Arch Hand Microsurg.  2018 Dec;23(4):281-289. 10.12790/ahm.2018.23.4.281.

Classification of Deep Inferior Epigastric Perforator Courses Based on Computed Tomography Angiography: Incidences and Clinical Implications

• Lee Y
• Kim SC
• Eom JS
• Kim EK

• KMID: 2427396
• DOI: http://doi.org/10.12790/ahm.2018.23.4.281

Abstract

PURPOSE
Preoperative surgical planning utilizing computed tomography angiography (CTA) has now become a routine in many practices. We analyzed the course of the deep inferior epigastric artery (DIEA) and its perforators (DIEP) that would either facilitate or hinder flap dissection based on CTA to aid surgical planning.
METHODS
The 115 consecutive patients who underwent abdominally based free flap breast reconstruction were enrolled in this prospective study. DIEA/P courses were categorized mainly according to their intramuscular courses and their incidences were investigated.
RESULTS
A total of 425 perforators were identified preoperatively on the CTA, with an average number of 3.7 distinctly visualized in the entire flap territory. Eighty-nine perforators (20.9%) had a favorable (less than 1 cm intramuscular course) pattern, namely long submuscular (34.8% of the patients), long subfascial (15.6%), and total circummuscular (13.9%). Overall 56.5% of the patients had at least one favorable DIEA/P. On the other hand, absence of DIEA and absence of adequate (>1 mm) DIEP was reported in 3 and 8 hemiabdomen.
CONCLUSION
Preoperative CTA evaluation of DIEA/P can be used to identify favorable as well as unfavorable courses for dissection to aid surgical planning.

Keyword

Breast reconstruction; Perforator flaps; Computed tomography angiography

MeSH Terms

Angiography*
Classification*
Epigastric Arteries
Female
Free Tissue Flaps
Hand
Humans
Incidence*
Mammaplasty
Perforator Flap
Prospective Studies

Figure

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  Fig. 1 A medial circummuscular deep inferior epigastric artery perforator. This perforator ran beneath the muscle after medially circumscribing the rectus abdominis, having no intramuscular course (arrows).

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  Fig. 2 A lateral circummuscular deep inferior epigastric artery perforator. This perforator ran on the surface of the muscle before laterally circumventing the rectus abdominis to join the main pedicle (arrows).

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  Fig. 3 Long subfascial course. This perforator ran immediately beneath the fascia (on the surface of the muscle) for a substantial length then pierced the muscle, having a short intramuscular course (arrows).

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  Fig. 4 Long submuscular course. This perforator pierced muscle almost vertically to have a long submuscular course (arrows).

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  Fig. 5 Absence of left deep inferior epigastric artery. This patient underwent gynecologic surgery in early 1990s (arrow).

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  Fig. 6 Absence of sizable perforator in left hemiabdomen. Our multiplanar reconstruction protocol only detected perforators >1 mm in diameter.

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  Fig. 7 Early entrance into the rectus abdominis muscle. Left deep inferior epigastric artery penetrated into the muscle almost immediately after branching from the external iliac artery. Note that right deep inferior epigastric artery was still staying at the lateral side of the muscle (arrows).

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