamentous structures.Methods

Breast cancer is now associated with long-term disease-free and overall survival, and in the setting of mastectomy, long term psycho-sexual health becomes an important consideration. To this end, breast reconstruction has been shown to significantly improve quality of life for mastectomy patients. With adjuvant radiotherapy often required in the setting of breast reconstruction, it is unclear what interaction the two can have.A thorough literature review was undertaken to assess the impact of radiotherapy on autologous breast reconstruction, and in particular, the influence of its timing on vessel selection, post-operative complications and both oncologic and cosmetic outcomes.A clear benefit was established for delaying reconstruction until after radiotherapy to improve cosmetic outcomes. Although the timing of radiotherapy administration may influence vessel selection and the nature of post-operative complications encountered, overall outcomes were not dissimilar. Likewise, oncologic outcomes have not been shown to be significantly affected by the timing of radiotherapy.Both immediate and delayed breast reconstruction are safe modes of treatment, however patients that are expected to require adjuvant radiotherapy may benefit from delaying reconstruction until completion of oncologic treatment.

Microscopic arteriovenous anastomoses are known structures that have many clinical implications, with disease states such as Reynaud's phenomenon and erythromelalgia known consequences of their abnormal functioning. These pre-capillary arteriovenous communications result in increased regional blood flow at the time of capillary filling. Recent advances in imaging technology, providing physiological and anatomical data, have identified a previously undescribed anatomical structure, that of large-vessel (macroscopic) arteriovenous communications, with profoundly different implications. Computed tomographic angiography (CTA) of the abdominal wall vasculature was undertaken in 140 patients prior to reconstructive surgery. All scans were arterial phase, demonstrating functional arteriovenous communications in all patients. These communications identified vascular shunting occurring prior to capillary filling. Fine-cut slices were able to visualise the structures, demonstrate their size as macroscopic (>1 mm diameter) and map the course of the arteriovenous communications. The potential clinical implications and therapeutic possibilities in a range of medical and surgical conditions are described.

Summary Background The pudendal thigh fasciocutaneous (PTF) flap is a useful flap in perineal reconstruction, that is reliable when small but is traditionally unreliable when large flaps are raised. Large flaps in particular, are associated with an increased incidence of apical necrosis. Thorough descriptions of the vascular anatomy of this flap have been lacking from the literature, with the current study evaluating this anatomy, aiming to provide the anatomical basis for vascular problems and for techniques to maximise its survival. Methods Five unembalmed human cadaveric pelvis specimens were studied. Lead oxide injectant enabled radiographic and dissection analysis of the arterial anatomy of the integument of the perineum. Results A consistent pattern of vascular supply was found in all specimens. 1: the blood supply to the pelvic floor was supplied sequentially by the posterior labial/scrotal arteries, cutaneous branches from the anterior branch of the obturator artery, and branches from the external pudendal arteries. 2: these vessels ran close to the midline, medial to the PTF flap. 3: the posterior labial/scrotal arteries were deep to the Colles' fascia and the branches from the obturator artery and external pudendal arteries were located superficial to the Colles' fascia. Conclusion This study has demonstrated that the PTF flap is a three vascular territory flap and that the pedicle is situated close to the midline. This may explain why regions of the PTF flap may have a potentially precarious blood supply, and suggests that the PTF flap should be designed more medially. Given the third territory of supply to the apex of the flap, a delay procedure may help to avoid flap necrosis.

Background: Effective postoperative monitoring of the vascular pedicle to a free flap can potentiate rapid return to the operating room in the setting of compromise, allowing for the potential to salvage the flap. The only ubiquitous method for postoperative monitoring of free flaps is clinical bedside monitoring, but although the use of clinical monitoring may be inferred in large reported series of free flaps, there has been little discussed in the literature of specific clinical outcome measures. Methods: The authors present their experience with 1140 consecutive cases of free tissue transfer and the use of clinical monitoring as a sole method of monitoring, and subgroup analysis of different recipient sites. Results: There were 94 take-backs, four of which had no pedicle compromise (false-positives) and there were four false-negatives. The overall flap salvage rate was 62.8 percent and the false-positive rate was 0.4 percent. Subgroup analyses demonstrated statistically significant differences between recipient sites for the false-positive rates: fewer false-positives with breast reconstruction cases (p < 0.05) and significantly more false-positives in the extremity group (p < 0.05). There was an improved flap salvage rate in cases of venous compromise compared with arterial compromise (69 percent versus 51 percent, p = 0.015). Conclusions: This largest reported series to date provides an outcome-based analysis of postoperative monitoring for free flaps, providing a benchmark standard against which adjunctive monitoring techniques can be compared. Future studies need to be assessed in the context of individual recipient sites, with significant differences in monitoring outcomes between sites.

