• Archives of Reconstructive Microsurgery
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• 제24권1호
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• pp.24-27
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• 2015

During flap elevation, most perforators are cut except one or more perforators that are essential to flap survival. However these cutout perforators can cause deterioration of the blood circulation of the flap. To salvage the jeopardized flaps, rebuilding the perforator system is essential for flap survival. In the first case, after flap elevation, the upper abdominal flap margin was severely ischemic. To supply blood to the upper abdominal flaps, we found and used a major perforator underneath the upper abdominal flap which was cut earlier during the elevation, and we performed reanastomosis with ipsilateral deep inferior epigastric artery. Upper abdominal flap ischemic area was limited to a narrow suture area. In the second case, we performed free superficial inferior epigastric artery (SIEA) flap reconstruction. After successful anastomosis of the SIEA and superficial inferior epigastric vein (SIEV) with internal mammary artery and vein, serious venous congestion occurred immediately because of SIEV malfunction. We found the largest perforator vein under the flap, as an alternate way to drain, then connected it with the thoracoacromial vein with a vein graft harvested in the contralateral SIEV. Circulation has improved. In conclusion, perforator system reconstruction is essential in a jeopardized flap salvage.

• Archives of Plastic Surgery
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• 제42권6호
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• pp.783-787
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• 2015

This procedure was developed for preservation of the rectus muscle components and deep inferior epigastric vessel after deep inferior epigastric perforator (DIEP) flap harvesting. A 53-year-old woman with granuloma caused by silicone injection underwent bilateral nipple-sparing mastectomies and immediate reconstruction with "mini-flow-through" DIEP flaps. The flaps were dissected based on the single largest perforator with a short segment of the lateral branch of the deep inferior epigastric vessel that was transected as a free flap for breast reconstruction. The short segments of the donor deep inferior epigastric vessel branch are primarily end-to-end anastomosed to each other. A short T-shaped pedicle mini-flow-through DIEP flap is interposed in the incised recipient's internal mammary vessels with two arterial and four concomitant venous anastomoses. Although it requires multiple vascular anastomoses and a short pedicle for the flap setting, the mini-flow-through DIEP flap provides a large pedicle caliber, enabling safer microsurgical anastomosis and well-vascularized tissue for creating a natural breast without consuming time or compromising the rectus muscle components and vascular flow of both the deep inferior epigastric and internal mammary vessels.

• Archives of Plastic Surgery
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• 제34권2호
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• pp.229-236
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• 2007

Purpose: Breast reconstruction with deep inferior epigastric perforator(DIEP) free flap is known to be the most advanced method of utilizing autologous tissue. The DIEP free flap method saves most of the rectus abdominis muscle as well as anterior rectus sheath. Therefore, the morbidity of the donor site is minimized and the risk of hernia is markedly decreased. Methods: We chose the internal mammary artery and its venae comitantes as recipient vessels, and deep inferior epigastric vessels as donor vessels. The number and location of the perforators derived from medial or lateral branch of deep inferior epigastric artery(DIEA) in 23 DIEP flaps were identified. Ten patients underwent evaluation of their abdominal wall function preoperatively and 6 months postoperatively by using Lacote's muscle grading system. Results: Of the 23 patients, a patient with one perforator from lateral branch of DIEA experienced partial necrosis of flap. Total flap loss occurred in one patient. Mild abdominal bulging was reported in one patient 4 months postoperatively probably because of early vigorous rehabilitational therapy for her frozen shoulder. Postoperative abdominal wall function tests in 10 patients showed almost complete recovery of muscle function upto their preoperative level of upper and lower rectus abdominis and external oblique muscle function at 6 months postoperatively. All patients have been able to resume their daily activities. Conclusion: The breast reconstruction with DIEP free flap is reliable and valuable method which provide ample soft tissue from abdomen without compromising the integrity of abdominal wall. Selection of reliable perforators is important and including more than two perforators may decrease fat necrosis and partial necrosis of flap.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제35권3호
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• pp.200-209
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• 2013

