Plastic Surgery, Volume Five: Breast (Fourth Edition): Cẩm nang Toàn diện Phẫu thuật Thẩm mỹ và Tái tạo Vú – Maurice Y. Nahabedian & Peter C. Neligan

313
Surgical variations
muscle.57 Due to a high rate of flap loss in their experi­
ence, Schwabegger and colleagues introduced the
muscle-sparing latissimus flap, which included a small
strip of latissimus muscle to increase the vascularity of
the overlying skin paddle.58 A disadvantage of this
technique was the use of a vertically oriented skin
paddle, which later led to the development of the ped­
icled muscle-sparing latissimus dorsi musculocutane­
ous flap, described by Saint-Cyr et al. in 2009 (Fig.
19.19).55 With this technique, the skin paddle is not
dependent on a specific perforator and can be designed
in any orientation along the axis of the descending
branch of the thoracodorsal artery.55
Intraoperatively, the thoracodorsal artery and the
location of its bifurcation into the transverse and
descending branches are identified with a Doppler
probe. The bifurcation point is found an average of
5.1 cm from the posterior axillary fold55 and 2.2 cm from
the lateral edge of the muscle.58 The skin paddle is
designed to capture the largest amount of back soft
tissue, with the lateral edge of the skin paddle extending
1–2 cm lateral to the anterior border of the latissimus
muscle to capture perforators from the descending
branch of the thoracodorsal artery. The superior skin
flap is elevated first, only above the descending branch
of the thoracodorsal vessel. The superior skin is draped
over the proposed skin excision to confirm primary
closure before committing to the skin paddle design.
Next, the inferior skin flap is elevated, again taking care
to only elevate the skin above the descending branch.
This key maneuver helps to minimize soft-tissue dissec­
tion and postoperative seroma formation.55 The latissi­
mus muscle is then split vertically along its fibers
beginning caudally, staying 1 cm medial to the descend­
ing branch, up to the point of its bifurcation. The flap is
then transposed through an axillary tunnel in standard
fashion.
Using this technique, Saint-Cyr reported no seromas
or hematomas in twenty-four patients; no significant
differences in shoulder range of motion, vertical
reach, or strength; low postoperative disability scores as
measured by the DASH (Disabilities of the Arm,
Shoulder, and Hand) score; and high levels of patient
satisfaction.55
Endoscopic-assisted reconstruction with
latissimus dorsi (EARLi)
The latissimus flap, as classically described, utilizes a
large skin incision on the back and may or may not
include a skin paddle.3 In an effort to minimize donor
morbidity, some authors have described “mini” latissi­
mus flaps.59,60 An additional technique that can be
Donor site closure
The back incision is closed in a layered fashion over two
7 mm or 10 mm flat drains placed to bulb suction.
Scarpa’s fascia is reapproximated using 0-polydioxanone
(PDS) sutures or a single #2 Quill. The skin is closed in
layers, with interrupted 3-0 PDS or Vicryl sutures in the
dermis, followed by a running subcuticular 3-0 PDS or
Monocryl. Steri-Strips are applied to the incision, which
is then covered by Telfa and Tegaderm.
Postoperative expansion
Once the incisions are healed, usually within two weeks,
serial expansions are begun until the desired size is
achieved. The tissues are then allowed to settle for a
period of 4–6 weeks before the patient is brought to
the operating room for an expander to implant exchange.
This is done through the previous incision, and the
latissimus muscle is split along the direction of its fibers.
At this point, any minor asymmetries or adjustments
to the implant pocket can be addressed. The nipple
areolar complex can be reconstructed in this or another
setting.
Surgical variations
Advances in the understanding of the blood supply to
the latissimus dorsi muscle and the overlying skin have
lead to the development of surgical variations of this
flap to minimize morbidity, namely the extended latis­
simus,53 the split latissimus,54 and the muscle-sparing
latissimus dorsi flap.55
Extended latissimus flap
Patients with larger breasts or those who desire com­
pletely autologous breast reconstruction and are not
candidates for abdominal-based tissue transfer can be
treated with an extended latissimus flap. One design
utilizes a three-pointed skin paddle, designed to capture
the largest amount of available soft tissues (Fig.
19.18).27,52,56 The design of the incision allows a well-
concealed donor site scar and minimizes dog-ear forma­
tion.52 While excellent aesthetic results can be achieved,52,53
it should be noted that the rates of seroma are increased,
particularly in obese patients.53
Muscle-sparing techniques
In an effort to reduce the donor site morbidity associ­
ated with harvest of a latissimus dorsi flap, Angrigiani
described the thoracodorsal artery perforator flap in
1995, allowing a skin paddle of 25 × 15 cm to be elevated
without incorporating any of the underlying latissimus

314
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
days following lumpectomy but should not be delayed
more than three weeks to avoid scar contracture that
may require release and skin paddle replacement. The
contraindications to an EARLi procedure are the same
as those for a standard latissimus flap, including known
or potential damage to the vascular pedicle.
The patient is positioned, prepped, and draped in the
same fashion as a unilateral latissimus flap reconstruc­
tion, with the ipsilateral arm prepped into the field so
that it can be manipulated during the procedure to
maximize visualization. The procedure is carried out
using modified laparoscopic instruments (Fig. 19.20)
with the primary surgeon facing the patient’s chest and
the assistant facing the patient’s back. The donor site is
then infused with tumescent solution in a plane super­
ficial to the latissimus muscle to facilitate intraoperative
hemostasis. The lumpectomy defect is then opened and
its size approximated using a laparotomy pad (Fig.
19.21) while the epinephrine in the tumescent solution
is taking effect.
A curvilinear incision is made at the inferior aspect of
the axillary hairline, which must be large enough to
applied for women undergoing BCT who wish to mini­
mize scar burden on the donor site is an endoscopic-
assisted harvest and transposition of the muscle only to
fill a partial breast defect. This technique, described at
the authors’ institution in 1994 by the senior author
(NAF), has been in use for more than twenty years and
has become the authors’ preferred method of recon­
struction in this patient population. This procedure,
which uses a much smaller incision and less traumatic
tissue dissection, has allowed many patients the benefits
of faster recovery, with decreased postoperative pain
and improved cosmesis.61 With indications for BCT
expanding to include larger tumors, more and more
breast parenchyma is resected, and many women will
require flap reconstruction for an aesthetically pleasing
result.3,62
This procedure is well suited for women who require
resection of 20–30% of their breast volume and is ideal
for resections in the upper outer quadrant of the breast,
where most cancers occur. This procedure is always
performed in a delayed fashion, once the final patho­
logic margins are known. This can be as early as three
Fig. 19.19  Relevant anatomy and design of the muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery, as described by Saint-Cyr
et al. Limited undermining of skin flaps is used to minimize seroma formation and limit donor site morbidity. (Redrawn from Saint-Cyr M, Nagarkar P, Schaverien M, et al.
The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr Surg. 2009;123:13–24.)
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315
Surgical variations
accommodate the surgeon’s hand. Typically, our inci­
sions measure approximately 9 cm. The dissection
begins with identification of the thoracodorsal vascular
pedicle (Fig. 19.22). In order to avoid the risk of avulsion
and to allow full movement of the muscle, the serratus
branch and any vascular tributaries supplying the ser­
ratus anterior muscle must be clipped and transected. It
is critical during this part of the procedure that the
thoracodorsal pedicle be unequivocally identified.