Introduction: The superficial inferior epigastric artery (SIEA) is a useful pedicle in supply to the lower abdominal integument, with its use sparing damage to rectus abdominis muscle or sheath. However, it is limited in usefulness due to its anatomical variability. While previous anatomical studies have been limited in number and study design, the use of preoperative imaging has enabled the analysis of this vasculature in large numbers and greater anatomical detail. Methods: A clinical anatomical study of 500 hemi-abdominal walls in 250 consecutive patients undergoing preoperative computed tomographic angiography (CTA) prior to autologous breast reconstruction was undertaken. The presence, size, location, and branching pattern of the SIEA were assessed in each case. Results: The SIEA was identified in 468 cases, an incidence of 94%. Its mean diameter was 0.6 mm, and in 24% of cases was of a diameter >1.5 mm. SIEA location was highly variable, with mean position 2-cm lateral to the linea semilunaris (range 0–8 cm lateral), and relationship to the superficial inferior epigastric vein (SIEV) was also highly variable, with the distance between them ranging from 0.3 to 8.5 cm apart. SIEA branches directly crossed the abdominal midline in 5% of cases. Larger SIEA diameters correlated with a decrease in diameter of ipsilateral DIEA perforators. Conclusion: The SIEA is present more frequently than previously demonstrated, but is typically too small for use in free tissue transfer. The variable degree of SIEA branching suggests that its territory of supply is also variable, and that preoperative imaging may be useful in planning SIEA flaps.

BACKGROUND: Cadaveric research has widely influenced our understanding of clinical anatomy. However, while many soft-tissue structures remain quiescent after death, other tissues, such as viscera, undergo structural and functional changes that may influence their use in predicting living anatomy. In particular, our understanding of vascular anatomy has been based upon cadaveric studies, in which vascular tone and flow do not match the living situation. METHODS: An angiographic analysis of the abdominal wall vasculature was performed using plain film and computed tomography angiography in 60 cadaveric hemi-abdominal walls (from 31 cadavers) and 140 living hemi-abdominal walls (in 70 patients). The deep inferior epigastric artery (DIEA) and all of its perforating branches larger than 0.5 mm were analysed for number, calibre and location. RESULTS: Both large, named vessels and small calibre vessels show marked differences between living anatomy and cadaveric specimens. The DIEA was of larger diameter (4.2 mm versus 3.1 mm, P < 0.01) and had more detectable branches in the cadaveric specimens. Perforators were of greater calibre (diameter 1.5 mm versus 0.8 mm, P < 0.01) and were more plentiful (16 versus 6, P < 0.01) in cadaveric specimens. However, the location of individual vessels was similar. CONCLUSIONS: Cadaveric anatomy displays marked differences to in vivo anatomy, with the absence of living vascular dynamics affecting vessel diameters in cadaveric specimens. Blood vessels are of greater measurable calibre in cadaveric specimens than in the living. Consequently, cadaveric anatomy should be interpreted with consideration of post-mortem changes, while living anatomical studies, particularly with the use of imaging technologies, should be embraced in anatomical research.

The anterior abdominal wall integument is frequently used in a range of reconstructive flaps. These tissues are supplied by the deep and superficial inferior epigastric arteries (DIEA and SIEAs) and the deep and superficial superior epigastric arteries (DSEA and SSEAs). Previous abdominal wall surgery alters this vascular anatomy and may influence flap design. One hundred and sixty-eight patients underwent abdominal wall computed tomographic angiography (CTA) for preoperative imaging. Fifty-eight of these patients had undergone previous abdominal surgery, and were assessed for scar pattern and relationship to the course and distribution of all major axial vessels and perforators. Two cadaveric abdominal wall specimens with midline abdominal scars underwent contrast injection of the DIEAs and DSEAs, with subsequent CTA. The course and distribution of all cutaneous vessels were assessed. In all clinical and cadaveric cases, the vasculature of the abdominal wall had been altered by previous surgery. In the clinical cases, vascular architecture was universally altered in the region of the scar, often modifying the filling patterns of the abdominal wall and occasionally precluding the use of an abdominal wall flap. In both cadaveric specimens, regions of non-filling were evident upon contrast injection, highlighting the angiosomes not supplied by the DIEA or DSEA. Previous abdominal wall surgery necessarily alters the vascular architecture of the abdominal wall, and may alter the source vessels supplying cutaneous tissues. CTA was useful in identifying and delineating these changes, and may be used as a preoperative tool in this role.

BACKGROUND: The deep inferior epigastric artery (DIEA) perforator flap is frequently used for autologous breast reconstruction following mastectomy. Thinning of the flap is often performed to debulk the flap of excess fatty tissue, such as in partial mastectomy defects. Thinning may disrupt the blood supply to the flap and compromise viability, however adequate guidelines for thinning are lacking from the literature. METHODS: Clinical and anatomical studies were concurrently undertaken to explore the cutaneous course of perforators as a guide to flap thinning. Twenty consecutive patients undergoing DIEA perforator flap breast reconstruction underwent preoperative computerised tomography angiography (CTA), and a cadaveric study was also undertaken, in which six fresh, whole abdominal walls underwent CTA. All perforators greater than 2 mm were analysed for their cutaneous course. RESULTS: In all cases, perforators emerged from the anterior rectus sheath and traversed an oblique, but direct course through the deep layer of adipose tissue, before reaching Scarpa's fascia. Branching of perforators occurred in two planes of the superficial adipose layer: just superficial to Scarpa's fascia (the fascial plexus) and in the subdermal plexus. CONCLUSION: Thinning of DIEA perforator flaps can only be performed safely deep to Scarpa's fascia. Thinning performed superficial to Scarpa's fascia threatens the intrinsic blood supply to the flap.

