Download PDF
J Reconstr Microsurg 2023; 39(01): 020-026
DOI: 10.1055/s-0042-1744310
Original Article

Characterizing Outcomes of Medial and Lateral Perforators in Deep Inferior Epigastric Perforator Flaps

Ashlie A. Elver 
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
,
Stephanie A. Matthews
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
,
Katie G. Egan 
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
,
Eva L. Bowles
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
,
Niaman Nazir
2   Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
,
Mitchell Flurry
3   Plastic & Cosmetic Surgery, Ascension Medical Group, Wichita, Kansas
,
Julie Holding
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
,
Eric C. Lai
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
,
James A. Butterworth
1   Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity.

Methods A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses.

Results Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators.

Conclusion There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

Keywords

fat necrosis - abdominal wall - perforator flap - autologous reconstruction


Publication History

Received: 31 October 2021

Accepted: 30 January 2022

Article published online:
27 April 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 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
    CrossrefPubMedGoogle Scholar
  • 2 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
    CrossrefPubMedGoogle Scholar
  • 3 Uda H, Tomioka YK, Sarukawa S, Sunaga A, Sugawara Y. Comparison of abdominal wall morbidity between medial and lateral row-based deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 2015; 68 (11) 1550-1555
    CrossrefPubMedGoogle Scholar
  • 4 Rozen WM, Ashton MW, Kiil BJ. et al. Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 2008; 122 (05) 1321-1325
    CrossrefPubMedGoogle Scholar
  • 5 Rozen WM, Ashton MW, Murray ACA, Taylor GI. Avoiding denervation of rectus abdominis in DIEP flap harvest: the importance of medial row perforators. Plast Reconstr Surg 2008; 122 (03) 710-716
    CrossrefPubMedGoogle Scholar
  • 6 Rozen WM, Palmer KP, Suami H. et al. The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg 2008; 121 (02) 367-373
    CrossrefPubMedGoogle Scholar
  • 7 Rozen WM, Tran TMN, Barrington MJ, Ashton MW. Avoiding denervation of the rectus abdominis muscle in DIEP flap harvest III: a functional study of the nerves to the rectus using anesthetic blockade. Plast Reconstr Surg 2009; 124 (02) 519-522
    CrossrefPubMedGoogle Scholar
  • 8 Kamali P, Lee M, Becherer BE. et al. Medial row perforators are associated with higher rates of fat necrosis in bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2017; 140 (01) 19-24
    CrossrefPubMedGoogle Scholar
  • 9 Hembd A, Teotia SS, Zhu H, Haddock NT. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg 2018; 142 (03) 583-592
    CrossrefPubMedGoogle Scholar
  • 10 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
    Google Scholar
  • 11 Garvey PB, Salavati S, Feng L, Butler CE. Abdominal donor-site outcomes for medial versus lateral deep inferior epigastric artery branch perforator harvest. Plast Reconstr Surg 2011; 127 (06) 2198-2205
    CrossrefPubMedGoogle Scholar
  • 12 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124 (03) 752-764
    CrossrefPubMedGoogle Scholar
  • 13 Mohan AT, Zhu L, Wang Z, Vijayasekaran A, Saint-Cyr M. Techniques and perforator selection in single, dominant DIEP flap breast reconstruction: algorithmic approach to maximize efficiency and safety. Plast Reconstr Surg 2016; 138 (05) 790e-803e
    CrossrefPubMedGoogle Scholar
  • 14 Patterson CW, Palines PA, Bartow MJ. et al. Stratification of surgical risk in DIEP breast reconstruction based on classification of obesity. J Reconstr Microsurg 2022; 38 (01) 1-9
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Daly LT, Doval AF, Lin SJ, Tobias A, Lee BT, Dowlatshahi AS. Role of CTA in women with abdominal scars undergoing DIEP breast reconstruction: review of 1,187 flaps. J Reconstr Microsurg 2020; 36 (04) 294-300
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Bond ES, Soteropulos CE, Yang Q, Poore SO. The impact of prior abdominal surgery on complications of abdominally based autologous breast reconstruction: a systematic review and meta-analysis. J Reconstr Microsurg 2021; 37 (07) 566-579
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 2010; 126 (02) 367-374
    CrossrefPubMedGoogle Scholar
  • 18 DellaCroce FJ, DellaCroce HC, Blum CA. et al. Myth-busting the DIEP flap and an introduction to the abdominal perforator exchange (APEX) breast reconstruction technique: a single-surgeon retrospective review. Plast Reconstr Surg 2019; 143 (04) 992-1008
    CrossrefPubMedGoogle Scholar
  • 19 Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010; 125 (05) 1335-1341
    CrossrefPubMedGoogle Scholar
  • 20 Gill PS, Hunt JP, Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113 (04) 1153-1160
    CrossrefPubMedGoogle Scholar
  • 21 Garvey PB, Salavati S, Feng L, Butler CE. Perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric artery branch perforators for breast reconstruction. Plast Reconstr Surg 2011; 128 (06) 581e-589e
    CrossrefPubMedGoogle Scholar
  • 22 Grover R, Nelson JA, Fischer JP, Kovach SJ, Serletti JM, Wu LC. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg 2014; 41 (01) 63-70
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Lindsey JT. Perforator number does not predict fat necrosis. Plast Reconstr Surg 2011; 127 (03) 1391-1392
    CrossrefPubMedGoogle Scholar
  • 24 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
    CrossrefPubMedGoogle Scholar
  • 25 Griffiths M, Chae MP, Rozen WM. Indocyanine green-based fluorescent angiography in breast reconstruction. Gland Surg 2016; 5 (02) 133-149
    PubMedGoogle Scholar
  • 26 Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg 2010; 125 (04) 1065-1073
    CrossrefPubMedGoogle Scholar
  • 27 Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J 2014; 34 (01) 61-65
    CrossrefPubMedGoogle Scholar