Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is currently viewed as the gold standard in autologous breast reconstruction. We studied three-dimensional computed tomography angiography (CTA) in 145 patients undergoing free abdominal flap breast reconstruction to try to correlate deep inferior epigastric artery (DIEA) branching pattern with the type of flap performed and patient outcome. Today, reconstructive breast surgeons have become more experienced in raising DIEP flaps and operative times are becoming more acceptable. However, there remains significant interest in finding ways to aid this challenging dissection.

METHODS

We retrospectively evaluated consecutive patients between January 2007 and August 2008. CTAs were analysed using the Moon and Taylor (1988) classification of the DIEA branching pattern. Data gathered included pre-operative morbidity, type of abdominal wall free flap performed, length of operation, length of stay and complications.

RESULTS

Some 150 breast reconstructions were performed in 145 patients. There were 67 DIEP flaps, 69 MS-2 transverse rectus abdominis myocutaneous (TRAM) flaps and 14 MS-1 TRAM flaps (where MS-1 spares the lateral muscle and MS-2 spares both lateral and medial segments). Proportionally more DIEP flaps were performed in patients with a type 2 branching pattern. There was one flap loss (0.67%).

CONCLUSIONS

In this large CTA series, we found a type 1 (single artery) DIEA pattern most frequently, in contrast to the predominance of the type 2 bifurcating pattern observed previously. The higher proportion of DIEP flaps performed in the type 2 pattern patients is consistent with the documented shorter intramuscular course in this group. We have found CTA useful for faster selection of the best hemiabdomen for dissection and flap loss rates in our unit have reduced from 1.5% to 0.67%.     

Groupe pour L��Avancement de la Microchirurgie Canada (GAM): Abstracts presented at the 29th Annual Meeting / 29e R��union annuelle June 25, 2008

PURPOSE: To maximize the benefits of deep inferior epigastric perforator flaps (DIEP) flaps, they should be based on one or two perforators. Harvesting large volumes of tissue on a limited number of perforators occasionally results in flaps with inadequate venous drainage. We routinely use the superficial inferior epigastric vein (SIEV) as a “bail out” for this situation.     

Breast reconstruction with deep inferior epigastric perforator flaps

INTRODUCTION

Approximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway.

METHODS

A retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010.

RESULTS

Overall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28–70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%).

CONCLUSIONS

DIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.     

The basilic vein: an alternative drainage of DIEP flap in severe venous congestion

The deep inferior epigastric perforator (DIEP) flap has become a major advance in autologous breast reconstruction, offering all the advantages of free TRAM flap with less donor-site morbidity and postoperative pain. The major drawback threatening the DIEP flap procedure is venous congestion, with potential partial or complete flap loss. Many authors reported different surgical tips aiming to solve this setback, including secondary anastomosis of deep inferior superficial epigastric vein with alternative venous outflow vessels. We present a case report of a DIEP flap salvaged by an alternative venous anastomosis, after comitant veins of the primary anastomosis widely thrombosed a few hours postoperatively. A venous bypass using ipsilateral basilica vein and superficial inferior epigastric vein was fashioned.     

A case of intraoperative venous congestion of the entire DIEP-flap--a novel salvage technique and review of the literature

The deep inferior epigastric perforator (DIEP) flap is gaining popularity for autologous breast reconstruction as it reportedly reduces abdominal donor site morbidity when compared with the transverse rectus abdominis musculocutaneous (TRAM) flap. Disadvantages include greater technical difficulties during flap harvest and a greater incidence of vascular compromise. A well-known and feared complication is venous congestion which requires immediate intervention. We present a novel salvage technique in a case of total flap venous congestion in the setting of absent drainage via the deep inferior epigastric vein (DIEV). Utilizing the superficial venous system via the superficial inferior epigastric vein (SIEV) and using the DIEV as a venous interposition graft resulted in successful salvage of the DIEP flap.     