Background: The previously described “perfusion zones” of the abdominal wall vasculature are based on filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With the advent of the DIEA perforator flap, only a single or several perforators are included in supply to the flap. As such, a new model for abdominal wall perfusion has become necessary. The concept of a “perforator angiosome” is thus explored. Methods: A clinical and cadaveric study of 155 abdominal walls was undertaken. This comprised the use of 10 whole, unembalmed cadaveric abdominal walls for angiographic studies, and 145 abdominal wall computed tomographic angiograms (CTAs) in patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators was explored, particularly exploring differences between medial and lateral row perforators. Results: Fundamental differences exist between medial row and lateral row perforators, with medial row perforators larger (1.3 mm vs. 1 mm) and more likely to ramify in the subcutaneous fat toward the contralateral hemiabdomen (98% of cases vs. 2% of cases). A model for the perfusion of the abdominal wall based on a single perforator is presented. Conclusion: The “perforator angiosome” is dependent on perforator location, and can mapped individually with the use of preoperative imaging. © 2009 Wiley-Liss, Inc. Microsurgery, 2010.

[Extract] Perforators of the deep superior epigastric artery traverse the rectus abdominis muscle to supply the upper abdominal wall integument. These perforators have been used in the past as the basis for vertical and transverse rectus abdominis myocutaneous flaps,1–4 and for thoracoepigastric fasciocutaneous flaps. Although flaps based on deep superior epigastric artery perforators have been described in a range of clinical settings, we would like to share our experience in applying this flap for sternal reconstruction. Sternal wound dehiscence is a challenging reconstructive problem, with reconstructive options including rectus abdominis muscle, pectoralis major muscle, and omentum, but situations exist where these are not feasible and other options are sought. The current study contributes to this list of options by reporting our experience with the deep superior epigastric artery perforator/thoracoepigastric flap for difficult sternal reconstructions. In developing this flap, we undertook an anatomical study with clinical computed tomographic angiography studies to improve flap design. Although previous cadaveric studies have delineated some of this anatomy, in vivo clinical studies of this anatomy have been sparse.

Background: The lumbar region has been scarcely explored as a donor site for free tissue transfer or as a free flap recipient site. The lumbar integument provides a versatile prospective flap site, with a potentially well-concealed scar. Similarly, defects of this region can require recipient vessels that may be difficult to identify. Although lumbar artery perforators have been described, the reliability of perforators in this region remains questionable. Methods: An anatomical study was undertaken combining both cadaveric and in vivo analysis of the lumbar vessels. The cadaveric component comprised both dissection and angiographic studies in fresh and embalmed cadavers (36 lumbar regions in 18 cadavers), and the clinical study comprised a computed tomographic angiographic study (44 sides in 22 patients) and an operative case report. Results: Perforators were shown to arise from all eight lumbar arteries to enter the lumbar integument, with their size, location, and course described. Lower lumbar perforators were more often septocutaneous and of larger caliber. A case in which the fourth lumbar artery and concomitant vein were used as free flap recipient vessels is described, the first such reported case in the literature. Conclusions: Improving the incidence of identifying lumbar perforators of large caliber and with a septocutaneous course can be achieved by selecting lower lumbar vessels, or with the use of preoperative computed tomographic angiography. Computed tomographic angiography can successfully identify the location, size, and course of lumbar artery perforators and can aid flap design. Lumbar artery perforators are highly useful for both donor and recipient vessels in free flap surgery.

Computed tomographic angiography (CTA) has become increasingly adopted for preoperative imaging in perforator flap surgery, as it has been shown to improve operative outcomes and decrease operating times prior to deep inferior epigastric artery perforator (DIEP) flap and anterolateral thigh perforator flap surgery. Current technologies are readily available for the preoperative imaging of all perforator flaps, however only sporadic reports of the use of CTA for the imaging of other perforators have been described. We describe our experience with 325 CTAs performed for the preoperative imaging of perforators prior to 370 perforator flaps throughout several body regions. The scanning techniques, software reconstructions and technical issues are explored. In all cases, CTA was scored by the radiologist as at least "sufficient", and described as "optimal" in the majority of cases. Similarly, the surgeon described the correlation of imaging to operative findings as at least "good", and described the correlation as "optimal" in the majority of cases. As such, a standardized protocol for the use of CTA prior to perforator flap surgery is provided, which has been shown to be successful prior to a range of perforator flap operations.

The abdominal wall is particularly advantageous as a donor site due to the reliability of its vascular supply. Although the cutaneous perforators of the deep inferior epigastric artery (DIEA) and the superficial inferior epigastric artery (SIEA) may show significant individual variability, the DIEA itself has been shown to be ever-present as a vascular pedicle and to be highly dependable. The increasing use of preoperative computed tomographic angiography (CTA) has led to increasing reports of anatomic variability. With the use of preoperative CTA, we describe a unique case of a completely absent DIEA in patient who had not previously undergone any open abdominal surgery. The absence of the DIEA had led to vascular changes throughout the abdominal wall, including dilatation of both SIEAs and the ipsilateral deep superior epigastric artery. Preoperative CTA in this setting helped us identify this anomaly and aided surgical planning. The incidence of this anomaly was subsequently reviewed in 150 consecutive CTA scans performed at our institution.