After the thoracodorsal pedicle has been identified,
the deep surface of the muscle is dissected free using a
combination of monopolar electrocautery and blunt
dissection. Once space has been created, the surgeon’s
hand is introduced to ensure the proper plane of dissec­
tion and to facilitate blunt dissection beneath the latis­
simus muscle. A retractor with an endoscope is inserted,
and the dissection of the deep surface of the muscle is
Fig. 19.20  Instrumentation used in endoscopically assisted harvest of the
latissimus dorsi muscle.
Fig. 19.21  A laparotomy pad may be used to approximate the configuration and
size of the latissimus dorsi muscle. The lumpectomy defect in this case was
estimated to be roughly the size of a single laparotomy pad. (A) Spread out in the
pretransposed configuration. (B) Balled up to simulate the inset configuration and
size similarity to one laparotomy pad. (C) Final inset, demonstrating adequate
soft-tissue volume to reconstruct the lumpectomy defect.
A
B
C

316
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
hand through the incision and grasps the muscle at the
point where it must be divided, then cuts just beyond
his or her fingertips with the endoscopic scissors. Freeing
the most inferior attachments is the most challenging
part of the procedure. Once complete, the tendinous
humeral insertion is divided using monopolar electro­
cautery, which fully mobilizes the muscle. An axillary
tunnel is then created to the breast defect and the flap
transposed into place and loosely secured with absorb­
able sutures. Endoscopic instruments are then used to
cauterize any vessels identified, specifically lumbar
perforators noted during flap harvest. It is noteworthy
that these vessels may not be actively bleeding due to
the epinephrine in the tumescent solution. Careful
attention must be paid to ensure all vessels are ade­
quately cauterized or clipped. Once adequate hemosta­
sis is achieved, two 7 mm flat drains are placed in the
back donor site and one in the breast, and the incisions
are closed in standard fashion. Typical operating time is
between two and three hours.
Secondary procedures
Common secondary surgical procedures following latis­
simus flap breast reconstruction include exchange of
tissue expander for permanent implant, donor site
revisions, reconstruction of the nipple areolar complex,
and procedures on the contralateral breast to improve
overall symmetry. Nipple areolar reconstruction and
contralateral breast surgery are beyond the scope of this
chapter.
Expander to implant exchange
In most cases, a tissue expander is placed at the time of
the latissimus flap operation, although direct-to-implant
reconstructions have been described.43,44 The expander
pocket is approached through the previous mastectomy
incision, with longitudinal splitting of the latissimus
muscle fibers to expose the expander. At this time,
capsulotomy or other pocket revision procedures can be
performed before placement of the final implant. If
desired, the skin paddle of the flap can be modified to
a more anatomic, areolar shape if the mastectomy flaps
are sufficiently mobile, which may improve the final
aesthetic appearance of the reconstruction.
Donor site revisions
Depending on the amount of breast skin removed
during the mastectomy, the size of the latissimus flap
skin paddle will vary greatly. With large skin paddles,
the donor site may be closed under excessive tension
that may lead to delayed wound healing, dog-ear
completed. Care must be taken to properly clip or cau­
terize the lumbar perforators encountered near the
dorsal midline. The authors find that marking the site
of these lumbar perforators on the overlying back skin
greatly facilitates final hemostasis (Fig. 19.23).
Once the deep dissection is complete, the next step is
to dissect on the superficial surface of the muscle. The
first 5–6 cm of this dissection represents the part of
the muscle that will ultimately be tunneled through the
axilla, where extra bulk is not desirable. After freeing
5–6 cm, the plane of dissection changes to the sub-
Scarpa’s layer to maximize flap volume where it will be
needed to fill the lumpectomy defect.
At this point, the remaining muscular attachments
are freed using a combination of direct visualization and
“tactile guidance”, whereby the surgeon places one
Fig. 19.22  Identification of the thoracodorsal neurovascular pedicle. The serratus
branch has been clipped in this photograph.
Fig. 19.23  The location of perforating vessels encountered during muscle
dissection is marked on the overlying skin to help ensure adequate hemostasis
prior to donor site closure.

317
Complications
surgical intervention is usually required to repair the
hernia and avoid serious complications.50
Lastly, in addition to several other roles, the latissimus
dorsi is an important adductor of the arm and internal
rotator of the shoulder. Harvest of this flap can lead to
shoulder weakness, stiffness, and loss of mobility. These
complications should be discussed with patients preop­
eratively; however, in most patients who are not elite
athletes or bodybuilders, the loss of strength and range
of motion is negligible and responds well to postopera­
tive physical therapy.66,67
Complication rates are, expectedly, commensurate
with the level of dissection and tissue harvest. Higher
rates of seroma are seen in extended latissimus flaps,
with conflicting data on the impact of obesity on seroma
formation.53,65,68 In a recent study directly comparing
outcomes between the two, the extended latissimus
dorsi flap showed significantly higher rates of seroma
(muscle-sparing latissimus vs extended latissimus flaps,
the rates of seroma were 62.2% vs. 5.6%), limitation of
shoulder movement (75.7% vs. 25%), and asymmetry
than the muscle-sparing latissimus dorsi flap.69
Flap loss
The latissimus dorsi flap has a robust axial blood supply
and reliable skin territory, making significant flap loss
unusual. This complication is almost universally associ­
ated with injury to the vascular pedicle during flap
dissection or twisting/kinking of the pedicle during
flap transposition. It is therefore very important to
understand the orientation of the pedicle before and
after tunneling through the axilla to avoid iatrogenic
flap loss. Partial flap loss has been reported with rates
as high as 7% but is seen more commonly with the
extended latissimus flap.70
Implant-related complications
In cases where a latissimus dorsi flap is used in conjunc­
tion with a tissue expander or implant, the risks of
prosthetic use are added to the risk profile of the flap,
including implant extrusion, rupture, periprosthetic
infection, and capsular contracture.71 Furthermore,
implant migration into the axilla has been reported.72
This complication is easily avoided by securing the
lateral flap to the chest wall to close the communication
between the mastectomy cavity and the flap donor site.72
Furthermore, the use of tabbed tissue expanders can
prevent or reduce the incidence of this complication.25
Individualized risk assessment
The development of large-scale, multi-institutional data­
bases has allowed a recent emphasis on individualizing
formation, and widening of the final scar. The donor site
responds well to scar revision once the skin tension has
relaxed, and dog-ear revision can be performed in the
office or in conjunction with secondary procedures on
an as-needed basis.
Postoperative management
All patients have two 7 mm or 10 mm closed-suction
drains placed in the flap donor site and one or two
drains in the mastectomy space. These drains are left in
place until the total output from each is 30 cc or less per
24-hour period. An elastic bandage may be gently
wrapped circumferentially around the upper torso for
comfort and gentle compression, but care must be
exercised not to excessively compress the vascular
pedicle or flap. All patients receive mechanical and
chemoprophylaxis for prevention of venous thrombo­
embolism, and early ambulation is encouraged. The
average length of stay is 1–2 days in the hospital.
Dressings are removed prior to discharge (24–48
hours postoperatively), at which time patients may
begin showering. Ambulation and activities of daily
living, including personal hygiene tasks, are encour­
aged immediately. More strenuous activities are resumed
later, typically 4–6 weeks postoperatively.