Easy venous superdrainage in DIEP flap breast reconstruction through the intercostal branch

The deep inferior epigastric perforator (DIEP) flap has been shown to be a valid option for breast reconstruction, as it has certain advantages over the free TRAM flap, including lower morbidity in the donor area, conservation of abdominal wall function, and reduced postoperative pain. However, some cases of venous congestion in using the DIEP flap have been described. The authors present a case in which the venous return in a DIEP flap objectively (by measurement with a flux meter) presented a marked improvement (from 4 ml/min to 13.9 ml/min) after venous drainage was increased by means of the supplementary anastomosis of a comitant vein from the deep inferior epigastric pedicle to the intercostal branch of the internal mammary vein. The preservation of this branch is a simple and effective technique to improve the venous drainage of DIEP flaps, whether signs of congestion are present or not.     

Venous drainage system of the transverse rectus abdominis musculocutaneous flap

The transverse rectus abdominis musculocutaneous (TRAM) flap has been widely used for reconstruction of the breast. Partial loss of the flap is still a problem, however, and venous congestion may cause partial necrosis of the flap. There are few studies of the venous anatomy of the TRAM flap that compares with that of the arterial system, so the aim of this study was to investigate the venous anatomy of the TRAM flap and assess its drainage pathway using venography. A mixture of barium and gelatin were injected through the cutaneous veins such as the superficial inferior epigastric vein (SIEV), the superficial circumflex iliac vein (SCIV), or the perforating branch of the deep inferior epigastric vein (DIEV) in 11 hemiTRAM flaps. Venograms of TRAM flaps were taken, and the venous anatomy evaluated. The study showed that it consisted of the dominant superficial venous system, the SIEV and SCIV, and the secondary deep venous system, and the perforating vein of DIEV (DIEV perforator). In addition, we saw the large communicating veins between the SIEV and DIEV perforator near the umbilicus. We think that these communicating veins, which are considered as the DIEV perforators between the superficial and deep venous system, are an important venous drainage pathway after the TRAM flap has been raised.     

Ten years’ experience of free flaps for breast reconstruction in a Danish microsurgical centre: An audit

We have done a total of 292 breast reconstructions using a free flap over a period of 10 years (1994–2003). During the last five years the number of deep inferior epigastric perforator (DIEP) flaps has increased. However, to secure an optimal blood supply we still use a muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap sometimes. Our results with the two flaps were identical as far as operating time and length of hospital stay were concerned, but the DIEP flap has less donor site morbidity. Our results are influenced by our selection of patients and our technique but we think that muscle-sparing TRAM flaps may be used as an alternative to DIEP flaps.     

Scars and perforator-based flaps in the abdominal region: A contraindication?

Background

Although multiple strategies for autologous breast reconstruction exist, a vertical midline scar in the abdominal wall as a result of previous laparatomy or abdominoplasty represents a major surgical challenge. To date, little research has been conducted on the regeneration potential of the abdominal wall’s superficial vascular, perforator and choke vessel system after surgery using a vertical approache.

Methods

We present the cases of 8 patients, of whom 7 underwent autologous breast reconstruction. One patient received a thigh reconstruction. All patients had a vertical abdominal midline scar as a result of a previous surgical intervention. In 3 of the 7 patients, the breast was reconstructed using an MS-2-vertical rectus abdominis myocutaneous (VRAM) free flap. In 4 of these patients, an MS-2-transverse rectus abdominis myocutaneous (TRAM) free flap was performed. The thigh reconstruction used a transverse deep inferior epigastric perforator (DIEP) free flap. Clinical follow-up was done 12 months after operation.

Results

All 3 patients who received an MS-2-VRAM had good aesthetic results. Vertical midline scars had no negative effect on surgical outcomes, perfusion and tissue viability of the 4 MS-2-TRAM and transverse DIEP free flaps.