Image-guided stereotaxy is a recent advancement in imaging technology, allowing computer guidance to aid surgical planning and accuracy. Despite the use of multiple techniques for patient registration in several surgical specialities, only fiducial marker registration has been described for use in soft tissue reconstructive surgery. The current study comprises an evaluation of the current techniques available for this purpose. A cohort of nine consecutive patients planned for elective free flaps were recruited, with the first five patients (four for the abdominal wall and one anterolateral thigh donor site) undergoing fiducial marker registration with a variable number of fiducial markers in order to determine the optimal number of fiducial markers to be used. Four subsequent patients undergoing perforator flap surgery underwent registration using three available registration modalities: fiducial marker registration, surface matching pointer/landmark and surface matching laser registration. For the abdominal wall, registration was not able to be achieved with five fiducial markers, and was successfully achieved in all cases with either six or seven fiducial markers. For the anterolateral thigh, registration was achieved with either nine or ten markers. The four patients who also underwent surface-landmark registration and ‘Z-touch’ laser surface matching registration all failed the registration process. Stereotactic navigation is a useful adjunct to the preoperative imaging of perforator flaps. Fiducial marker registration was able to be achieved in all cases, can be successfully achieved with a low and predictable number of fiducial markers, is highly accurate, and was the only reliable registration process in our experience.

BACKGROUND: The anterolateral thigh (ALT) flap has become increasingly popular due to its versatility and minimal donor site morbidity. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. The variability of this anatomy has not been adequately explored previously. METHODS: A cadaveric study was undertaken, in which 19 thighs (from 10 fresh cadavers) underwent contrast injection and angiographic imaging. Anatomical variations of the vasculature were recorded. A clinical study of 44 patients undergoing ALT flap reconstruction was also undertaken. Perforator anatomy was described in the first 32 patients, and the subsequent 12 patients underwent computed tomography angiography with a view to predicting individual anatomy and improving operative outcome. RESULTS: Cadaver angiography was able to highlight and classify the variations in arterial anatomy, with four patterns observed and marked variability between cases. In 32 patients undergoing ALT flaps without preoperative CT angiography (CTA), five patients (16%) did not have any suitable perforators from the descending branch of the lateral circumflex femoral artery. By selecting the limb of choice with preoperative CTA, the incidence of flap unsuitability was reduced to 0%. Comparing CTA with Doppler, CTA was more accurate (sensitivity 100%) and provided more information. CONCLUSION: The perforators supplying the ALT flap show significant variability in location and course, with the potential for unsuitable perforators limiting flap success. Preoperative CTA can demonstrate the vascular anatomy and can aid perforator selection and operative success.

The deep circumflex iliac artery (DCIA) provides a dependable option for use as an osteo-musculo-cutaneous flap, particularly in mandibular reconstruction. Modifications to flaps based on DCIA perforators have been sought to prevent donor site morbidity as a consequence of muscle cuff harvest. Previous studies have been inconsistent in their descriptions of perforator anatomy, and means of assessing these preoperatively have not been widely described. A clinical anatomical study was undertaken, with a cohort of 44 hemiabdominal walls in 22 consecutive patients undergoing preoperative computed tomographic angiography (CTA) before free flap surgery. The feasibility of CTA and the regional vascular anatomy were both assessed. The use of CTA was shown to demonstrate DCIA perforators with high resolution and to be able to assess vessel size and location. In 44 hemiabdominal walls, there were 44 perforators of >0.8 mm diameter. There were no suitable perforators in 40% of sides, with 32% of sides having one perforator >0.8 mm diameter, 16% having two perforators

The sartorius muscle is a superficial muscle of the thigh that possesses highly suitable qualities for many uses in local transposition and free muscle transfer. However, a paucity of description of the neurovascular anatomy of the sartorius has contributed to its infrequent use in these roles.Both human and canine studies were undertaken to delineate the neurovascular anatomy of the sartorius and to determine the role for surgical delay clinically. Fifty-five human cadaveric sartorius muscles and 30 canine cadaveric sartorius muscles underwent angiographic and dissection studies, and the location and course of the vessels and nerves supplying sartorius are described. A subsequent study was undertaken in two live canines in which the vascular supply to the sartorius was evaluated before and after surgical delay.The sartorius is supplied by an average of six or seven vascular pedicles, the size, location, and course of which are described. The nerve supply to the sartorius enters at its proximal end and uniformly arises from a branch of the femoral nerve. Variations in branching patterns and course of nerves and vessels are described. Living canine studies demonstrated the dilatation of intramuscular vessels following surgical delay, with the contrast injection of a single remaining vascular pedicle shown to vascularize the entire length of the sartorius muscle.The sartorius is highly suitable for local transposition and free muscle transfer for facial reanimation. The neurovascular anatomy is reliable, and the use of surgical delay can augment its vascular supply and increase the arc of rotation for local transposition.

Background. The lymphatic pathways of the nasal cavity are of enormous clinical importance. To date there has been no accurate radiographic record of these pathways. Methods. Four halves of the head and neck from 2 fresh human cadavers were studied. Results. The capillary network arises from the mucous membrane of the atrium, the turbinates, the floor of the nasal cavity, and the nasopharynx. They drain into the lateral pharyngeal and retropharyngeal lymph nodes. There is 1 lymphatic communication at the junction of the lateral posterior wall of the turbinates and the nasopharynx and another communication between 2 groups of lymph nodes situated between the origin of the facial artery and the bifurcation of the carotid artery. Conclusions. A rich avalvular lymph capillary network exists in the mucous membrane and 2 major lymph collecting vessels course through the parapharyngeal space to multiple first tier lymph nodes. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

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.

