title: Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars.
abstract: OBJECTIVE
  Subcostal scars pose a risk of upper abdominal flap ischaemia when raising a free abdominal flap. The aim of this study was to describe a clinical approach to increase flap reliability and donor site healing in the presence of transverse abdominal scars while harvesting lower abdominal free flaps.
  
  
  METHODS
  A total of 11 patients who had subcostal scars and one who had an extended subcostal scar (rooftop or chevron incision) underwent free abdominal flaps for breast reconstruction. Preoperative radiological imaging was used to evaluate the blood supply to the planned flaps. A classification of clinical approaches (I-IV) was used. When the cranial (the abdominal closure) flap width was equal to or greater than half length, a caudal (the breast) flap could safely be harvested (Type I); if not, the cranial flap was enlarged by more caudal flap planning (Type II), an oblique design of the free flap (Type III) or by lowering the free flap marking more distally (Type IV) with a sparing of the peri-umbilical perforators to preserve blood supply to the caudal (abdominal closure) flap.
  
  
  RESULTS
  Unilateral free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps were successfully harvested in eight and two cases, respectively. In two cases, a bipedicled DIEP/SIEA flap was harvested for unilateral breast reconstruction. Slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in flaps or at donor sites.
  
  
  CONCLUSIONS
  Using a pragmatic approach to flap design, based on clinical classification, we have found that both flap and donor site morbidity can be avoided in patients who have previous upper abdominal scars.
  
  
  METHODS
  IV, Therapeutic.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium. Electronic address: moustapha.hamdi@uzbrussel.be.
authors.forename: Moustapha
authors.initials: M
authors.lastname: Hamdi
authors.affiliation: Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium.
authors.forename: Mikko
authors.initials: M
authors.lastname: Larsen
authors.affiliation: Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium.
authors.forename: Barbara
authors.initials: B
authors.lastname: Craggs
authors.affiliation: Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium.
authors.forename: Bert
authors.initials: B
authors.lastname: Vanmierlo
authors.affiliation: Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel (VUB), Brussels, Belgium.
authors.forename: Assaf
authors.initials: A
authors.lastname: Zeltzer
mesh_terms: D000005:Abdomen / Q000601:surgery*; D002921:Cicatrix / Q000150:complications*; D019074:Epigastric Arteries; D005260:Female; D006801:Humans; D016462:Mammaplasty; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply* / Q000601:surgery*; D012189:Retrospective Studies; D020858:Tissue and Organ Harvesting / Q000379:methods*; D060053:Transplant Donor Site / Q000502:physiology; D014945:Wound Healing
keywords: Breast reconstruction; Chevron; Complication; DIEP flap; Donor site; SIEA flap; Scar; Subcostal Scar