Over the past few years, a large number of perforator flaps have been revised by several microsurgeons in the USA, France, Canada and Japan. A perforator flap is a flap of skin or subcutaneous tissue that is based on the dissection of a perforating vessel, which is a perforator. In short, a perforator is a vessel that has its origin in one of the axial vessels of the human body. By reducing any muscle harvesting and trauma to a minimum, perforator flaps aim to minimize donor site morbidity, and by avoiding the transfer of dennervated muscle, the long-term bulk of the free tissue transfer becomes more predictable. There are a finite number of potential perforator flaps in the body, which are based on the named source arteries. The most commonly used perforator flaps are deep inferior epigastric perforator, superior gluteal artery perforator, thoraco dorsal artery perforator, medial sural artery perforator, and anterolateral thigh perforator flap. For a better understanding of perforators as a routine reconstructive procedure in oral and maxillofacial surgery, the definition with nomenclature, classifications with special characteristics, and review points for their individual applications must be learned and memorized by the young doctors in the course regarding the special curriculum periods for the Korean national board of oral and maxillofacial surgery. Perforator flaps have been known to have many advantages, so this review article summarized their applications to the maxillofacial reconstruction in the Korean language.

• Archives of Plastic Surgery
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• 제35권1호
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• pp.28-35
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• 2008

Purpose: The pedicle of transverse rectus abdominis myocutaneous(TRAM) flap and deep inferior epigastric arterial perforator flap is deep inferior epigastic artery (DIEA) and accurate anatomic knowledge about perforator of DIEA is very important for the elevation of these flap. The authors investigated a detailed vascular network of perforator of DIEA in Koreans. Methods: 24 fresh cadavers were studied. Among them, 15 were examined based on the plain X-ray examination for the distribution and location of perforator of DIEA. And 9 fresh cadavers were examined based on the 3-dimensional computed tomography(CT) study for the distance between ending point of perforator of DIEA and mother artery, the distance between most medial mother artery and midline, the distance between most lateral mother artery and midline, and the running type of perforators of DIEA. Results: Based on the plain X-ray examination, suitable(external diameter$${\geq_-}0.5mm$$) perforators of DIEA are located between the level of umbilicus and 8 cm below it. Based on the 3D-CT study, average distance between the ending point of perforator of DIEA and the mother artery is 30.26 mm on the left, 28.62 mm on the right, respectively. The average distance between most medial mother artery and midline is 17.13 mm on the left, 15.76 mm on the right, respectively. The average distance between most lateral mother artery and midline is 56.31 mm on the left, 50.90 mm on the right, respectively. The main running course of suitable perforators of DIEA is type a, which is a direct musculocutaneous perforator vessel from main vascular axis passing outward to join the subdermal plexus, directly. Conclusion: 3-dimensional computed tomography study as well as plain X-ray examination provided more accurate and detail informations about perforators of DIEA in Koreans. These informations will help us understand the detailed vascular anatomy and operation with ease and safe in the lower abdomen of Koreans.

• Archives of Plastic Surgery
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• 제47권1호
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• pp.97-101
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• 2020

Although the success rate of deep inferior epigastric perforator (DIEP) flaps has increased, late flap failures still occur and have a low salvage rate. The present article describes a case of salvage of a case of late flap failure using the pedicle vein as a vein graft source. A 50-yearold woman underwent a bilateral DIEP free flap procedure. On postoperative day 6, she experienced flap compromise and underwent emergency flap revision. In the flap revision, flap venous drainage and the superficial inferior epigastric vein were completely obstructed. A Fogarty catheter was used to remove a thrombus from the completely obstructed pedicle vein, and this pedicle vein was used as a graft source and was ligated in retrograde fashion to the flap vein stump. After injection of urokinase into the arterial branch, venous flow to the flap was restored. At a 6-month follow-up visit in the outpatient clinic, only partial fat necrosis at the flap was noted. By dissecting various perforators in the initial operation, decisions regarding immediate revision can be made with more confidence. Additionally, the combined procedures performed in this case may be helpful even for practitioners treating cases of late flap compromise.