BACKGROUND: Cutaneous perforators that do not originate from the deep inferior epigastric artery (DIEA) are rare, but may significantly affect operative outcome. Peritoneal-cutaneous perforators have been described as a source for augmenting the blood flow to a deep inferior epigastric perforator (DIEP) flap, however if unrecognized, may compromise flap survival. METHODS: We reviewed 375 DIEA perforator (DIEP) flaps (325 with preoperative CTA and 50 cadaveric dissections) to investigate the incidence of this anomaly. RESULTS: We detected this variation in 3/325 (1%) of DIEP flaps following preoperative computed tomography. In 1/50 (2%) of the cadaveric specimens, a peritoneal-cutaneous perforator was found and injected with lead oxide contrast. It was shown to fill the cutaneous veins of the majority of the lower abdominal integument. CONCLUSION: Peritoneal-cutaneous perforators are rare anatomical variations (4/375: 1.1%) that may have significant ramifications for surgery utilizing the vasculature of the abdominal wall. CTA was significantly able to detect this anomaly and aid operative planning. Preoperative CTA helps to safely identify individual vascular anatomy including rare variations.

The deep inferior epigastric artery perforator (DIEP) flap aims to reduce donor-site morbidity by minimizing rectus muscle damage; however, damage to motor nerves during perforator dissection may denervate rectus muscle. Although cadaveric research has demonstrated that individual nerves do not arise from single spinal cord segments and are not distributed segmentally, the functional distribution of individual nerves remains unknown. Using intraoperative nerve stimulation, the current study describes the motor distribution of individual nerves supplying the rectus abdominis, providing a guide to nerve dissection during DIEP flap harvest.Twenty rectus abdominis muscles in 17 patients undergoing reconstructive surgery involving rectus abdominis (DIEP, transverse rectus abdominis musculocutaneous, or vertical rectus abdominis musculocutaneous flaps) underwent intraoperative stimulation of nerves innervating the infraumbilical segment of the rectus. Nerve course and extent of rectus muscle contraction were recorded.In each case, three to seven nerves entered the infraumbilical segment of the rectus abdominis. Small nerves (type 1) innervated small longitudinal strips of rectus muscle, rather than transverse strips as previously described. There was significant overlap between adjacent type 1 nerves. In 18 of 20 cases, a single large nerve (type 2) at the level of the arcuate line supplied the entire width and length of rectus muscle.Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.

Institutional review board approval was obtained for this study, and all patients gave written informed consent. Autologous surgical breast reconstruction with use of abdominal wall donor flaps based on the deep inferior epigastric artery (DIEA) and one or more of its anterior musculocutaneous perforating branches (DIEA perforator flap) is being used with increasing frequency instead of breast reconstruction with use of traditional transverse rectus abdominus musculocutaneous and modified muscle-sparing flaps. Preoperative mapping of the DIEA perforators with abdominal wall computed tomographic (CT) angiography may improve patient care by providing the surgeon with additional information that will lead to optimization of the surgical technique, shorter procedure time, and reduction in the frequency of surgical complications. The branching patterns of the DIEA, the segmental anatomy of the anterior adipocutaneous perforating branches of the DIEA, and the importance of these features in pre- and intraoperative surgical planning necessitate a different approach to abdominal wall CT angiography than that used with other abdominal CT angiographic techniques. In abdominal wall CT angiography, the common femoral artery is used as the bolus trigger, CT scanning is performed in the caudocranial direction, the automatic exposure control feature is disabled, a scaled grid overlay tool is used to present information to the surgeons, and radiation dose is minimized (average dose, 6 mSv). The anatomic accuracy of abdominal wall CT angiography has been investigated in cadaveric and surgical studies, with sensitivity of 96%-100% and specificity of 95%-100%. This detailed description will allow other radiologists and surgeons interested in free DIEP flap surgery to incorporate this useful tool into their practice.

Background: The deep inferior epigastric artery (DIEA) perforator flap for breast reconstruction spares rectus abdominis muscle and has low donor-site morbidity. However, abdominal wall weakness and bulge remain significant complications, with damage to the motor innervation of the rectus abdominis postulated as a cause. This study describes the relationship between the nerves supplying rectus abdominis and perforators, based on a thorough cadaveric study and review of the literature. Methods: Twenty hemiabdominal walls from fresh and embalmed cadavers were dissected, mapping the course of the nerve and vascular supply of rectus abdominis. Results: The infraumbilical segment of rectus abdominis was innervated by T9-L1, with four to seven nerve branches entering rectus abdominis from its lateral border (12 cases) or posterior surface (93 cases). Each nerve entered a nerve plexus running with the most lateral branch of the DIEA, before running with arterial perforators into rectus abdominis. Nerves entered rectus muscle more medial than the lateral row perforators (83 percent of cases), with the medial branches of the DIEA devoid of these nerve branches. Conclusions: The nerves innervating rectus abdominis are at risk during the raising of a DIEA perforator flap. These nerves enter the posterior surface of rectus abdominis and run with the most lateral branch of the DIEA and its perforators. Damage to these nerves may denervate rectus abdominis muscle and contribute to donor-site morbidity. As medial row perforators were not related to these motor nerves, these perforators are ideal for inclusion in DIEA perforator and transverse rectus abdominis myocutaneous flaps.