Conclusion

These clinical findings indicate that the regeneration potential of the abdominal wall’s superficial vascular system in the presence of vertical surgical scars has been greatly underestimated. Use of MS-2-VRAM free flaps in patients with vertical abdominal scars seems to be a suitable and successful alternative in the reconstruction algorithm.Autologous breast reconstruction following a mastectomy still represents a major challenge for reconstructive surgeons.^1,2 At present, surgeons may choose from a multitude of available method to determine the most favourable surgical approach.^3–11 Every method has its own particular indication, benefits and disadvantages, and the optimal one should be specifically tailored to each patient’s individual needs. Thus, the preoperative plan for breast reconstruction should be made with great care and in close communication with the patient.¹² Hartrampf and colleagues⁸ described the transverse rectus abdominis myocutaneous (TRAM) free flap and thereby set a keystone for surgical possibilities in autologous breast reconstruction. Advances in the field of microsurgical perforator flap surgery have made the use of autologous tissue for breast reconstruction a preferred concept.In this context, the transverse deep inferior epigastric perforator (DIEP) flap or the MS-2-TRAM with a small part of the rectus abdominis muscle are ideal flaps suitable for autologous breast reconstruction.^13–16 Reasons for the popularity of the DIEP or MS-2-TRAM flaps include the availability of a large amount of tissue for the reconstruction of large breasts, an aesthetically pleasing donor-site scar and a reliable vascular anatomy, as described by Allen.^5,6 However, these particular kinds of perforator-based flaps are usually only indicated when the abdominal wall is fully intact. Scars and lesions from previous surgical procedures, such as laparotomy or abdominoplasty, represent a contraindication to such flaps. In particular, a vertical scar in the midline of the abdominal wall may cause major postoperative complications. Necrosis of the distal part of the flap may occur because of poor midline crossover blood flow into zones 2 and 4, which are located distal to the horizontal midline scar (Fig. 1).^17–19Open in a separate windowFig. 1Position of perfusion zones 1 to 4 according to the midline vertical scar in a left-sided transverse deep inferior epigastric perforator flap.Patients with a small breast volume on the healthy side usually only require a small tissue volume for reconstruction. As a result, a 1-side transverse DIEP or MS-2-TRAM free flap, which includes only zones 1 and 3, may be favourable and possible. In cases of bilateral breast reconstruction, these techniques are also used.When large amounts of tissue are required for reconstruction, other surgical concepts have to be used. In these cases, surgeons may use a vertical DIEP or an MS-2-vertical rectus abdominis myocutaneous (VRAM) free flap. In contrast to the transverse DIEP flaps, the vertical DIEP or MS-2-VRAM flaps have only 2 zones of perfusion (Fig. 2).²⁰ To date, vertical DIEP and MS-2-VRAM flaps have not been well described in the literature, but they seem to be suitable and successful alternatives and should be included in surgeons’ reconstruction algorithms.Open in a separate windowFig. 2In contrast to the transverse deep inferior epigastric perforator (DIEP) flap, the vertical DIEP flap has only 2 zones of perfusion, as described by Dinner and colleagues.²⁰Few research data are available about the regeneration potential of the abdominal wall’s superficial vascular, perforator and choke vessel system in the presence of vertical scarring. In addition, the delay phenomenon has been described solely for local flaps.^21,22 So far, it has been believed that a vertical abdominal scar represents a contraindication for the use of a transverse DIEP or MS-2-TRAM free flap when reconstructive tissue located distally from the scar is needed. In this context the “delay phenomenon” for angiosomes, as described by Taylor and colleagues,²³ needs to be discussed. It may also be relevant to the regeneration potential of perforator vessels, choke vessels and the subdermal vascular plexus in the presence of vertical abdominal scarring. A new understanding of these mechanisms may lead to the prudent use of flap tissue distal to a scar.     

Aesthetical outcome after breast reconstruction using deep inferior epigastric perforator flap: Personal techniques

Background:

Now-a-days, deep inferior epigastric perforator (DIEP) flap breast reconstruction is widespread throughout the world. The aesthetical result is very important in breast reconstruction and its improvement is mandatory for plastic surgeons.

