Deep Inferior Epigastric Artery Perforator Flap

Abstract

As a consequence of the well-reported morbidity which can be associated with harvesting the conventional rectus abdominis flap, strategies to reduce the amount of muscle have been developed, first resulting in the muscle-sparing flap-raising technique and finally evolving to the perforator flap principle. Very early, the significance of the perforating vessels of the rectus muscle to perfuse the abdominal skin was emphasized by numerous authors [224, 432, 515], but it took until 1989 that Koshima and Soeda reported the first clinical application of the inferior epigastric artery perforator flap [290]. With the introduction of this important modification, complications like weakness of the abdominal wall with herniation or bulging, which made techniques for closure of the muscle defect like direct approximation [203, 551] using turnover flaps from the contralateral rectus sheath [356], or inserting synthetic material into the created muscle defect [125, 309] unnecessary. After identifying a strong perforating vessel, Koshima left all the rectus muscle tissue intact when he followed this perforator to the deep epigastric system by gently spreading the muscle fibers. This procedure first met all criteria of raising perforator flaps according to the current definition [290]. The attractiveness of this procedure was further increased when the same author introduced the technique of primary flap thinning, which became possible with the targeted dissection and preservation of the perforator, allowing for safe removal of all superfluous fatty tissue [287]. Like with the conventional transverse rectus abdominis (TRAM) or rectus abdominis flaps, these deep inferior epigastric artery perforator (DIEAP) flaps were still anastomosed to the deep inferior epigastric vessels [9, 160]. Allen and Treece were among the first to use this flap for breast reconstruction and confirmed its advantages of decreasing the possibility of ventral hernia or muscle weakness [9]. If there is a need to extend the flap to the contralateral side of the abdomen, which is regularly the case in breast reconstruction, a perforator from the contralateral side can additionally be anastomosed to the end of the ipsilateral deep inferior epigastric vessels, thus increasing the safety of blood supply (supercharging technique) [160, 405]. This technique is also useful in the presence of vertical scars which can reduce blood circulation contralateral to the side of anastomoses [469]. A similar technique was also described by Blondeel and Boeckx, who additionally used contralateral perforators, which they anastomosed to the internal thoracic vessels instead of using the ipsilateral main vessels of the flap alone [46]. The first anastomosis of a deep inferior epigastric perforator flap exclusively to its perforating vessels was again performed by Koshima et al., describing this technique as supramicrosurgery [284]. Moreover, they recognized another significant advantage of perforator flaps, namely, the possibility of primary radical flap thinning. Indications of those super-thin perforator flaps with a short pedicle were superficial skin defects of the lower extremities, scalp, abdomen, or head and neck [284, 478, 518, 611]. Meanwhile, many comparative studies have shown that DIEAP flaps are associated with higher patient satisfaction, reduced abdominal bulge, but comparable aesthetic results like TRAM flaps [43, 370, 387].