Breast reconstruction plays a significant role in the management of breast cancer. The removal of a breast has implications for the psychologic, social, and sexual well-being of the patient, establishing the need for discussion of postmastectomy breast reconstruction with suitable patients. However, operative morbidity and the potential for diminished oncologic safety are ongoing issues of contention. A Medline literature review was performed to evaluate the interplay between the psychosocial need for breast reconstruction in patients after mastectomy and the issues surrounding its oncologic safety. Immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiation therapy (RT). Immediate breast reconstruction in the setting of chemotherapy is not associated with greater complication rates; however, there is some evidence for increased complications in the setting of adjuvant RT. Breast reconstruction has a positive effect on the psychosocial outcomes of mastectomy and is oncologically safe in the immediate and delayed settings. Ultimately, the decision-making process of whether to reconstruct, how to reconstruct, and when to reconstruct requires a multidisciplinary approach, with the patient, plastic surgeon, oncologic surgeon, medical oncologist, and radiation oncologist all contributing.

Preoperative imaging of the donor site vasculature for deep inferior epigastric artery (DIEA) perforator flaps and other abdominal wall reconstructive flaps has become more commonplace. Abdominal wall computed tomography angiography (CTA) has been described as the most accurate and reproducible modality available for demonstrating the location, size, and course of individual perforators. We drew on our experience of 75 consecutive patients planned for DIEA-based flap surgery undertaking CTA at a single institution. Seven of these cases have been reported to highlight the utility of CTA for preoperative planning, emphasizing the unique information supplied by CTA that may influence operative outcome. Among all cases that underwent preoperative imaging with CTA, there was 100% flap survival, with no partial or complete flap necrosis. We found that in three of the cases described, the choice of operation was necessarily selected based on CTA findings (DIEA perforator flap, transverse rectus abdominis myocutaneous flap, and superficial superior epigastric artery flap). In addition, three cases demonstrate that CTA findings may dictate the decision to operate at all, and one case demonstrates the utility of CTA for evaluating the entire abdominal contents for comorbid conditions. Our experience with CTA for abdominal wall perforator mapping has been highly beneficial. CTA may guide operative technique and improve perforator selection in uncomplicated cases, and in difficult cases it can guide the most appropriate operation or indeed if an operation is appropriate at all. This is particularly the case in the setting of comorbidities or previous abdominal surgery.

Introduction: The anterolateral thigh flap is an increasingly popular reconstructive option despite uncertainty in its perforator anatomy. Perforators are not always present, vary in size and intramuscular course, and have variable cutaneous courses and supply. As such, preoperative imaging has become favored. Methods: The current study describes the preliminary use of two new modalities for preoperative imaging: computed tomography (CT) Angiography and CT-guided stereotaxy. These have been utilized in the preoperative imaging of two patients undergoing ALT flap reconstruction. Each patient underwent each of these techniques combined with Doppler ultrasound, the previous standard modality. The size, location, and course of perforators were explored and compared with operative findings. Results: Both techniques are technically feasible, highly accurate, and provide more information to the surgeon than ultrasound. Conclusion: CT Angiography and CT-guided stereotaxy are useful adjuncts to Doppler ultrasound for imaging perforators prior to ALT flaps. A larger study is suggested to quantify the accuracy of these techniques.

Previous descriptions of the thoracolumbar spinal nerves innervating the anterior abdominal wall have been inconsistent. With modern surgical and anesthetic techniques that involve or may damage these nerves, an improved understanding of the precise course and variability of this anatomy has become increasingly important. The course of the nerves of the anterior abdominal is described based on a thorough cadaveric study and review of the literature. Twenty human cadaveric hemi-abdominal walls were dissected to map the course of the nerves of the anterior abdominal wall. Dissection included a comprehensive tracing of nerves and their branches from their origins in five specimens. The branching pattern and course of all nerves identified were described. All thoracolumbar nerves that innervate the anterior abdominal wall were found to travel as multiple mixed segmental nerves, which branch and communicate widely within the transversus abdominis plane (TAP). This communication may occur at multiple locations, including large branch communications anterolaterally (intercostal plexus), and in plexuses that run with the deep circumflex iliac artery (DCIA) (TAP plexus) and the deep inferior epigastric artery (DIEA) (rectus sheath plexus). Rectus abdominis muscle is innervated by segments T6-L1, with a constant branch from L1. The umbilicus is always innervated by a branch of T10. As such, identification or damage to individual nerves in the TAP or within rectus sheath is unlikely to involve single segmental nerves. An understanding of this anatomy may contribute to explaining clinical outcomes and preventing complications, following TAP blocks for anesthesia and DIEA perforator flaps for breast reconstruction.

Since the introduction of cross-facial nerve grafting and free vascularized muscle transfer for the treatment of longstanding facial paralysis, substantial progress has been made toward restoration of facial expression that is as normal as possible. Much of the focus has remained on the gracilis as a donor muscle. However, its inherent anatomical characteristics may preclude it from ever being more than simply a mass of contractile tissue in the face. The coracobrachialis muscle, which is the analogue in the arm of the lower limb adductor mass, was proposed as an alternative donor muscle because it was thought that certain features would allow it to improve on the overall results that are currently possible with the gracilis. A comparative anatomical study was conducted to gauge this potential. A total of 133 muscles were analyzed, including 96 dissected specimens, 16 arterial and 14 venous study specimens, and seven neurovascular study specimens. Anatomical parameters were recorded for each muscle and later tabulated. Histological analysis of the nerves to 10 gracilis and 10 coracobrachialis muscles was performed, and the findings were confirmed with intraneural dissection of an additional 20 nerves under an operating microscope. The coracobrachialis was observed to be a practical alternative to the gracilis. Indeed, it has many of the attributes that initially drew attention to the gracilis as a possible donor muscle, including a reliable neurovascular supply, minimal donor-site morbidity, and the option of having two teams operate simultaneously. In addition, it has a size, shape, and form that make it an excellent choice for transfer to the face. It could be easily attached in the face to provide static support as well as animation, because of its long proximal tendon, the thick intermuscular septum along its lateral surface, and, when present, the ligament of Struthers.