Complications
Donor site morbidity
The most common complications associated with the
latissimus dorsi flap are related to the donor site. Spe­
cifically, donor site seroma formation is particularly
problematic, with published rates ranging from 3.9% to
79%.63,64 Often, these are managed on an outpatient basis
with needle aspiration; however, on rare occasions, a
persistent seroma may require surgical debridement of
the seroma cavity and long-term closed suction drain­
age. The risk of seroma may be increased with the
extended latissimus dorsi flap.65
When very large skin paddles are used, the donor site
closure may be placed under excessive tension that can
lead to delayed wound healing, contour irregularity,
and scar widening. Fortunately, these complications are
usually minor and can be corrected with minor, second­
ary procedures.
The latissimus dorsi muscle forms the roof of the
superior lumbar triangle. During flap harvest, inadver­
tent injury to the aponeurosis of the internal oblique and
transversus abdominis muscles, which form the floor of
this triangle, can lead to lumbar herniation. While this
complication is rare, it is important to consider, as

318
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
database, latissimus flaps accounted for nearly one third
of all breast reconstructions (32.7%), and 30 day compli­
cation rates were lower than pedicled TRAM and free
flap reconstructions.2 Specifically, rates of flap failure,
surgical site infection, and overall complications were
lowest in patients undergoing latissimus flap breast
reconstruction. Several studies have demonstrated the
reliability of the latissimus flap with low rates of flap-
related complications and high levels of patient satisfac­
tion.7,19,27,29,31,48,51,55,68,72,73 Clinical examples are shown in
Figs. 19.24–19.27.
Conclusion
In conclusion, the latissimus dorsi flap is an anatomically
reliable, technically straightforward option for breast
reconstruction with generally fewer complications than
risk assessment through statistical modeling. Recently,
one of the authors (JYSK) developed the Breast Recon­
struction Risk Assessment Score (BRA Score) using
widely available resources, like the American Society
of Plastic Surgeons Tracking Operations and Outcomes
for Plastic Surgeons (TOPS) and the American College
of Surgeons National Surgical Quality Improvement
Program (NSQIP) databases. This tool aims to provide
individualized and quantifiable risk assessment for
patients undergoing breast reconstruction in an effort
to better inform surgical decision-making and manage
patient expectations (see Fig. 14.2).64
Outcomes
In a recent review of the American College of Surgeons
National Surgical Improvement Program (NSQIP)
Fig. 19.24  A 48-year-old female who underwent bilateral skin-sparing mastectomy after left lumpectomy and bilateral latissimus flap reconstruction. (A) Preoperative
appearance. (B) Postoperative appearance following bilateral latissimus flap reconstruction with 550 cc Moderate Plus silicone gel implants and nipple/areolar
reconstruction and tattooing. (Photos courtesy of Dr. John Y.S. Kim.)
A
B
Fig. 19.25  A 54-year-old female with left lumpectomy defect who underwent endoscopic-assisted reconstruction with latissimus dorsi (EARLi) procedure for left breast
volume augmentation. (A) Following left lumpectomy. (B) Following reconstruction with muscle-only latissimus flap. (Photos courtesy of Dr. John Y.S. Kim.)
A
B

319
Conclusion
an era of outcomes-based reimbursement and health­
care cost containment, this combination of utility, ease,
and relative cost-efficacy will ensure continued use of
varying permutations of the latissimus flap in breast
reconstruction.
other autologous techniques. Moreover, there are
variants of the latissimus flap – including minimally
invasive muscle harvest techniques and the extended
version – which can diversify its utility for both primary
and secondary lumpectomy and mastectomy defects. In
A
B
C
Fig. 19.26  A 54-year-old female who presented following left lumpectomy and radiation therapy. (A) Preoperative anteroposterior (AP) view. (B) Preoperative oblique view.
(C) AP view following latissimus flap reconstruction with inferolateral skin paddle designed to release constricted breast skin. (D) Postoperative oblique view. (Photos
courtesy of Dr. John Y.S. Kim.)
D
A
B
Fig. 19.27  A 47-year-old female who presented following failed bilateral prosthetic-based reconstruction. (A) Preoperative appearance. (B) Following bilateral latissimus
flap reconstruction and expander to implant exchange (nipple/areolar reconstruction was deferred per patient preference). (Photos courtesy of Dr. John Y.S. Kim.)

320
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
19. Hammond DC. Latissimus dorsi flap breast reconstruction. Clin
Plast Surg. 2007;34:75–82, abstract vi–vii. Dr. Hammond describes his
extensive experience with the latissimus flap and the technical
modifications he has made over time to improve outcomes andaesthetics.
He demonstrates that impressive results can be achieved with these
modifications and improvements in the design of breast prostheses.
26. Fisher J, Bostwick J 3rd, Powell RW. Latissimus dorsi blood supply
after thoracodorsal vessel division: the serratus collateral. Plast
Reconstr Surg. 1983;72:502–511.
31. Delay E, Gounot N, Bouillot A, et al. Autologous latissimus breast
reconstruction: a 3-year clinical experience with 100 patients. Plast
Reconstr Surg. 1998;102:1461–1478. Delay et al. demonstrate their
technique for latissimus dorsi flap breast reconstruction and reported on
results and complications. Patient satisfaction was high. Postoperative
complications included partial necrosis (1%), total necrosis (1%), and
seroma (79%). Seroma was noted to occur more regularly in obese
patients.
39. Disa JJ, Cordeiro PG, Heerdt AH, et al. Skin-sparing mastectomy
and immediate autologous tissue reconstruction after whole-breast
irradiation. Plast Reconstr Surg. 2003;111:118–124.
46. Hammond DC, Simon AM, Khuthaila DK, et al. Latissimus dorsi
flap salvage of the partially failed TRAM flap breast reconstruction.
Plast Reconstr Surg. 2007;120:382–389.
48. Spear SL, Boehmler JH, Taylor NS, Prada C. The role of the
latissimus dorsi flap in reconstruction of the irradiated breast. Plast
Reconstr Surg. 2007;119:1–9, discussion 10–11. The authors describe
their 10-year experience using the latissimus dorsi flap in prosthetic
reconstruction of irradiated breasts. Twenty-eight patients were identified,
18 of whom had a latissimus flap at the time of expander placement and
10 of whom underwent secondary latissimus flap reconstruction. No
patients developed capsular contracture, and overall patient satisfaction
was very high (8.8/10). The authors conclude that latissimus flaps can be
combined with prosthetic reconstruction to produce a cosmetically-pleasing
result in the previously irradiated breast.
53. Chang DW, Youssef A, Cha S, Reece GP. Autologous breast
reconstruction with the extended latissimus dorsi flap. Plast
Reconstr Surg. 2002;110:751–759, discussion 760–761. The authors in
this study present their clinical series of 75 extended latissimus dorsi flaps
for purely autologous breast reconstruction. In this series of 67 patients,
28% developed flap-related complications and 38.7% developed donor site
complications. Overall, donor site seroma was the most common
complications (25.3%), and the authors conclude that obese patients are at
higher risk of developing this complication.
55. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled
descending branch muscle-sparing latissimus dorsi flap for breast
reconstruction. Plast Reconstr Surg. 2009;123:13–24. Saint-Cyr et al.
present a series of 24 muscle-sparing latissimus flaps in 20 patient and
report on outcomes, complications, and functional disability compared
with the nonoperated side. The technique for the pedicled muscle-sparing
latissimus flap is also presented. There were no postoperative seromas
reported in this series and only one case of partial flap necrosis. When
comparing the operated and nonoperated sides, no statistically significant
functional differences were detected using the DASH questionnaire.
67. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of
latissimus dorsi donor site. Plast Reconstr Surg. 1986;78:336–344.
