Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
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Deep Inferior Epigastric Perforators Topography for "Island Transverse Rectus Abdominis Musculocutaneous Flap" in Breast Reconstruction

  • Tae Hyun Kim (Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University Graduate School of Medicine) ;
  • Seong Heum Jeong (Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University Graduate School of Medicine) ;
  • Hee Chang Ahn (Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University Graduate School of Medicine)
  • Received : 2023.02.14
  • Accepted : 2023.05.10
  • Published : 2023.07.15
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Abstract

Background The Island transverse rectus abdominis musculocutaneous (TRAM) flap is well vascularized with very reliable blood flow, because all perforators of the zone I are included when it is harvested. The number of perforators, topographic mapping, and their relationship with reconstructed outcomes were investigated. Methods Fifty patients with Island TRAM breast reconstruction from September 2021 to August 2022 were investigated. The zone I was divided into a total of eight sections. Under the loupe magnification, all perforators larger than 0.5 mm in zone I were counted with fine dissection, and photographs were taken in background of vessel loops. Complications like flap necrosis, seroma, and hematoma were also investigated. Result There are 12 ideal perforators on average in zone I such as one perforator in section I, II, IV, V, VI, VIII, and three perforators in section III and VII. However, two perforators (M6 and L6) below arcuate line were sacrificed in the time of flap harvest to prevent hernia. Island TRAM included 10 perforators on average (5 perforators in each side) above arcuate line to be transferred to the recipient site. Only minor complications were identified. Conclusion The Island TRAM flap includes 10 perforators to get the vigorous blood flow. The periumbilical to upper medial perforators become more dominant in the perfusion of the flap after deep inferior epigastric artery division. Well preserved perforators will guarantee the satisfactory breast reconstruction with the least complication.

Keywords

Acknowledgement

We would like to thank Kim Jinyoung for the drawings of ►Fig. 1 and ►Fig. 4, and to Enago (www.enago.co.kr) for review and grammatical corrections of the manuscript.

References

  1. Buck DW II, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg 2009;124(04):1047-1054 https://doi.org/10.1097/PRS.0b013e3181b457b2
  2. Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7-year experience. Clin Plast Surg 1988;15(04):703-716 https://doi.org/10.1016/S0094-1298(20)31402-4
  3. Yoon JS, Oh J, Chung MS, Ahn HC. The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg 2020;73(06):1060-1067 https://doi.org/10.1016/j.bjps.2020.01.010
  4. Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006;117(03):737-746, discussion 747-750 https://doi.org/10.1097/01.prs.0000200062.97265.fb
  5. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006;117(06):1711-1719, discussion 1720-1721 https://doi.org/10.1097/01.prs.0000210679.77449.7d
  6. Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients. Ann Plast Surg 2009;63(04):378-382 https://doi.org/10.1097/SAP.0b013e3181951708
  7. Lie KH, Barker AS, Ashton MW. A classification system for partial and complete DIEP flap necrosis based on a review of 17,096 DIEP flaps in 693 articles including analysis of 152 total flap failures. Plast Reconstr Surg 2013;132(06):1401-1408 https://doi.org/10.1097/01.prs.0000434402.06564.bd
  8. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002;110(02):466-475, discussion 476-477 https://doi.org/10.1097/00006534-200208000-00015
  9. Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 2005;115(02):436-444, discussion 445-446 https://doi.org/10.1097/01.PRS.0000149535.34107.2D
  10. Nelson JA, Guo Y, Sonnad SS, et al. A comparison between DIEP and muscle-sparing free TRAM flaps in breast reconstruction: a single surgeon's recent experience. Plast Reconstr Surg 2010;126(05):1428-1435 https://doi.org/10.1097/PRS.0b013e3181ef8b20
  11. Rozen WM, Ashton MW, Taylor GI. Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery. Clin Anat 2008;21(02):89-98 https://doi.org/10.1002/ca.20585
  12. Schwitzer JA, Miller HC, Pusic AL, et al. Satisfaction following unilateral breast reconstruction: a comparison of pedicled TRAM and free abdominal flaps. Plast Reconstr Surg Glob Open 2015;3(08):e482
  13. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56(03):243-253 https://doi.org/10.1097/00006534-197509000-00001
  14. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73(01):1-16 https://doi.org/10.1097/00006534-198401000-00001
  15. Milloy FJ, Anson BJ, McAfee DK. The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 1960;110:293-302
  16. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82(05):815-832 https://doi.org/10.1097/00006534-198811000-00014
  17. El-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches. Plast Reconstr Surg 2002;109(02):539-543, discussion 544-547 https://doi.org/10.1097/00006534-200202000-00020
  18. Heitmann C, Felmerer G, Durmus C, Matejic B, Ingianni G. Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg 2000;53(03):205-208 https://doi.org/10.1054/bjps.1999.3257
  19. Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg 1993;91(05):853-863, discussion 864 https://doi.org/10.1097/00006534-199304001-00017
  20. Kikuchi N, Murakami G, Kashiwa H, Homma K, Sato TJ, Ogino T. Morphometrical study of the arterial perforators of the deep inferior epigastric perforator flap. Surg Radiol Anat 2001;23(06):375-381 https://doi.org/10.1007/s00276-001-0375-5
  21. Munhoz AM, Ishida LH, Sturtz GP, et al. Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting. Plast Reconstr Surg 2004;113(02):517-524 https://doi.org/10.1097/01.PRS.0000100812.37842.A8
  22. Ohjimi H, Era K, Fujita T, Tanaka T, Yabuuchi R. Analyzing the vascular architecture of the free TRAM flap using intraoperative ex vivo angiography. Plast Reconstr Surg 2005;116(01):106-113 https://doi.org/10.1097/01.PRS.0000169717.84221.D7
  23. Ohjimi H, Era K, Tanahashi S, Kawano K,Manabe T, NaitohM. Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps. Plast Reconstr Surg 2002;109(07):2247-2256 https://doi.org/10.1097/00006534-200206000-00013
  24. Rozen WM, Ashton MW, Pan WR, Taylor GI. Raising perforator flaps for breast reconstruction: the intramuscular anatomy of the deep inferior epigastric artery. Plast Reconstr Surg 2007;120(06):1443-1449 https://doi.org/10.1097/01.prs.0000282030.77894.bb
  25. Stokes RB, Whetzel TP, Sommerhaug E, Saunders CJ. Arterial vascular anatomy of the umbilicus. Plast Reconstr Surg 1998;102(03):761-764 https://doi.org/10.1097/00006534-199809010-00021
  26. Vandevoort M, Vranckx JJ, Fabre G. Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction. Plast Reconstr Surg 2002;109(06):1912-1918 https://doi.org/10.1097/00006534-200205000-00021
  27. Aubry S, Pauchot J, Kastler A, Laurent O, Tropet Y, Runge M. Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skeletal Radiol 2013;42(03):319-327 https://doi.org/10.1007/s00256-012-1461-y
  28. Leung R, Chae MP, Tobin V, Hunter-Smith DJ, Rozen WM. In-vivo quantitative mapping of the perforasomes of deep inferior epigastric artery perforators. Plast Reconstr Surg Glob Open 2018;6(10):e1960