BACKGROUND: There are minimal data in the current literature regarding the depth of the superficial lymphatic collectors of the limbs in relation to the various subcutaneous tissue layers. METHODS: Injection, microdissection, radiographic, and histologic studies of the superficial lymphatics and the subcutaneous tissues of 32 limbs from 15 human cadavers were performed. RESULTS: Five layers were consistently identified in the integument of all the upper and lower limb specimens: (1) skin, (2) subcutaneous fat, (3) superficial fascia, (4) loose areolar tissue, and (5) deep fascia. Layer 2 was further divided into superficial (2a) and deep (2c) compartments by a thin, transparent, horizontal septum (layer 2b). The main superficial veins and the superficial nerves coursed in layer 4. The lymphatic collectors were found at layer 2c and layer 4. CONCLUSIONS: The use of consistent nomenclature to describe the subcutaneous tissue layers facilitates a greater understanding and discussion of the anatomy. In lymphovenous anastomosis for the treatment of lymphedema, indocyanine green lymphography is an unreliable method for identification of the superficial collectors of the thigh. The medial proximal leg, the dorsum of the wrist over the anatomical snuffbox, and the volar proximal forearm provide suitable areas for locating superficial collectors with nearby matching size veins. In vertical medial thigh lift, choosing a dissection plane superficial to the great saphenous vein is unlikely to preserve the collectors of the ventromedial bundle.

BACKGROUND Previous studies of venous anatomy lack the detail of their arterial counterparts because of (1) the technical challenge of retrograde perfusion against competent valves and (2) anterograde venous perfusion failing to adequately delineate the area of interest. We introduced a novel technique: retrograde hydrogen peroxide priming that dilates veins and renders valves incompetent, thereby facilitating complete cadaveric venous perfusion. METHODS The superficial and deep venous systems of 41 hemiabdomens and 20 hemichests of unembalmed human cadavers were primed by retrograde injection with 6% hydrogen peroxide. Specimens were then injected with lead oxide contrast, radiographed, and dissected. In five hemiabdomens, the valves were mapped by dissection. Results were compared with archival venous studies of six total body injections, six abdominal lipectomy specimens, and two intraoperative venograms of delayed transverse rectus abdominis musculocutaneous flaps. RESULTS Unprecedented venous filling of the anterior torso was demonstrated. Two types of superficial-to-deep venous connections were defined: large venae communicantes and small venae comitantes. Venae communicantes (>2 mm) formed major connections between large superficial and deep veins, mostly within 5 cm of the umbilicus in the abdomen, the axilla and fifth or sixth intercostal space parasternally. Seventy-four percent of venae communicantes coursed with arteries greater than 1.0 mm. Four major longitudinal valved subcutaneous pathways of the superficial inferior epigastric vein and superficial circumflex iliac vein were defined bilaterally with large avalvular transverse connections in the midline and small-caliber connections laterally that explain venous complications seen sometimes in transverse abdominal flaps. CONCLUSION Retrograde hydrogen peroxide priming of veins in cadavers renders valves incompetent and facilitates detailed venous studies that help refine flap design and explain venous complications.

