Abstract
Autologous breast reconstruction can often provide a more aesthetic outcome than other options for breast reconstruction because breast volume and shape can be extensively modified based on individual need, the texture of the reconstructed breast is a closer match to the native breast, and complications such as capsular contracture are avoided. However, with these benefits come the potential for complications unique to autologous tissue transfer. While overall complications are low, there are ways to maximize operative success and minimize the risk of complications. Deep inferior epigastric artery perforator (DIEP) flaps, the current mainstay in choice of autologous reconstruction, provide generally good outcomes. However, improvements in outcomes can still be achieved with a better understanding of individual anatomy. Perforator size, location, intramuscular and subcutaneous course, and association with motor nerves are all factors that can significantly affect operative technique, length of operation, and operative outcomes. With significant variation between individuals, preoperative imaging has become an essential element of DIEP flap surgery. Computed tomography angiography (CTA) is currently the gold standard but evolving techniques such as magnetic resonance angiography (MRA) and image-guided stereotaxy are rapidly contributing to improved outcomes.
Similar content being viewed by others
References
Allen RJ, Treece P (1994) Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32(1):32–38
Blondeel N, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, Tonnard P, Lysens R, Boeckx WD, Matton G (1997) The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 50(5):322–330
Blondeel PN (1999) One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 52(2):104–111
Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J, Metzinger SE, Dupin CL, Allen RJ (2004) A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 113(4):1153–1160
Arnez ZM, Khan U, Pogorelec D, Planinsek F (1999) Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg 52(5):351–354
Bajaj AK, Chevray PM, Chang DW (2006) Comparison of donor site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 117(3):737–746
Chen CM, Halvorson EG, Disa JJ, McCarthy C, Hu Q, Pusic AL, Cordeiro PG, Mehrara BJ (2007) Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg 120(6):1477–1482
Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA (2007) A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg 59(2):137–142
Lindsey JT (2007) Integrating the DIEP and muscle-sparing (MS-2) free TRAM techniques optimizes surgical outcomes: presentation of an algorithm for microsurgical breast reconstruction based on perforator anatomy. Plast Reconstr Surg 119(1):18–27
Nahabedian MY, Dooley W, Singh N, Manson PN (2002) Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 109(1):91–101
Nahabedian MY, Manson PN (2002) Contour abnormalities of the abdomen after transverse rectus abdominis muscle flap breast reconstruction: a multifactorial analysis. Plast Reconstr Surg 109(1):81–87
Nahabedian MY, Momen B (2005) Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction. Ann Plast Surg 54(2):124–129
Nahabedian MY, Momen B, Galdino G, Manson PN (2002) Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 110(2):466–475
Nahabedian MY, Tsangaris T, Momen B (2005) Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 115(2):436–444
Schaverien MV, Perks AG, McCulley SJ (2007) Comparison of outcomes and donor-site morbidity in unilateral free TRAM versus DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 60(11):1219–1224
Tran NV, Buchel EW, Convery PA (2007) Microvascular complications of DIEP flaps. Plast Reconstr Surg 119(5):1397–1405
Zhong T, Lao A, Werstein MS, Downey DB, Evans HB (2006) High-frequency ultrasound: a useful tool for evaluating the abdominal wall following free TRAM and DIEP flap surgery. Plast Reconstr Surg 117(4):1113–1120