73. Pacella SJ, Vogel JE, Locke MB, Codner MA. Aesthetic and technical
refinements in latissimus dorsi implant breast reconstruction: a
15-year experience. Aesthet Surg J. 2011;31:190–199.
Access the complete reference list online at

320.e1
References
References
1. National Cancer Institute. Surveillance, Epidemiology, and End Results
(SEER) Program. Cancer Stat Facts: Female Breast Cancer; 2014.
[Online] Available from: <
breast.html>.
2. Gart MS, Smetona JT, Hanwright PJ, et al. Autologous options for
postmastectomy breast reconstruction: a comparison of outcomes
based on the American College of Surgeons National Surgical
Quality Improvement Program. J Am Coll Surg. 2013;216:229–238.
3. Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi
musculocutaneous flap. Plast Reconstr Surg. 1980;65:686–692.
4. Olivari N. The latissimus flap. Br J Plast Surg. 1976;29:126–128.
5. Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi
myocutaneous flap for breast reconstruction. Br J Plast Surg.
1977;30:277–281.
6. Bostwick J 3rd. Breast reconstruction: a comprehensive approach.
Clin Plast Surg. 1979;6:143–162.
7. Bostwick J 3rd, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus
dorsi flaps. Plast Reconstr Surg. 1979;63:31–41.
8. Bostwick J 3rd, Vasconez LO, Jurkiewicz MJ. Breast reconstruction
after a radical mastectomy. Plast Reconstr Surg. 1978;61:682–693.
9. McCraw JB, Penix JO, Baker JW. Repair of major defects of the chest
wall and spine with the latissimus dorsi myocutaneous flap. Plast
Reconstr Surg. 1978;62:197–206.
10. Mendelson BC, Masson JK. Treatment of chronic radiation injury
over the shoulder with a latissimus dorsi myocutaneous flap. Plast
Reconstr Surg. 1977;60:681–691.
11. Maxwell GP, Leonard LG, Manson PN, Hoopes JE. Craniofacial
coverage using the latissimus dorsi myocutaneous island flap. Ann
Plast Surg. 1980;4:410–421.
12. Quillen CG. Latissimus dorsi myocutaneous flaps in head and neck
reconstruction. Plast Reconstr Surg. 1979;63:664–670.
13. Quillen CG, Shearin JC Jr, Georgiade NG. Use of the latissimus
dorsi myocutaneous island flap for reconstruction in the head and
neck area: case report. Plast Reconstr Surg. 1978;62:113–117.
14. Maxwell GP, Manson PN, Hoopes JE. Experience with thirteen
latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg.
1979;64:1–8.
15. Maxwell GP, Stueber K, Hoopes JE. A free latissimus dorsi
myocutaneous flap: case report. Plast Reconstr Surg. 1978;62:462–466.
16. Watson JS, Craig RD, Orton CI. The free latissimus dorsi
myocutaneous flap. Plast Reconstr Surg. 1979;64:299–305.
17. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg. 1982;69:
216–225.
18. Grotting JC, Neligan PC. Plastic Surgery. Vol. 5. Breast. Edinburgh:
Elsevier Health Sciences; 2012.
19. Hammond DC. Latissimus dorsi flap breast reconstruction. Clin
Plast Surg. 2007;34:75–82, abstract vi–vii. Dr. Hammond describes his
extensive experience with the latissimus flap and the technical
modifications he has made over time to improve outcomes andaesthetics.
He demonstrates that impressive results can be achieved with these
modifications and improvements in the design of breast prostheses.
20. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67:177–187.
21. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle:
a fresh cadaver study of the primary neurovascular pedicle. Plast
Reconstr Surg. 1981;67:631–636.
22. Rowsell AR, Eisenberg N, Davies DM, Taylor GI. The anatomy of
the thoracodorsal artery within the latissimus dorsi muscle. Br J
Plast Surg. 1986;39:206–209.
23. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular
neurovascular anatomy of the latissimus dorsi muscle: the basis for
splitting the flap. Plast Reconstr Surg. 1981;67:637–641.
24. Brown JM, Wickham JB, McAndrew DJ, Huang XF. Muscles within
muscles: coordination of 19 muscle segments within three shoulder
muscles during isometric motor tasks. J Electromyogr Kinesiol.
2007;17:57–73.
25. Gust MJ, Nguyen KT, Hirsch EM, et al. Use of the tabbed expander
in latissimus dorsi breast reconstruction. J Plast Surg Hand Surg.
2013;47:126–129.
26. Fisher J, Bostwick J 3rd, Powell RW. Latissimus dorsi blood supply
after thoracodorsal vessel division: the serratus collateral. Plast
Reconstr Surg. 1983;72:502–511.
27. McCraw JB, Papp C, Edwards A, McMellin A. The autogenous
latissimus breast reconstruction. Clin Plast Surg. 1994;21:279–288.
28. Germann G, Steinau HU. Breast reconstruction with the extended
latissimus dorsi flap. Plast Reconstr Surg. 1996;97:519–526.
29. Papp C, McCraw JB. Autogenous latissimus breast reconstruction.
Clin Plast Surg. 1998;25:261–266.
30. Papp C, Wechselberger G, Schoeller T. Autologous breast
reconstruction after breast-conserving cancer surgery. Plast Reconstr
Surg. 1998;102:1932–1936, discussion 1937–1938.
31. Delay E, Gounot N, Bouillot A, et al. Autologous latissimus breast
reconstruction: a 3-year clinical experience with 100 patients. Plast
Reconstr Surg. 1998;102:1461–1478. Delay et al. demonstrate their
technique for latissimus dorsi flap breast reconstruction and reported on
results and complications. Patient satisfaction was high. Postoperative
complications included partial necrosis (1%), total necrosis (1%), and
seroma (79%). Seroma was noted to occur more regularly in obese
patients.
32. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy &
Technique. New York: Churchill Livingstone; 1997.
33. Parviz M, Cassel JB, Kaplan BJ, et al. Breast conservation therapy
rates are no different in medically indigent versus insured patients
with early stage breast cancer. J Surg Oncol. 2003;84:57–62.
34. Evans GR, Schusterman MA, Kroll SS, et al. Reconstruction and the
radiated breast: is there a role for implants? Plast Reconstr Surg.
1995;96:1111–1115, discussion, 1116–1118.
35. Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in
the treatment of early breast carcinoma with mastectomy versus
breast conservation therapy: the National Cancer Institute
Randomized Trial. Cancer. 2003;98:697–702.
36. Forman DL, Chiu J, Restifo RJ, et al. Breast reconstruction in
previously irradiated patients using tissue expanders and implants:
a potentially unfavorable result. Ann Plast Surg. 1998;40:360–363,
discussion 363–364.
37. Chawla AK, Kachnic LA, Taghian AG, et al. Radiotherapy and
breast reconstruction: complications and cosmesis with TRAM
versus tissue expander/implant. Int J Radiat Oncol Biol Phys.
2002;54:520–526.
38. Contant CM, van Geel AN, van der Holt B, et al. Morbidity of
immediate breast reconstruction (IBR) after mastectomy by a
subpectorally placed silicone prosthesis: the adverse effect of
radiotherapy. Eur J Surg Oncol. 2000;26:344–350.
39. Disa JJ, Cordeiro PG, Heerdt AH, et al. Skin-sparing mastectomy
and immediate autologous tissue reconstruction after whole-breast
irradiation. Plast Reconstr Surg. 2003;111:118–124.