To the Editor, Clinical Anatomy:We would like to congratulate Tregaskiss et al. for theirstudy utilizing computerized tomography angiography(CTA) for mapping the vasculature of the body wall(Tregaskiss et al., 2007). This is a significant contribution tothe literature in this evolving field of anatomical research. Asmentioned in their article, CTA has only recently been sug-gested as an imaging modality for mapping vasculature inanatomical research, and even more recently as a modalityfor preoperative imaging in microsurgical, reconstructiveflap surgery. We have conducted similar studies, in the set-tings of both cadaveric research and clinical studies (in theprocess of publication in this journal (Rozen et al., in press-b)), utilizing plain radiography, ultrasonography, CTA, andmagnetic resonance angiography (MRA), the findings ofwhich complement those of Tregaskiss et al.Tregaskiss et al. discuss in their introduction the motiva-tion for three-dimensional (3D) CTA being the differentiationof vessels between tissue layers and their course betweenlayers. Our early anatomical research aimed to address thiswith cross-sectional studies. Cross-sectional studies canaccurately map the course of vessels in a similar fashion toCTA, as the cross sections permit analysis of the third spatialdimension (depth) (Rozen et al., in press-a). However,cross-sectional studies are significantly limited by time,labor-intensiveness, and inadequate spatial resolution.We also undertook CTA studies of our cadaveric speci-mens, with 10 cadaveric hemiabdominal walls injected, har-vested, and scanned in a similar fashion to Tregaskiss et al.Our CT scanner did differ, in being a 64 multidetector row CTscanner (Siemens Somatom Sensation Cardiac 64). Ourreformatting also differed, in that we created maximum in-tensity projection images in addition to 3D volume-renderedtechnique images. These changes in scanning and reformat-ting technique, we believe, enable a greater spatial apprecia-tion of the vasculature, and achieve the aim of high resolu-tion images of the course of vessels relative to tissue planes.Tregaskiss et al. have been diligent in performing an eval-uation of the efficacy of CTA by measuring the diameters ofvessels seen on CTA. This was an effective method, but doesnot achieve a formal evaluation of the accuracy of the CTAtechnique. We have performed a double-blinded anatomicdissection, evaluating for all musculocutaneous vessels ineach specimen, after a CTA of the same specimen had beenperformed (see Figs. 1 and 2). A vessel map was created foreach technique and the accuracy of CTA compared to ana-tomic dissection (total number on CTA ¼ 154 vessels). Wefound that the mapping of vessels was highly accurate, withonly eight false positives and six false negatives out of 154vessels seen on CTA, establishing a sensitivity of 96% anda specificity of 95% for the mapping of such vessels. Ourresults confirm the successful use of CTA for vessel mappingin cadaveric studies, and as a potential tool for preoperativeimaging prior to reconstructive flap surgery.Our research has demonstrated that CTA can be used witha high accuracy in anatomical studies such as that of Tregas-kiss et al, and suggests that this may be an ongoing modalityfor imaging vasculature in both anatomical studies and forpreoperative imaging. Our preliminary clinical studies haveshown high concordance of CTA with operative findings (seeFig. 3), and demonstrated high sensitivities (up to 95%) andpositive predictive values (up to 95%) to match the accuracyof the anatomical studies (Rozen et al., in press-c).Tregaskiss et al. also briefly mention the potential use ofMRA for preoperative imaging of these blood vessels, butacknowledge the lack of research in this area. Of note, wehave performed clinical studies of MRA for mapping theabdominal wall vasculature prior to breast reconstructionflaps, and have had good preliminary results (Rozen et al.,in press-d). As demonstrated in Figure 4, contrast-enhanced vessels are able to be clearly identified within thesurrounding soft tissues, but are not characterized with thesame resolution of CTA.The study by Tregaskiss et al. is an important study ofthe utilization of advancing imaging technologies in basicanatomical research, and will certainly form the foundationfor clinical application in the field of reconstructive surgery.Although this type of anatomic cadaveric study does notnecessarily reflect the accuracy of CTA in clinical settings,our studies certainly complement this work in delineatingthe clinical role for CTA in preoperative localization of themusculocutaneous perforating vessels of the abdominalwall for planning reconstructive surgery with the abdominalwall integument.

Background: Despite the widespread use of autologous fat grafting in both reconstructive and cosmetic surgery, volume retention remains a significant problem. We aimed to critically appraise the current body of literature in fat grafting to provide a framework to guide application and comparison. Method: Search of scientific databases and gray literature was conducted. Articles examining nonadipogenic applications of adipose tissue and those specific to breast reconstruction were excluded. Results: One hundred three articles were included. These fell under the headings of donor site, effect of infiltration solution, harvest method, effect of centrifugation, reinjection method, supplementation, the role of adipose-derived stem cells, and scaffolding. Conclusions: Despite the significant research effort in this field, there remains no consensus as to the optimum technique. This stems from the vast array of research methods and short follow-up durations. Further, extrapolation of in vitro results to clinical settings has led to many conflicting practices.

Cadaveric studies have revealed that cutaneous perforators are linked by either reduced-caliber "choke" arteries, or by vessels without change in caliber, the true anastomoses. These true anastomotic vessels are often found in parallel with the cutaneous nerves and accompanying veins, and are associated both experimentally and clinically with larger areas of flap survival. The Doppler probe and computed tomographic angiography are already used preoperatively to determine perforator locations but currently cannot reveal the type of anastomotic connections.Thermal images were taken in a previously described fashion and compared with both computed tomographic angiographic studies where available and with cadaveric angiographic studies previously performed by the authors' laboratory.Perforators larger than 1 mm were accurately localized by thermography when compared with computed tomographic angiography. Perforator angiosome rewarming closely approximated a log-based line of best fit. Interperforator zones were variable in their rewarming and correlated with known anatomical patterns of true and choke anastomoses between perforator angiosomes.Thermography now offers a new modality with which to bridge the gap not only by identifying the perforator "hot spots" but also by the robustness of their interconnections. The pattern of these interconnections seen on thermographic imaging has in turn been found to match those seen in the authors' cadaveric studies.

Reports of more than two cutaneous perforator angiosome territories being raised successfully in distally based sural flaps are appearing in the literature. Previous anatomical studies have noted that cutaneous arteries, connected by true anastomosis without change in caliber, frequently parallel cutaneous nerves.Twenty-four (48 sides) total body lead oxide cadaver injection studies, including seven arterial and two venous neurovascular, were examined, and the results were compared with clinical thermography in Part II.Long branches of cutaneous perforators, connected in a series by true anastomoses, paralleled at variable distances the main trunks of cutaneous nerves in the head, neck, torso, and upper and lower extremities. Specifically, in the leg, an average of 3.2 true anastomoses (range, 1 to 5) connected perforators that paralleled the sural nerve on the back of the calf; and 2.5 (range, 1 to 4) connected perforators on the medial side of the leg. These vascular freeways were paralleled by the short and long saphenous veins, respectively.True anastomoses frequently connect skin perforators that course in parallel with cutaneous nerves and veins. They provide an explanation for the long viable flaps noted in the leg, and it will be shown in Part II that they can be detected preoperatively with thermography.