Avoiding Denervation of Rectus Abdominis in DIEP Flap Harvest: The Importance of Medial Row Perforators

Rozen, Warren M.; Ashton, Mark W.; Murray, Alice; Taylor, G. Ian

doi:10.1097/prs.0b013e318180ed8b

Cited by 92 publications

(56 citation statements)

References 39 publications

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“…19,20 We used medial perforators for all our patients because studies have indicated that medial row perforators provide a wider area of perfusion than do lateral row perforators 21 and that their use helps avoid denervation of the rectus abdominus muscle. 22 As expected, marked contralateral venous congestion was the most common intraoperative finding with the clamp test. Attention was given to prevent flap hypothermia or physical stress to the perforator, and time was allowed for vascular equilibration.…”

Section: Discussionmentioning

confidence: 72%

Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

Christiano

Rosson

2010

Microsurgery

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Section: Discussionmentioning

confidence: 72%

Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

Christiano

Rosson

2010

Microsurgery

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“…In fact, elevation of perforator flaps always requires meticulous dissection of the myocutaneous perforator(s) through the underlying muscle. Recent anatomical studies on cadavers indicate that use of the medial row of perforators reduce the potential risks of muscle denervation [22]. Motor nerve fibers run from lateral to medial beneath the muscle belly, so that harvesting DIEAP-ra based on lateral row perforators can expose the patient to muscle denervation and abdominal wall weakness.…”

Section: Discussionmentioning

confidence: 99%

Deep inferior epigastric artery perforated rectus abdominis free flap for head and neck reconstruction

Cappiello

Piazza

Taglietti

et al. 2011

Eur Arch Otorhinolaryngol

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The deep inferior epigastric artery perforated rectus abdominis (DIEAP-ra) free flap is a modification of the classic myocutaneous DIEA free flap in which only fasciocutaneous tissue is harvested based on the paraumbilical perforators of the medial row. The aim of this retrospective study is to describe our experience with this reconstructive technique in head and neck surgery. Between 2004 and 2009, 24 patients affected by oncologic maxillofacial, skull base, oral, and oropharyngeal defects were submitted to reconstruction with DIEAP-ra. After harvesting the DIEAP-ra, the longitudinally split muscular belly was sutured and the anterior rectus sheath closed with a nonabsorbable mattress suture without inlay mesh interposition. Surgical defects encompassed half of the hard palate in ten patients, orbit and part of the cranial vault in one, radical extended parotidectomy in four, subtotal glossectomy in seven, and total glossectomy in two cases. The only complete flap necrosis (4%) developed as a consequence of an orocutaneous fistula and required a second latissimus dorsi free flap. Another case (4%) developed a partial necrosis for oropharyngeal fistula after total glossectomy that healed after transposition of a pedicled myofascial pectoralis major. Two patients (8%) presented a minor salivary fistula that healed by medication alone. No major complication of the donor site was observed. DIEAP-ra is a valid alternative to the DIEA free flap when applied to complex maxillofacial or tongue major defects. Its greatest advantages are the reduced donor site morbidity and a more adjustable thickness of the skin paddle, particularly in females and obese patients.

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“…The anatomic basis of using medial perforators for this reason has already been established in the literature. 9 Thus within the spectrum of DIEP harvest, donor site dissection has been minimized (only to be surpassed by SIEA flap harvest). This has resulted in improved confidence in bilateral cases, and reduction in fatigue, which better allows the surgeon to be creative during fabrication of the breast mound(s).…”

Section: Discussionmentioning

confidence: 99%

“…Similar dissections were then performed on the left side (Figs. 8,9). Figure 10 shows the vector of the right pedicle extraction, with the left side discontinuous incisions already repaired, and Figure 11 with both sides repaired.…”

Section: Example 2: Bilateral Diepmentioning

confidence: 98%

Improving Surgeon Confidence in the DIEP Flap

Feingold

2009

Annals of Plastic Surgery

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Criticisms of the DIEP (deep inferior epigastric perforator) flap include difficulties in perforator identification and dissection and prolonged operative times. Likewise, the stress level in such harvests varies considerably, particularly in bilateral breast reconstruction where 2 successful flap harvests are mandatory. Various operative strategies were explored in 100s of DIEP flaps to refine the DIEP harvest from a safety, expediency, and musculofascial preservation perspective, both for total mastectomy and partial mastectomy applications. Ultimately, a strategy based on the antegrade pedicle dissection technique, usually with a single perforator harvest and discontinuous fascial incisions, has lead to a safer, more expeditious and minimally invasive DIEP flap harvest that is applicable in many cases. Flap harvest time is now generally on the order of one hour with significantly less stress and minimized fascial incisions. DIEP free flap harvest can be managed with greater confidence, reduced operative times and less muscle, and fascial invasion using the specific operative strategy of the antegrade pedicle dissection technique.

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Avoiding Denervation of Rectus Abdominis in DIEP Flap Harvest: The Importance of Medial Row Perforators

Cited by 92 publications

References 39 publications

Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

Deep inferior epigastric artery perforated rectus abdominis free flap for head and neck reconstruction

Improving Surgeon Confidence in the DIEP Flap

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