Hartrampf CR (1988) The transverse abdominal island flap for breast reconstruction. A 7-year experience. Clin Plast Surg 15(4):703–716
Hartrampf CR, Scheflan M, Black PW (1982) Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69(2):216–225
Holmstrom H (1979) The free abdominoplasty flap and its use in breast reconstruction. Scand J Plast Reconstr Surg 13:423–429
Robbins TH (1979) Rectus abdominis myocutaneous flap for breast reconstruction. Aust N Z J Surg 49(5):527–530
Robbins TH (1981) Post-mastectomy breast reconstruction using a rectus abdominis musculocutaneous island flap. Br J Plast Surg 34(3):286–290
Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N (1992) Free thin paraumbilical perforator-based flaps. Ann Plast Surg 29(1):12–17
Koshima I, Soeda S (1989) Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 42(6):645–648
Onishi K, Maruyama Y (1986) Cutaneous and fascial vasculature around the rectus abdominis muscle: anatomic basis of abdominal fasciocutaneous flaps. J Reconstr Microsurg 2(4):247–253
Phillips TJ, Stella DL, Rozen WM, Ashton MW, Taylor GI (2008) Abdominal wall CT angiography: a detailed account of a newly established preoperative imaging technique. Radiology 249(1):32–44
Rozen WM, Ashton MW, Taylor GI (2008) Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery. Clin Anat 21(2):89–98
Tansatit T, Chokrungvaranont P, Sanguansit P, Wanidchaphloi S (2006) Neurovascular anatomy of the deep inferior epigastric perforator flap for breast reconstruction. J Med Assoc Thai 89(10):1630–1640
Boyd JB, Taylor GI, Corlett RJ (1984) The vascular territories of the superior epigastric and deep inferior epigastric systems. Plast Reconstr Surg 73(1):1–16
Moon HK, Taylor GI (1988) The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82(5):815–829
Taylor GI, Corlett RJ, Boyd JB (1983) The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 72(6):751–765
Taylor GI, Corlett RJ, Boyd JB (1984) The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 37(3):330–350
Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body: Experimental study and clinical application. Br J Plast Surg 40(2):113–141
Taylor GI, Daniel RK (1975) The anatomy of several free flap donor sites. Plast Reconstr Surg 56(3):243–253
El-Mrakby HH, Milner RH (2002) 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 109(2):539–543
Heitmann C, Felmerer G, Durmus C, Matejic B, Ingianni G (2000) Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg 53(3):205–208
Itoh Y, Arai K (1993) The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg 91(5):853–863
Kikuchi N, Murakami G, Kashiwa H, Homma K, Sato TJ, Ogino T (2001) Morphometrical study of the arterial perforators of the deep inferior epigastric perforator flap. Surg Radiol Anat 23(6):375–381
Milloy FJ, Anson BJ, McAfee DK (1960) The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 110:293–302
Munhoz AM, Ishida LH, Sturtz GP, Cunha MS, Montag E, Saito FL, Gemperli R, Ferreira MC (2004) Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting. Plast Reconstr Surg 113(2):517–524
Ohjimi H, Era K, Fujita T, Tanaka T, Yabuuchi R (2005) Analyzing the vascular architecture of the free TRAM flap using intraoperative ex vivo angiography. Plast Reconstr Surg 116(1):106–113
Ohjimi H, Era K, Tanahashi S, Kawano K, Manabe T, Naitoh M (2002) Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps. Plast Reconstr Surg 109(7):2247–2256
Rozen WM, Ashton MW, Pan WR, Taylor GI (2007) Raising perforator flaps for breast reconstruction: the intramuscular anatomy of the DIEA. Plast Reconstr Surg 120(6):1443–1449
Rozen WM, Ashton MW, Stella DL, Phillips TJ, Grinsell D, Taylor GI (2008) The accuracy of CT angiography for mapping the perforators of the DIEA: a blinded, prospective cohort study. Plast Reconstr Surg 122(4):1003–1009
Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI (2008) The accuracy of CT angiography for mapping the perforators of the DIEA: a cadaveric study. Plast Reconstr Surg 122(2):363–369
Rozen WM, Palmer KP, Suami H, Pan WR, Ashton MW, Corlett RJ, Taylor GI (2008) The DIEA branching pattern and its relationship to perforators: the importance of preoperative CT angiography for DIEA perforator flaps. Plast Reconst Surg 121(2):367–373
Rozen WM, Ashton MW, Murray ACA, Taylor GI (2008) Avoiding denervation of rectus abdominis during DIEP flap harvest: the importance of medial row perforators. Plast Reconstr Surg 122(3):710–716
Bottero L, Lefaucheur JP, Fadhul S, Raulo Y, Collins ED, Lantieri L (2004) Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg 113(1):156–161
Duchateau J, Declety A, Lejour M (1988) Innervation of the rectus abdominis muscle: implications for rectus flaps. Plast Reconstr Surg 82(2):223–227
Galli A, Adami M, Berrino P, Leone S, Santi P (1992) Long-term evaluation of the abdominal wall competence after total and selective harvesting of the rectus abdominis muscle. Ann Plast Surg 28(5):409–413
Hammond DC, Larson DL, Severinac RN, Marcias M (1995) Rectus abdominis muscle innervation: implications for TRAM flap elevation. Plast Reconstr Surg 96(1):105–110
Rozen WM, Ashton MW, Taylor GI (2008) Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat 21(4):325–333
Rozen WM, Kiil BJ, Ashton MW, Grinsell D, Seneviratne S, Taylor GI (2008) Avoiding denervation of rectus abdominis during DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 122(5):1321–1325
Taylor GI, Doyle M, McCarten G (1990) The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg 43(1):1–16
Blondeel PN, Beyens G, Vergaeghe R, Van Landuyt K, Tonnard P, Monstrey SJ, Matton G (1998) Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 51(3):202–209
Giunta RE, Geisweid A, Feller AM (2000) The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 105(7):2381–2386
Hallock GG (2003) Doppler sonography and colour duplex imaging for planning a perforator flap. Clin Plast Surg 30(3):347–357
Hallock GG (1994) Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg 94(5):644–651
Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI (2008) Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 121(1):9–16
Bluemke DA, Chambers TP (1995) Spiral CT angiography: an alternative to conventional angiography. Radiology 195(2):317–319
Chow LC, Napoli A, Klein MB, Chang J, Rubin GD (2005) Vascular mapping of the leg with multi-detector row CT angiography prior to free-flap transplantation. Radiology 237(1):353–360
Karanas YL, Antony A, Rubin G, Chang J (2004) Preoperative CT angiography for free fibula transfer. Microsurgery 24(2):125–127
Nagler RM, Braun J, Daitzman M, Laufer D (1997) Spiral CT angiography: an alternative vascular evaluation technique for head and neck microvascular reconstruction. Plast Reconstr Surg 100(7):1697–1702
Rieker O, Duber C, Schmiedt W, Von Zitzewitz H, Schweden F, Thelen M (1996) Prospective comparison of CT angiography of the legs with intraarterial digital subtraction angiography. AJR Am J Roentgenol 166:269–276
Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Cano D, Martinez-Cuesta A, Pina LJ (2006) Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multi-slice-CT angiography: imaging findings and initial experience. J Plast Reconstr Aesthet Surg 59(6):585–593
Fishman EK (2001) CT angiography: clinical applications in the abdomen. Radiographics 21:S3–S16
Masia J, Clavero JA, Larranaga JR, Alomar X, Pons G, Serret P (2006) Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 59(6):594–599
Masia J, Larranaga JR, Clavero JA, Vives L, Pons G, Pons JM (2008) The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap. Ann Plast Surg 60(1):29–36
Rosson GD, Williams CG, Fishman EK, Singh NK (2007) 3D CT angiography of abdominal wall vascular perforators to plan DIEAP flaps. Microsurgery 27(8):641–646