40. Kroll SS, Schusterman MA, Reece GP, et al. Breast reconstruction
with myocutaneous flaps in previously irradiated patients. Plast
Reconstr Surg. 1994;93:460–469, discussion 470–471.
41. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled
implants in the irradiated breast: recent trends and therapeutic
implications. Plast Reconstr Surg. 2000;105:930–942.
42. Spear SL, Clemens MW, Boehmler J. Latissimus dorsi flap in
reconstruction of the radiated breast. In: Spear SL, ed. Surgery of the
Breast: Principles and Art. Amsterdam: Wolters Kluwer; 2010.
43. Kim JYS. Anecdotal report. 2015.
44. Codner MA. Anecdotal report. 2014.
45. Fine NA, Hirsch EM. Keeping options open for patients with
anticipated postmastectomy chest wall irradiation: immediate tissue
expansion followed by reconstruction of choice. Plast Reconstr Surg.
2009;123:25–29.
46. Hammond DC, Simon AM, Khuthaila DK, et al. Latissimus dorsi
flap salvage of the partially failed TRAM flap breast reconstruction.
Plast Reconstr Surg. 2007;120:382–389.
47. Chang DW, Kroll SS, Dackiw A, et al. Reconstructive management
of contralateral breast cancer in patients who previously underwent

320.e2
SECTION II
CHAPTER 19 • Latissimus dorsi flap breast reconstruction
unilateral breast reconstruction. Plast Reconstr Surg. 2001;108:352–
358, discussion 359–360.
48. Spear SL, Boehmler JH, Taylor NS, Prada C. The role of the
latissimus dorsi flap in reconstruction of the irradiated breast. Plast
Reconstr Surg. 2007;119:1–9, discussion 10–11. The authors describe
their 10-year experience using the latissimus dorsi flap in prosthetic
reconstruction of irradiated breasts. Twenty-eight patients were identified,
18 of whom had a latissimus flap at the time of expander placement and
10 of whom underwent secondary latissimus flap reconstruction. No
patients developed capsular contracture, and overall patient satisfaction
was very high (8.8/10). The authors conclude that latissimus flaps can be
combined with prosthetic reconstruction to produce a cosmetically-pleasing
result in the previously irradiated breast.
49. Bailey S, Saint-Cyr M, Zhang K, et al. Breast reconstruction with the
latissimus dorsi flap: women’s preference for scar location. Plast
Reconstr Surg. 2010;126:358–365.
50. Mickel TJ, Barton FE Jr, Rohrich RJ, et al. Management and
prevention of lumbar herniation following a latissimus dorsi flap.
Plast Reconstr Surg. 1999;103:1473–1475.
51. Gerber B, Krause A, Reimer T, et al. Breast reconstruction with
latissimus dorsi flap: improved aesthetic results after transection of
its humeral insertion. Plast Reconstr Surg. 1999;103:1876–1881.
52. Aitken ME, Mustoe TA. Why change a good thing? Revisiting the
fleur-de-lis reconstruction of the breast. Plast Reconstr Surg.
2002;109:525–533, discussion 534–538.
53. Chang DW, Youssef A, Cha S, Reece GP. Autologous breast
reconstruction with the extended latissimus dorsi flap. Plast
Reconstr Surg. 2002;110:751–759, discussion 760–761. The authors in
this study present their clinical series of 75 extended latissimus dorsi flaps
for purely autologous breast reconstruction. In this series of 67 patients,
28% developed flap-related complications and 38.7% developed donor site
complications. Overall, donor site seroma was the most common
complications (25.3%), and the authors conclude that obese patients are at
higher risk of developing this complication.
54. Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi
myocutaneous flap. Ann Plast Surg. 1981;7:272–280.
55. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled
descending branch muscle-sparing latissimus dorsi flap for breast
reconstruction. Plast Reconstr Surg. 2009;123:13–24. Saint-Cyr et al.
present a series of 24 muscle-sparing latissimus flaps in 20 patient and
report on outcomes, complications, and functional disability compared
with the nonoperated side. The technique for the pedicled muscle-sparing
latissimus flap is also presented. There were no postoperative seromas
reported in this series and only one case of partial flap necrosis. When
comparing the operated and nonoperated sides, no statistically significant
functional differences were detected using the DASH questionnaire.
56. McCraw JB, Papp C. The Fleue de Lis Autogenous Latissimus Breast
Reconstruction. New York: Raven Press; 1991.
57. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous
flap without muscle. Plast Reconstr Surg. 1995;96:1608–1614.
58. Schwabegger AH, Harpf C, Rainer C. Muscle-sparing latissimus
dorsi myocutaneous flap with maintenance of muscle innervation,
function, and aesthetic appearance of the donor site. Plast Reconstr
Surg. 2003;111:1407–1411.
59. Dixon JM, Venizelos B, Chan P. Latissimus dorsi mini-flap: a
technique for extending breast conservation. Breast. 2002;11:58–65.
60. Nano MT, Gill PG, Kollias J, Bochner MA. Breast volume
replacement using the latissimus dorsi miniflap. ANZ J Surg.
2004;74:98–104.
61. Cho BC, Lee JH, Ramasastry SS, Baik BS. Free latissimus dorsi
muscle transfer using an endoscopic technique. Ann Plast Surg.
1997;38:586–593.
62. Woerdeman LA, Hage JJ, Thio EA, et al. Breast-conserving therapy
in patients with a relatively large (T2 or T3) breast cancer: long-
term local control and cosmetic outcome of a feasibility study. Plast
Reconstr Surg. 2004;113:1607–1616.
63. Menke H, Erkens M, Olbrisch RR. Evolving concepts in breast
reconstruction with latissimus dorsi flaps: results and follow-up of
121 consecutive patients. Ann Plast Surg. 2001;47:107–114.
64. Mlodinow AS, Kim JY, Khavanin N, et al. Individualized risk of
surgical complications: an application of the Breast Reconstruction
Risk Assessment (BRA) Score. Plast Reconstr Surg. 2014;134:77–78.
65. Clough KB, Louis-Sylvestre C, Fitoussi A, et al. Donor site sequelae
after autologous breast reconstruction with an extended latissimus
dorsi flap. Plast Reconstr Surg. 2002;109:1904–1911.
66. Brumback RJ, McBride MS, Ortolani NC. Functional evaluation of
the shoulder after transfer of the vascularized latissimus dorsi
muscle. J Bone Joint Surg Am. 1992;74:377–382.
67. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of
latissimus dorsi donor site. Plast Reconstr Surg. 1986;78:336–344.
68. Yezhelyev M, Duggal CS, Carlson GW, Losken A. Complications of
latissimus dorsi flap breast reconstruction in overweight and obese
patients. Ann Plast Surg. 2013;70:557–562.
69. Kim H, Wiraatmadja ES, Lim SY, et al. Comparison of morbidity of
donor site following pedicled muscle-sparing latissimus dorsi flap
versus extended latissimus dorsi flap breast reconstruction. J Plast
Reconstr Aesthet Surg. 2013;66:640–646.
70. Hokin JA, Silfverskiold KL. Breast reconstruction without an
implant: results and complications using an extended latissimus
dorsi flap. Plast Reconstr Surg. 1987;79:58–66.
71. McCraw JB, Maxwell GP. Early and late capsular “deformation” as
a cause of unsatisfactory results in the latissimus dorsi breast
reconstruction. Clin Plast Surg. 1988;15:717–726.
72. De Mey A, Lejour M, Declety A, Meythiaz AM. Late results and
current indications of latissimus dorsi breast reconstructions. Br J
Plast Surg. 1991;44:1–4.