Materials and Methods:

The most frequent problems, we have observed in breast reconstruction with DIEP flap are breast asymmetry in terms of volume and shape, the bulkiness of the inferior lateral quadrant of the new breast, the loss of volume of the upper pole and the lack of projection of the inferior pole. We proposed our personal techniques to improve the aesthetical result in DIEP flap breast reconstruction. Our experience consists of more than 220 DIEP flap breast reconstructions. Results: The methods mentioned for improving the aesthetics of the reconstructed breast reported good results in all cases.

Conclusion:

The aim of our work is to describe our personal techniques in order to correct the mentioned problems and improve the final aesthetical outcome in DIEP flap breast reconstruction.KEY WORDS: Aesthetic refinements, breast reconstruction, deep inferior epigastric perforator flap     

Why do free flap vessels thrombose? Lessons learned from implantable Doppler monitoring

BACKGROUND:

Before implantable venous Doppler monitoring, by the time the failing flap was explored, thrombosis had often occurred and therefore the cause of flap flow cessation was often difficult to determine. The Doppler allowed the detection of flow cessation in failing flaps before thrombosis occurred in every case since the authors started using it in 1999.

OBJECTIVES:

To review the authors’ experiences with the implantable venous Doppler.

METHODS:

The authors reviewed 43 free flaps in 40 consecutive patients (1999 to 2002) in which the implantable venous Doppler was used. All cases were performed at the Saint John Regional Hospital, Saint John, New Brunswick, by the senior author. Data were collected from the hospital and office charts.

RESULTS:

The Doppler detected inadequate blood flow in nine free flaps. In five of the cases, the cause was a kink in the vein. Repositioning the vein to get rid of the kink salvaged all five flaps. In the sixth case, compression of the vein after insetting was detected and successfully corrected. Flow cessation in the seventh case was attributable to arterial vasospasm, which was also salvaged. In the last two cases, the cause was low flow in the flap from the time the vessel clamps were let go. In spite of patent anastomoses, these two flaps were lost because there was not enough flow to sustain them.

CONCLUSION:

The implantable venous Doppler has allowed intraoperative detection of free flap vessel flow cessation, identification of the reasons for, and the correction of these prethrombotic states.     

Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps

ObjectivesThe transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies.Materials and methodsA literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate.ResultsEleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge..ConclusionAlthough pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors..     

DIEP flap salvage by cannula venesection of the superficial inferior epigastric vein

The deep inferior epigastric perforator (DIEP) flap is a technique of autologous breast reconstruction that is gaining popularity. The main advantage of the DIEP flap over the traditional transverse rectus abdominis myocutaneous (TRAM) flap is that there is a lower incidence of abdominal wall donor-site morbidity with the DIEP flap. However, venous congestion is the most dreaded complication of DIEP flap surgery which requires prompt intervention. In this case report, we present a simple but effective procedure to salvage the congested DIEP flap. A 55-year-old female underwent left breast reconstruction with DIEP flap and developed venous congestion during surgery. Cannula venesection of the superficial inferior epigastric vein (SIEV) was performed intraoperatively followed by intermittent aspiration of blood for 3 days. A satisfactory aesthetic result was achieved with no evidence of fat necrosis. This procedure eliminated the need for performing an additional microvascular anastomosis, required less operative time, and allowed augmentation of the venous drainage of the congested flap.Level of Evidence: Level V, therapeutic study.     

Venous augmentation of the free TRAM flap.

Venous congestion in a free TRAM or DIEP flap when the main pedicle is still patent (both the artery and the vein) is an occasional dire situation. Here, we describe ways of salvaging the free TRAM or DIEP flap from imminent loss. In the last 4 years, we have had three patients who developed venous congestion after the use of the TRAM or DIEP flap for breast reconstruction. This was detected as late as the third postoperative day in our first patient. On exploration, patent arterial and venous anastomoses were found. Fortunately, the opposite pedicle had been dissected and preserved with the flap. The patent congested vein in this pedicle was anastomosed to the cephalic vein using an interpositional vein graft, relieving the congestion. In the other two patients congestion was detected earlier and relieved using the superficial inferior epigastric vein. It has been our policy to dissect a length of the opposite pedicle and/or preserve a length of the superficial inferior epigastric vein or the superficial circumflex iliac vein. These can then be used to augment venous drainage if inadequacy is noted at the end of the operation or during the postoperative period.     

