The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results.
BACKGROUND
Successful outcomes with the deep inferior epigastric artery perforator (DIEP) flap are heavily dependent on identifying the largest perforators. The purpose of this study was to describe the vascular anatomy (location, size, zones of perfusion, and variations) of the single most dominant deep inferior epigastric artery perforator and to report a clinical series based on this flap.


METHODS
Eleven abdominal flaps were harvested from fresh adult cadavers, and measurements were combined with clinical measurements from 16 patients. Details such as perforator size, location, type, and zones of perfusion were documented for all flaps and clinical outcomes for all patients.


RESULTS
A total of 36 flaps were dissected with an average perforator location within a 3-cm radius of the umbilicus and an average perforator size greater than 1.8 mm. Computed tomographic scans of the cadaver abdominal flaps demonstrated consistent perfusion in zones I and II and half of zones III and IV. Clinical results showed partial flap necrosis in one patient and fat necrosis of less than 5 percent in three patients, all of which occurred in the distal portion of zone III. The deep inferior epigastric artery medial row perforators near the umbilicus were found to be the largest perforators in the entire deep inferior epigastric artery system and abdomen.


CONCLUSIONS
The single dominant medial row perforator has a maximal vascularity in zones I and II, and less in zones III an IV. The authors recommend that half of zone III and all of zone IV be discarded to avoid the risks of partial flap loss and fat necrosis.
Bailey
Steven H
SH
Dallas, Texas From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.
Saint-Cyr
Michel
M
Wong
Corrine
C
Mojallal
Ali
A
Zhang
Kathy
K
Ouyang
Da
D
Arbique
Gary
G
Trussler
Andrew
A
Rohrich
Rod J
RJ
D000328:Adult; D002102:Cadaver; D019074:Epigastric Arteries; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008875:Middle Aged; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply*
Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–38.
Koshima I, Moriguchi T, Fukuda H, Yoshikawa Y, Soeda S. Free, thinned, paraumbilical perforator-based flaps. J Reconstr Microsurg. 1991;7:313–316.
Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N. Free thin paraumbilical perforator-based flaps. Ann Plast Surg. 1992;29:12–17.
Koshima I, Inagawa K, Urushibara K, Moriguchi T. Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg. 1998;102:1052–1057.
Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plast Reconstr Surg. 2000;106:61–65.
Lin ZH. Clinical application of a paraumbilical axial flap: Report of 16 cases (in Chinese). Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 1989;5:249–250, 315.
Wong C, Saint-Cyr M, Arbique G, et al. Three and four-dimensional computer tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124:18–27.
Tan BK, Ng RT, Tay NS, Tan BS. Tissue microangiography using a simplified barium sulphate cadaver injection technique. Ann Acad Med Singapore 1999;28:152–154.
Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg. 1997;50:322–330.
Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg. 1999;52:104–111.
Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg. 2000;53:578–583.
Hamdi M, Weiler-Mithoff EM, Webster MH. Deep inferior epigastric perforator flap in breast reconstruction: Experience with the first 50 flaps. Plast Reconstr Surg. 1999;103:86–95.
Kroll SS, Sharma S, Koutz C, et al. Postoperative morphine requirements of free TRAM and DIEP flaps. Plast Reconstr Surg. 2001;107:338–341.
Schaverien M, Saint-Cyr M, Arbique G, Brown SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg. 2008;121:1909–1919.
Rozen WM, Ashton MW, Murray AC, Taylor GI. Avoiding denervation of rectus abdominis in DIEP flap harvest: The importance of medial row perforators. Plast Reconstr Surg. 2008;122:710–716.