73. Pacella SJ, Vogel JE, Locke MB, Codner MA. Aesthetic and technical
refinements in latissimus dorsi implant breast reconstruction: a
15-year experience. Aesthet Surg J. 2011;31:190–199.

SECTION II • Reconstructive Breast Surgery
20.1 
Introduction to abdominally based
free flaps
Maurice Y. Nahabedian
Breast reconstruction using autologous tissue provides
an option for women that is natural, lasts forever, and
often provides body-contouring advantages. There are
several anatomic regions of the body that can be used
including the abdomen, posterior thorax, gluteal region,
and thigh. The abdomen is the most commonly consid­
ered donor site for a variety of reasons that include
sufficient quantity to reconstruct a breast, abdomino­
plasty type closure, and patient desire. Flaps derived
from the abdomen can be based on a pedicle or as a free
tissue transfer. Advantages of abdominal free flaps
include the ability to optimally position the flap on
the chest wall; typically abdominally based free tissue
transfer has become the most common form of breast
reconstruction.
The evolution of breast reconstruction using abdomi­
nal tissue dates back to 1979, when Holmström described
a free tissue transfer technique using the abdominal skin
and fat.1 However, this operation was overshadowed
primarily because of the work of Carl Hartrampf et al.
who described the pedicle TRAM (transverse rectus
abdominis musculocutaneous) flap in 1982.2 The pedicle
TRAM flap revolutionized the state-of-the-art for breast
reconstruction because it did not require microvascular
techniques, it provided an alternative to prosthetic
devices and the latissimus dorsi flap, as well as improved
abdominal aesthetics. Although the aesthetic outcomes
related to the breast were usually excellent, concerns
regarding the donor site gradually became an issue due
to loss of strength and occasional contour abnormalities.
In most cases, the entire rectus abdominis muscle was
harvested because the vascularity to the TRAM flap
was derived from the perforators emanating from the
superior epigastric artery and vein that traversed
through the rectus abdominis muscle. The role of the
muscle was essentially that of a conduit for perfusion
and occasionally provided volume. While a few sur­
geons were preserving the continuity of the rectus
abdominis muscle, most were elevating the entire length
and width, placing the patients at increased risk for
weakness and contour abnormality. The use of pros­
thetic materials to reinforce the abdominal wall was
effective; however, the loss of strength could not be
overcome, especially when both rectus abdominis
muscles were harvested for unilateral or bilateral
reconstruction.
The free TRAM did not become a universally accepted
option until 1989, when Grotting et al. compared the
free TRAM flap to the conventional TRAM flap (see
Chapter 20.4).3 With this flap, the same adipocutaneous
territory could be used; however, the vascularity was
derived from the inferior epigastric artery and vein
rather than the superior epigastric artery and vein. The
inferiorly based vessels traversed a shorter length, had
a larger caliber, and were not associated with choke
vessels, all of which could potentially enhance the per­
fusion to the flap. Although the free TRAM was still a
musculocutaneous flap, less muscle and fascia was
removed compared with the pedicle TRAM that served
to minimize compromising the anterior abdominal wall.
The flap could be harvested with varying degrees of
muscle sparing (MS) that included sparing the medial
and lateral segments (MS-2) and the medial or lateral
segments (MS-1). In some cases, the entire width of the
muscle could be harvested (MS-0). Functionally, the
MS-0 free TRAM was similar to the pedicle TRAM flap
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322
SECTION II
CHAPTER 20.1 • Introduction to abdominally based free flaps
focused over flap perfusion and abdominal morbidity.
It can be argued that the free TRAM has the best perfu­
sion because it typically includes the greatest number of
perforators. However, the free TRAM by definition
includes a segment of the rectus abdominis muscle
whereas the others do not. Thus, the questions that arise
are whether there is a functional difference between the
free TRAM, DIEP, and SIEA flaps, whether this differ­
ence is amplified with bilateral reconstruction compared
with unilateral reconstructions, and whether differences
in perfusion results in differences in fat necrosis, re-
operation rates, or total flap failure. The following
chapters will address the specifics of all three flaps to
improve the readers understanding of the risks and
benefits of microvascular breast reconstruction using
the abdomen as the donor site.
References
1. Holmström H. The free abdominoplasty flap and its use in
breast reconstruction. Scand J Plast Reconstr Surg. 1979;13:423–427.
This is the first paper describing the free abdominoplasty flap for breast
reconstruction. Failures and successes are reviewed as well as angiographic
studies.
2. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction
with a transverse abdominal island flap. Plast Reconstr Surg.
1982;69:216–225. This is the original manuscript describing the pedicle
TRAM for breast reconstruction. The anatomy and surgical technique is
highlighted.
3. Grotting JC, Urist MM, Maddox WA, et al. Conventional TRAM flap
versus free microsurgical TRAM flap for immediate breast
reconstruction. Plast Reconstr Surg. 1989;83:828–841. This paper
compares the pedicle and free TRAM flaps for breast reconstruction. The
free TRAM compared favorably to the pedicle TRAM in terms of
complications, operating time, blood loss, hospitalization, and functional
return.
4. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg. 1994;32:32–38. This is the original paper
describing the DIEP flap for breast reconstruction. A total of 15 flaps were
used based on 1, 2, or 3 perforators.
5. Koshima I, Soeda S. Inferior epigastric artery skin flaps without
rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648. The DIEP
flap is described without harvesting the rectus abdominis muscle. The
authors demonstrate that a single perforator is capable of perfusing an
entire flap.
6. Arnez ZM, Khan U, Pogorelec D, et al. Breast reconstruction using
the free superficial inferior epigastric artery (SIEA) flap. Br J Plast
Surg. 1999;52:276–279. This paper reviews the authors’ experience with
five flaps based on the superficial system. The authors describe the anatomy
and technique for flap harvest.
7. Grotting JC. The free abdominoplasty flap for immediate breast
reconstruction. Ann Plast Surg. 1991;27:351–354. The free
abdominoplasty flap is described demonstrating that muscle does not have
to be harvested with a flap to achieve successful outcomes.
because the continuity of the rectus abdominis muscle
was lost. Thus, the era of free tissue transfer for autolo­
gous breast reconstruction began.
In 1994, Allen and Treece4 described the DIEP (deep
inferior epigastric perforator) flap for breast reconstruc­
tion (see Chapter 20.2). The DIEP flap was similar to the
free TRAM, in that it utilized the same adipocutaneous
territory and the same vascularity. The principal differ­
ence was that the rectus abdominis muscle was pre­
served in its entirety, thus reducing the likelihood of
abdominal weakness or contour abnormality.5 Although
the muscle is preserved, the anterior rectus sheath is
incised and a myotomy is performed in order to dissect
the inferior epigastric artery and vein. Complexities
associated with the DIEP flap include selection of the
proper perforator(s) and determination of the perfora­
somes. There is a plethora of perforators of varying
caliber with variable perfusion capacity. The ability to
perform a DIEP flap has been facilitated using preopera­
tive technology such as magnetic resonance angiogra­
phy or computerized tomographic angiography to
identify the location and caliber of the dominant perfo­
rators. Intraoperative technologies such as fluorescent
angiography can provide important information regard­
ing tissue perfusion.