• Archives of Reconstructive Microsurgery
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• 제11권2호
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• pp.141-145
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• 2002

Rectus abdominis muscle free flap is widely used for breast reconstruction and soft tissue defect in lower leg but donor-site morbidities such as abdominal wall weakness, hernia, bulging are troublesome. Recently, to minimize donor-site morbidity, there has been a surge in interest in deep inferior epigastric perforator(DIEP) free flap preserving the anatomy of rectus abdominis muscle, fascia, and motor nerve. Between August of 1995 and September of 2002, topographic investigation of DIEP was performed during the elevation of 97 cases of TRAM free flap and 5 cases of DIEP free flap. There were 84 cases of breast reconstructions, 12 cases of lower leg reconstructions, and 6 cases of head and neck reconstruction. We could observe total 10 to 12 perforators on each rectus abdominis muscle below umbilicus. Among these, the numbers of large perforators(>1.5mm of diameter) were mean 2.1 in lateral half of rectus abdominis muscle, mean 1.2 in medial half, and mean 0.5 in linea alba and paramedian. DIEP free flap provides ample amount of well vascularized soft tissue without inclusion of any rectus abdominis muscle and fascia and minimizes donor-site morbidity. One perforator with significant flow can perfuse the whole flap. For large flap, a perforator of the medial row provides better perfusion to zone-4 than one of lateral row and, if diameter of perforator is small, $2{\sim}3$ perforators can be used. According to the condition of recipient-site, thin flap can be harvested. As DIEP free flap has many advantage, perforator topography will be useful in increasing clinical usage of DIEP free flap.

• Archives of Plastic Surgery
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• 제41권2호
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• pp.171-173
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• 2014

Preoperative perforator marking for deep inferior epigastric artery perforator flaps is vital to the success of the procedure in breast reconstruction. Advances in imaging have facilitated accurate identification and preselection of potentially useful perforators. However, the reported imaging accuracy may be lost when preoperatively marking the patient, due to 'mapping errors', as this relies on the use of 2 reported vectors from a landmark such as the umbilicus. Observation errors have been encountered where inaccurate perforator vector measurements have been reported in relation to the umbilicus. Transcription errors have been noted where confusing and wordy reports have been typed or where incorrect units have been given (millimetres vs. centimetres). Interpretation errors have also occurred when using the report for preoperative marking. Furthermore, the marking process may be unnecessarily time-consuming. We describe a bespoke template, created using an individual computed tomography angiography image, that increases the efficiency and accuracy of preoperative marking. The template is created to scale, is individually tailored to the patient, and is particularly useful in cases where multiple potential suitable perforators exist.

• Archives of Plastic Surgery
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• 제49권4호
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• pp.482-487
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• 2022

In lower abdominal flap representing transverse rectus abdominis musculocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric vein (SIEV) exists as superficial and independent venous system from deep system. The superficial venous drainage is dominant despite a dominant deep arterial supply in anterior abdominal wall. As TRAM or DIEP flaps began to be widely used for breast reconstruction, venous congestion issue has been arisen. Many clinical series in regard to venous congestion despite patent microvascular anastomosis site were reported. Venous congestion could be divided in two conditions by the area of venous congestion and each condition is from different anatomical causes. First, if venous congestion was shown in whole flap, it is due to the connection between SIEV and vena comitantes of DIEP. Second, if venous congestion is limited in above midline (Hartrampf zone II), it is due to problem in venous midline crossover. In this article, the authors reviewed the role of SIEV in lower abdominal flap based on the various anatomic and clinical studies. The contents are mainly categorized into four main issues; basic anatomy of SIEV, the two cause of venous congestion, connection between SIEV and vena comitantes of DIEP, and midline crossover of SIEV.

• Archives of Plastic Surgery
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• 제49권1호
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• pp.34-38
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• 2022

The deep inferior epigastric perforator (DIEP) flap has been widely used for autologous breast reconstruction after mastectomy. In the conventional surgical method, a long incision is needed at the anterior fascia of the rectus abdominis muscle to obtain sufficient pedicle length; this may increase the risk of incisional hernia. To shorten the incision, several trials have investigated the use of endoscopic/robotic devices for pedicle harvest; however, making multiple additional incisions for port insertion and operating in the intraperitoneal field were inevitable. Here, we describe the first case, in which a DIEP free flap was successfully made using the da Vinci SP model. Our findings can help surgeons perform operations in smaller fields with a single port in the extraperitoneal space. Moreover, this method is expected to lead to fewer donor-related complications and faster healing.