The efficacy of preoperative vascular mapping by MDCTA in selecting flap in abdominal flap breast reconstruction

Current methods of breast reconstruction using abdominal tissue include the transverse abdominal myocutaneous (TRAM) flap, deep inferior epigastric arterial perforator (DIEP) flap, superficial inferior epigastric arterial (SIEA) flap, and some other composite flaps. Because of the variant vascular anatomy in abdominal region, it is hard to choose an appropriate flap for a specific patient without accurate preoperative vascular mapping. This study was drawn to address the efficacy of preoperative vascular mapping by multidetector-row computed tomographic angiography (MDCTA) in selecting flap in abdominal flap breast reconstruction. A total of 34 breast reconstructions using abdominal flap from December 2006 to July 2009 were included. In all the patients included, MDCTA was performed preoperatively. Three indexes were obtained including choice of flaps, operation time, and flap complication rate. Then, these data were compared with the former data stored in the databank of our hospital from January 2004 to December 2006, before MDCTA was introduced in our center. Among the 34 patients, the flap selection was: SIEA flaps 11.8%, DIEP flaps 61.8%, TRAM flaps 11.8%, and bilateral flaps 14.7%. The correlate indexes from the data bank were as follows: SIEA flap 0; DIEP flaps 51.7%; TRAM flaps 32.8%; bilateral flaps 15.5%. p < 0.05 occurred between the comparison of SIEA, DIEP, and TRAM flap choice in the two groups. The operation time in the study group was as follows: SIEA flap (4.02 ± 0.46) hours, DIEP flap (6.23 ± 1.42) hours, TRAM flap (4.72 ± 1.53) hours, Bilateral flap (7.86 ± 1.16) hours; while the former correlate data were: DIEP (9.67 ± 1.74) hours, TRAM flap (6.64 ± 1.83) hours, bilateral flap (11.83 ± 1.35) (all the three comparison p < 0.05). The total flap complication rate was about 5.9% in the test group; while in the databank, it was 12.1% (p < 0.05). With the accurate mapping of vascular territory in abdomen by MDCTA, we could easily select a suitable abdominal flap for breast reconstruction, and we can also simplify the procedure to save operation time and make the process more safely.     

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation.MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline.ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively.ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.     

A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in postmastectomy reconstruction: A cost-effectiveness analysis

PURPOSE:

To perform a cost-effectiveness analysis comparing the superficial inferior epigastric artery (SIEA) and deep inferior epigastric perforator (DIEP) flaps in postmastectomy reconstruction.

METHODS:

A decision analytic model with seven clinically important health outcomes (health states) was used, incorporating the Ontario Ministry of Health’s perspective. Direct medical costs were estimated from a university-based hospital. The utilities of each health state converted into quality-adjusted life years (QALYs) were obtained from previously published data. Health state probabilities were computed from a systematic literature review. Analyses yielded SIEA and DIEP expected costs and QALYs allowing calculation of the incremental cost-utility ratio (ICUR). One-way sensitivity analyses were conducted under five plausible scenarios, assessing result robustness.

RESULTS:

Five SIEA and 27 DIEP studies were identified. The baseline SIEA expected cost was slightly higher than that for the DIEP ($16,107 versus $16,095), with slightly higher QALYs (33.14 years versus 32.98 years), giving an ICUR of $77/QALY. Taking into account conversions from SIEA to DIEP, the ICUR increased to $4,480/QALY. Sensitivity analysis gave ICURs ranging from $2,614/QALY to ‘dominant’, all consistent with the adoption of the SIEA over the DIEP.