The superficial inferior epigastric artery (SIEA) flap
is not technically a perforator flap because the blood
supply does not perforate a muscle; rather it is an adi­
pocutaneous flap based on an entirely different blood
supply (see Chapter 20.3).6 This flap was initially
described by Grotting in 19917 and has the distinct
advantage over the other free and pedicle abdominally
based flaps, in that it does not require an incision in the
anterior rectus sheath or a myotomy in the rectus
abdominis muscle. The advantages of this flap are that
it is a true abdominoplasty flap and does not violate the
integrity of the anterior abdominal wall. The disadvan­
tages of this flap are that the superficial inferior epigas­
tric artery and vein are not usable in approximately 50%
of patients and that the perfusion capacity of the flap is
generally restricted to zones 1 and 2.
Since the initial descriptions of these three microvas­
cular flaps for breast reconstruction, controversies have
existed as to which is best or preferred. The debates are

SECTION II • Reconstructive Breast Surgery
20.2 
The deep inferior epigastric artery
perforator (DIEAP) flap
Philip N. Blondeel, Colin M. Morrison, and Robert J. Allen, Sr
SYNOPSIS
■ The deep inferior epigastric artery perforator (DIEAP) flap provides a
large volume of soft, malleable tissue that resembles the natural
consistency of the breast.
■ DIEAP flap dissection is comparable with conventional myocutaneous
free flap surgery, once the initial learning curve is overcome.
■ The main advantage of the DIEAP flap is preservation of full rectus
abdominis muscle function with less donor site morbidity.
■ In experienced hands, the DIEAP flap loss rate is less
than 1%.
■ The DIEAP flap is the perforator flap of choice for autologous breast
reconstruction.
Access the Historical Perspective section online at

Introduction
Perforator flaps have become increasingly popular in
recent years. They are at the top of the reconstructive
ladder and are considered an advancement of musculo­
cutaneous and fasciocutaneous flaps. Passive muscle
and fascial carriers are no longer required to ensure flap
vascularity, and by virtue of their composition, perfora­
tor flaps permit excellent “like for like” tissue replace­
ment with minimal aesthetic or functional donor
morbidity. Perforator flaps are usually thin, pliable,
easily moldable flaps that are well suited to resurfacing
work. They are also ideal for reconstructing pliable
structures such as the tongue or for molding complex
contours in the head and neck region. Perforator flaps
with large amounts of subcutaneous fat are ideal for
reconstructing the breast.
A perforator flap is defined as a flap of skin and
subcutaneous tissue, which is supplied by an isolated
perforator vessel. Perforators pass from their source
vessel to the skin surface either through or between the
deep tissues (mostly muscle). Any vessel that traverses
through muscle before perforating the outer layer of the
deep fascia to supply the overlying skin is termed a
“myocutaneous perforator”. A vessel that traverses
through septum, i.e., between the muscle bellies, is
designated a “septocutaneous perforator”.
Evolution of perforator flaps has been intimately
related to growing knowledge of the blood supply to
the skin and the history of musculocutaneous and fas­
ciocutaneous flap development.
The deep inferior epigastric artery perforator (DIEAP)
flap arose as a refinement of the conventional myocuta­
neous lower abdominal flap. The myocutaneous perfo­
rators of the inferior epigastric vessels were described1
soon after the first transverse rectus abdominis myocu­
taneous (TRAM) flap was performed for breast recon­
struction by Holmström and Robbins.2,3 In the mid-1980s,
following Taylor’s landmark work on the vascular ter­
ritory of the deep inferior epigastric artery, it became
apparent that the lower abdominal flap could be per­
fused solely by a large periumbilical perforating vessel.
That assumption was confirmed in 1989, when Koshima
and Soeda4 published two cases of “inferior epigastric
skin flaps without rectus abdominis muscle”.
Initially the DIEAP flap met with animosity from
many in the surgical community, as it challenged con­
ventional teaching and was thought to be unsafe.
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324
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
The anatomy of the deep inferior epigastric artery
system is very variable.15,16 The average pedicle length
is 10.3 cm, and the average vessel diameter is 3.6 mm.
Normally, the deep inferior epigastric artery divides
into two branches, with a dominant lateral branch (54%).
However, if the deep inferior epigastric artery does not
divide, the vessel has a central course (28%) with mul­
tiple small branches to the muscle and centrally located
perforators. If the medial branch is dominant (18%),
However, we are now in an era where DIEAP flaps are
routinely performed in plastic surgery units throughout
the world.5
With an increased emphasis on optimizing the aes­
thetic result and minimizing donor site morbidity, in the
authors’ opinion, the DIEAP flap is the current gold
standard in breast reconstruction.
Basic science/anatomy
The deep inferior epigastric artery perforator
(DIEAP) flap
The deep inferior epigastric artery arises from the exter­
nal iliac, immediately above the inguinal ligament. It
curves forward in the subperitoneal tissue and then
ascends obliquely along the medial margin of the
abdominal inguinal ring. Continuing its course upward,
it pierces the transversalis fascia, passing in front of the
linea semicircularis, ascending between the rectus
abdominis and the posterior lamella of its sheath.
The deep inferior epigastric artery finally divides
into numerous branches, which anastomose, above the
umbilicus, with the superior epigastric branch of the
internal thoracic artery and with the lower intercostal
arteries (Figs. 20.2.1 & 20.2.2).
Fig. 20.2.1  The vascular anatomy of the lower abdomen.
In the right hemi-abdomen, the skin is removed down to the
superficial inferior epigastric vessels. The artery with its
common veins, and the superficial inferior epigastric vein
can be found medial to the superficial circumflex iliac
vessels. Around the umbilicus, the perforators of the deep
inferior epigastric system connect with arteries and veins of
the superficial system. The anterior branches of the
intercostal arteries and veins move anterior and distally
from their origin at the midaxillary line. Variable
anastomoses between these different vessels make up for a
complex and intense random network between the skin and
the deep fascia. On the left side of the abdomen, the deep
fascia of the rectus abdominis muscle is removed and the
fascia of the external and internal oblique have been
retracted. The deep inferior epigastric artery and vein pass
deep to the lateral board of rectus abdominis as they move
more cranially and enter into the rectus abdominis a few
centimeters higher. Segmental branches of the deep inferior
epigastric system connect with the anterior branch of the
intercostal artery and veins (particularly the lateral branch of
the deep inferior epigastric artery). The anterior intercostal
nerves run together with the segmental branches and
branch into sensory branches that run with the perforators
into the subcutaneous tissues and motor branches that run
medial and distally in the rectus abdominis muscle. More
cranially, the deep inferior epigastric vessels anastomose in
the diffuse network throughout the muscle with the superior
epigastric artery. DIEA, deep inferior epigastric artery; SEA,
superior epigastric artery; SCIA, superficial circumflex iliac
artery; SIEA, superficial inferior epigastric artery; SIEV,
superficial inferior epigastric vein.
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324.e1
Historical perspective
Historical perspective
In 1989, Koshima and Soeda4 reported the first clinical
application of the inferior epigastric artery perforator
flap. They demonstrated that it was possible to harvest
the same amount of lower abdominal skin and fat as in
the TRAM flap, without sacrificing the rectus abdominis
muscle. Koshima et al.6 then reported another 13 cases
with free thin paraumbilical perforator based flaps.