Rozen WM, Anavekar NS, Ashton MW, Stella DL, Grinsell D, Bloom R, Taylor GI (2008) Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction? Microsurgery 28(7):516–523
Rozen WM, Ashton MW, Grinsell D, Stella DL, Phillips TJ, Taylor GI (2008) Establishing the case for CT angiography in the preoperative imaging of perforators for DIEA perforator flaps. Microsurgery 28(5):227–232
Rozen WM, Phillips TJ, Ashton MW, Stella DL, Taylor GI (2008) A new preoperative imaging modality for free flaps in breast reconstruction: computed tomographic angiography. Plast Reconstr Surg 122(1):38e–40e
Rozen WM, Stella DL, Ashton MW, Phillips TJ, Taylor GI (2007) Three-dimensional CT angiography: a new technique for imaging microvascular anatomy. Clin Anat 20(8):1001–1003
Rozen WM, Stella DL, Ashton MW, Phillips TJ, Taylor GI (2008) The cutaneous arteries of the anterior abdominal wall: a three-dimensional study. Plast Reconstr Surg 121(4):1510–1512
Rozen WM, Murray AC, Ashton MW, Bloom R, Stella DL, Phillips TJ, Taylor GI (2008) The cutaneous course of deep inferior epigastric perforators: implications for flap thinning. J Plast Reconstr Aesthet Surg
Ahn CY, Narayanan K, Shaw WW (1994) In vivo anatomic study of cutaneous perforators in free flaps using magnetic resonance imaging. J Reconstr Microsurg 10:157–163
Rozen WM, Stella DL, Phillips TJ, Ashton MW, Corlett RJ, Taylor GI (2007) Magnetic resonance angiography in the preoperative planning of DIEA perforator flaps. Plast Reconstr Surg, in press
Rozen WM, Murray ACA, Ashton MW, Bloom R, Stella DL, Phillips TJ, Taylor GI (2007) Improving operative outcome in DIEP flap breast reconstruction: radiological advances for preoperative imaging of the abdominal wall. 4th European Conference of Plastic and Reconstructive Surgery of the Breast, December 2007, Milan, Italy
Alonso-Burgos A, Garcia-Tutor E (2008) Clinical experience in MR angiography in DIEP and perforator flaps. 2nd international course on planning DIEP and perforator flaps with 3D angio-CT and angio-MR, April 2008, Pamplona, Navarra, Spain
Perks AG, Neil-Dwyer JG, Ludman C, Mcculley SJ (2008) Contrast enhanced magnetic resonance angiography in preoperative planning for DIEP flap elevation. Royal Australasian College of Surgeons Annual Scientific Congress, May 2008, Hong Kong
Barnett GH, Miller DW, Weisenberger J (1999) Frameless stereotaxy with scalp-applied fiducial markers for brain biopsy procedures: experience in 218 cases. J Neurosurg 91(4):569–576
Klimek L, Mösges R, Schlöndorff G, Mann W (1998) Development of computer-aided surgery for otorhinolaryngology. Comput Aided Surg 3(4):194–201
McInerney J, Roberts DW (2000) Frameless stereotaxy of the brain. Mt Sinai J Med 67(4):300–310
Paleologos TS, Wadley JP, Kitchen ND, Thomas DG (2000) Clinical utility and cost-effectiveness of interactive image-guided craniotomy: clinical comparison between conventional and image-guided meningioma surgery. Neurosurgery 47(1):40–47
Papadopoulos EC, Girardi FP, Sama A, Sandhu HS, Cammisa FP (2005) Accuracy of single-time, multilevel registration in image-guided spinal surgery. Spine J 5(3):263–267
Spivak CJ, Pirouzmand F (2005) Comparison of the reliability of brain lesion localization when using traditional and stereotactic image-guided techniques: a prospective study. J Neurosurg 103(3):424–427
Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI (2008) Stereotactic image-guided navigation in the preoperative imaging of perforators for DIEP flap breast reconstruction. Microsurgery 28(6):417–423
Author information
Authors and Affiliations
Corresponding author
Additional information
W. M. Rozen and M. W. Ashton contributed equally to this work.
Rights and permissions
About this article
Cite this article
Rozen, W.M., Ashton, M.W. Improving Outcomes in Autologous Breast Reconstruction. Aesth Plast Surg 33, 327–335 (2009). https://doi.org/10.1007/s00266-008-9272-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00266-008-9272-1