Importance of Lateral Row Perforator Vessels in Deep Inferior Epigastric Perforator Flap Harvesting

Abstract

Free flaps based on perforator vessels, and in particular the deep inferior epigastric perforator (DIEP) flap, are currently being applied in abdominal reconstruction. However, one of the main disadvantages is the operative complexity. Through anatomical study and clinical experience with the DIEP flap in breast reconstruction, the intramuscular path of the perforator vessels was comparatively studied, to establish the main anatomical parameters that favor procedure planning. Thirty DIEP flaps from 15 fresh cadavers were used. The number, location, and intramuscular course of the perforator vessels were determined. In addition, an initial clinical study was performed in 31 patients using 35 DIEP flaps in breast reconstruction. The number, location, and the intramuscular course of the perforators were assessed. In the cadaver study, 191 perforator vessels were detected (6.4 vessels per flap). Thirty-four percent were located in the lateral row, and the rectilinear course was observed in 79.2 percent of these vessels. In the medial row, only 18.2 percent of the perforator vessels presented this configuration (p = 0.001). Thirty-one patients underwent DIEP flap breast reconstruction, with 26 immediate and four bilateral reconstructions. In 22 of 35 flaps (62.9 percent), two perforators were used. In 25 flaps (71.4 percent), the lateral row perforators with a rectilinear course were observed. Mean operative time was 7 hours and 37 minutes. Two total flap losses and two partial necroses were observed. The majority of the lateral row perforators presented a rectilinear intramuscular course, which was shorter than that of the medial row perforators. This anatomical characteristic favors dissection with reduced operative time and vascular lesion morbidity, resulting in an important anatomical parameter for DIEP flap harvesting.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

“…Thus, alternatively free tissue transfer including the deep inferior epigastric perforator (DIEP), pedicled thoracodorsal perforator flap (TAP), free TRAM or the gluteal artery perforator (GAP) flaps can be indicated with a lower donor site morbidity. In fact, the DIEP flap diverges from abdominal myocutaneous flaps with maintenance of well-vascularized tissue and total abdominal muscular and aponeurotic layer preservation [89][90][91][92][93][94] . Mosahebi et al [83] in a series of 61 NSM reconstructions compared alloplastic and autologous tissue in terms of aesthetic outcome and satisfaction survey.…”

“…Thus, a correct selection of a suitable recipient pedicle is decisive for a successful outcome [90,[92][93][94] . In NSM, the use of internal thoracic recipient vessels can be troublesome since the surgical exposure is restricted [8,95] .…”

“…The main advantages are sparing the internal mammary vessels and decreasing the operative time by limited dissection. However, Munhoz et al [92] reported that the internal thoracic branches are potentially available in only 55% of patients, therefore, this should not be the first option as recipient site.…”

Um longo debate: albumina versus soro fisiológico

“…Em geral, por serem vasos de pequeno calibre, demanda paciência e aprimoramento técnico por parte do cirurgião. Detalhes anatômicos na distribuição dos vasos perfurantes na região do abdome 4 , bem como a qualidade dos vasos receptores para a realização das anastomoses na região torácica 5 , são também aspectos relevantes na opção por esta modalidade de reconstrução. Estes fatos constituem uma desvantagem em relação aos tradicionais retalhos pediculados, prejudicando assim a reprodutibilidade destes procedimentos.…”

Estudo crítico da anatomia arterial do retalho vascularizado pela artéria perfurante muscular da artéria epigástrica inferior

“…A partir da década de 80 surgiram questionamentos em relação à ressecção do músculo reto do abdome e suas implicações na dinâmica da parede do abdome (BUNKIS et al, 1983;SCHEFLAN;DINNER, 1983;HARTRAMPF, 1984;HARTRAMPF;BENNETT, 1987;GROTING et al, 1989;SOEDA, 1989;LE JOUR;DOME, 1991;MARCHI, 1992;SCHUSTERMAN et al, 1992;ELLIOT et al, 1993;FELLER, 1994;MIZGALA et al, 1994;SUOMINEM et al, 1996;FERREIRA, 2000;MUNHOZ et al, 2002a;MUNHOZ et al, 2002b;CRAIGIE et al, 2003;MUNHOZ et al, 2003;MUNHOZ et al, 2004a;GILL et al, 2004 Dessa maneira, cria-se a possibilidade de transferência de regiões semelhantes de pele e de panículo adiposo correspondentes aos retalhos TRAM pediculado e microcirúrgico, sem as desvantagens inerentes à transferência muscular (KOSHIMA; SOEDA, 1989;KOSHIMA et al, 1992;TREECE, 1994;BLONDEEL et al, 1998;HAMDI et al, 1998;BLONDEEL et al, 1999;MUNHOZ et al, 2001;ISHIDA et al, 2002;VANDEVOORT et al, 2002;CRAIGIE et al, 2003;MUNHOZ et al, 2003;MUNHOZ et al, 2004a;GILL et al, 2004).…”