CONCLUSION:

The best available evidence suggests the SIEA is a cost-effective procedure. However, given the high SIEA to DIEP conversion rates and small marginal differences in cost and effectiveness, the ICUR may be sensitive to minor changes in costs or QALYs. The ‘truth’ can only be obtained from a randomized, controlled trial comparing both techniques side by side, simultaneously capturing the costs of the competing interventions.     

Duplex ultrasound imaging in free transverse rectus abdominis muscle, deep inferior epigastric artery perforator, and superior gluteal artery perforator flaps: early and long-term comparison of perfusion changes in free flaps following breast reconstruction

OBJECTIVE: Our objective was to assess the hemodynamic differences in free DIEP (deep inferior epigastric artery perforator flap), S-GAP (superior gluteal artery perforator flap) flaps versus TRAM (transverse rectus abdominis muscle) flaps and to analyze any perfusion change due to perforator dissection (study 1). To examine the hypothesis as to whether flap perfusion is maintained through the pedicle (study 2), we also compared short- and long-term DIEP flap perfusion. MATERIAL AND METHODS: Blood volume flow, velocity, and diameter of the donor and recipient vessels of 4 TRAM flaps, 5 S-GAP flaps, and 17 DIEP flaps were examined preoperatively on day 5 and also 18 months postoperatively using duplex ultrasound. RESULTS: The greatest volume flow and velocity are measured in the TRAM flaps, followed by S-GAP and DIEP flaps. Blood flow in the musculocutaneous and perforator flaps is twice as great as in the donor vessels, which is proof of flap hyperperfusion. SUMMARY: The minimum perfusion requirement is easily satisfied in musculocutaneus and free perforator flaps. In the long term, DIEP flap perfusion increases 13%, which assumes that DIEP flap perfusion is maintained on the pedicle.     

Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis

The deep inferior epigastric perforator flap (DIEP) is an increasingly popular method for autologous breast reconstruction because of less abdominal wall donor-site morbidity. However, disadvantages with the DIEP flap are its greater technical difficulties for flap harvest and a greater incidence of venous congestion. We report a case of salvage of a congested DIEP flap with a superficial inferior epigastric vein (SIEV) to deep inferior epigastric vein reverse flow anastomosis. Drainage of both the superficial and deep system resulted in complete reversal of venous congestion and flap salvage. Preservation and use of the SIEV for venous augmentation via a reverse flow anastomosis is a novel and simple method for DIEP flap salvage of venous congestion.     

腹壁下动脉穿支皮瓣在乳房再造和胸壁溃疡修复中的应用

目的　在解剖学研究基础上 ,对以腹壁下动静脉为蒂的横行腹直肌 (TRAM)肌皮瓣的切取进行完善和改进 ,将其精确为腹壁下动脉穿支 (DIEP)皮瓣 ,从而提供一种更为理想的乳腺癌术后乳房再造和胸壁创面修复的皮瓣。　方法切取DIEP皮瓣 ,移植至胸壁受区 ,腹壁下动静脉分别与胸廓内动静脉相吻合 ,用于乳腺癌术后乳房再造和胸壁放射性溃疡的修复。　结果　解剖学研究和临床观察发现自腹壁下动脉有粗大的肌皮穿支或皮支自血管主干发出 ,穿过腹直肌纤维直接进入皮瓣 ,因此 ,术中只剪开腹直肌前鞘 ,钝性分离腹壁下动静脉及其穿支周围的腹直肌纤维 ,无须离断腹直肌纤维 ,临床应用DIEP皮瓣再造乳房 4例 ,修复胸壁缺损 2例 ,皮瓣面积 (10cm× 12cm )～ (12cm× 35cm) ,全部成活 ,效果满意。　结论　DIEP皮瓣是对传统的TRAM皮瓣的一种技术改良 ,既保留了TRAM皮瓣血运丰富、组织量大、易于塑形的优点 ,尚可保持腹直肌的完整性 ,同期进行腹壁整形