Later, Pennington et al.7 used an anastomosis between
the distal end of the ipsilateral pedicle and the contra­
lateral pedicle to augment the blood supply of a free
TRAM flap. Allen and Treece8 reported 22 successful
breast reconstructions with the DIEAP free flap, and
finally, Blondeel and colleagues9,10 improved the under­
standing of the flap and popularized its use in autolo­
gous breast reconstruction.11–14

325
Basic science/anatomy
are frequently large and have few muscular side
branches. The distance from the subcutaneous fat to the
deep inferior epigastric vessels is also shorter, simplify­
ing this most delicate part of the dissection.18
As a result, the design of a DIEAP flap is made over
the most centrally located, dominant perforator, lateral
or medial, as long as sufficient abdominal subcutaneous
fat tissue is available and the least vascularized part of
the flap across the midline can be discarded (Fig. 20.2.4).
At the origin of the perforator, several nerves are
encountered (see Fig. 20.2.3). Although there is no con­
stant anatomy, mixed segmental nerves run underneath
or through the muscle from laterally and split into a
sensate nerve running with the perforator into the flap
and a motor nerve crossing on top of the deep inferior
epigastric vessels distal to the bifurcation of the perfora­
tor, into the medial part of the rectus abdominis muscle.19
One should always expect and anticipate a variety of
anatomic differences.
The superficial inferior epigastric artery (SIEA) origi­
nates 2–3 cm below the inguinal ligament directly from
the common femoral artery (17%) or from a common
origin with the superficial circumflex iliac artery (48%).
It then passes superiorly and laterally in the femoral
triangle lying deep to Scarpa’s fascia and crosses the
inguinal ligament at the midpoint between the anterior
superior iliac spine and the pubic tubercle. Above the
flow appears to be significantly lower than in a central
system or in patients with a dominant lateral branch.17
Blondeel et al.17 found between two and eight large
(>0.5 mm) perforators on each side of the midline. The
majority of these perforators emerged from the anterior
rectus fascia in a paramedian rectangular area 2 cm
cranial and 6 cm caudal to the umbilicus and between
1 and 6 cm lateral to the umbilicus. Anatomic symmetry
was hardly ever encountered. The closer a perforator is
to the midline, the better the blood supply to the least
vascularized part of the flap across the midline, as one
choke vessel less has to be transgressed. However, the
lateral perforators are often dominant and easier to
dissect because they run more perpendicularly through
the muscle. The sensory nerve that runs with these
perforating vessels is also often much larger (Fig. 20.2.3).
The medial perforators provide better perfusion of the
flap, but they have a longer intramuscular course,
requiring more elaborate dissection with extensive
longitudinal splitting of the muscle. An alternative is to
extend the design of the flap to include more tissue from
the flank. If one is uncertain as to whether or not enough
volume can be transferred, the perforators can be dis­
sected on both sides (Siamese flap).6
Preference is also given to perforators that pass
through the rectus abdominis muscle at the level of the
tendinous intersections. At this point, the perforators
Fig. 20.2.3  (A,B) The anatomy of the intercostal nerves. The mixed intercostal nerves run below the fascia of the internal oblique and predominantly enter the rectus
abdominis muscle at its posterior surface at the level of the lateral branch of the deep inferior epigastric artery. They follow the intercostal and segmental vessels and
mostly pass over the submuscular or intramuscular part of the lateral branch of the deep inferior epigastric artery. At that point, it splits into two motor branches, one lateral
and one medial, and additionally into a pure sensory nerve that accompanies the perforating artery and vein.
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326
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
perforator destined to vascularize the fat and skin that
has few or no side branches to the muscle.
The superficial inferior epigastric vein is the largest
vein draining the skin paddle of the DIEAP flap. It is
located below the dermal plexus but above Scarpa’s
fascia, midway between the anterior superior iliac spine
and the pubic symphysis. Harvesting an elliptical skin
island transects this vein, redirecting the venous drain­
age through the smaller perforating veins. Connections
between the superficial epigastric vein and the deep
inferior epigastric system exist in every patient, but
substantial medial branches crossing the midline have
been found to be absent in 36% of cases.21,22 In these
flaps, venous connections are only present through the
subdermal capillary network. This explains why the
portion of a flap farthest from the midline may suffer
from venous congestion and why the presence of this
problem is so variable and unpredictable.
The lymphatic drainage of the DIEAP flap can be
divided into a superficial and a deep system. The
superficial collectors are located directly underneath
the reticular dermis. Deep cuts performed during
de-epithelialization may injure this system. The super­
ficial collectors drain to the superficial lymph nodes in
the groin. The deep system drains the deep structures
of the abdominal wall, i.e., the muscles and fascia
and is located in close proximity to the arteries and
veins. Careful dissection of the vascular pedicle avoids
iatrogenic damage to this lymphatic system. The deep
system drains to the inferior epigastric artery and then
to the deep iliac nodes.23
Recipient vessels
The internal mammary artery and its accompanying
veins are the first choice for DIEAP flap breast recon­
struction.10,12,24 Its central position on the chest wall
facilitates microsurgery and offers the most flexibility
during breast shaping. The vessels are easy to dissect
and are usually protected from radiotherapy damage.
In a number of irradiated vessels perivascular fibrosis
can be encountered. Chest wall inflammation, following
infected implant removal or extreme capsular fibrosis,
can sometimes cause severe perivascular scarring.
Although the artery is usually of sufficient caliber, the
size of the veins is very variable. In most cases, the veins
on the left side of the chest wall are smaller than those
on the right side. For this reason, the authors prefer to
dissect the vessels at the level of the left third or fourth
rib, but at the level of the fourth rib on the right side. A
small segment of cartilage can be removed together
with some intercostal muscles, both cranially and cau­
dally (Fig. 20.2.6). This provides sufficient exposure of
Fig. 20.2.4  Once the position of the dominant perforator is located on the
abdomen, the flap is centered over this perforator. The incision on the abdomen is
symmetrical on both sides, but the least vascularized part of the flap will be
discarded.
Fig. 20.2.5  The different types of perforators that can be found at the lower
abdominal wall. (1) The branches of the superficial inferior epigastric artery are
direct perforators that vascularize the subcutaneous fat and skin after perforating the
deep and superficial fascia. All other perforators are indirect perforators; (2)
perforators that have a predominant vascularization of the subcutaneous fat tissue
and skin with few muscular branches; (3) perforators that branch off of side
branches that have a predominant goal of nourishing the muscle; (4) perforators
that pass through the rectus abdominis muscle without branching; (5) perforators
that pass through the septum or around the rectus abdominis muscle with the sole
purpose of vascularizing the subcutaneous tissues.
1
2
3
4
5
Septum
Muscle
Deep fascia
Subcutaneous fat
inguinal ligament, the SIEA pierces Scarpa’s fascia and
lies in the superficial subcutaneous tissue. During its
course, the SIEA lies deep to and parallel to the super­
ficial inferior epigastric vein. The vein drains directly
into the saphenous bulb.20
The SIEA is seen as a direct perforator to the skin
while the perforators of the deep system are consid­
ered indirect perforators (Fig. 20.2.5). Of all vessels,
it is important to choose the largest, most dominant

327
Patient presentation
addition to producing accurate and detailed images,
there is no radiation exposure,26 unlike CT imaging.
Besides this imaging, the conventional preoperative
work-up includes blood work, oncologic screening, and
additional tests for concomitant diseases if necessary.
Ultrasound evaluation of perforator vessels
This is performed with a color Doppler, which employs
a combination of grayscale and color Doppler imaging.
This modality has 100% positive predictive value and
few false-negatives.27
Grayscale imaging shows the anatomic detail of fixed
points, axial vessels, and perforating branches. The
addition of color Doppler allows identification of blood
flow, direction (towards or away from the probe), pattern
of flow (i.e., venous or arterial), and finally a measure
of blood flow velocity.28–31
The disadvantages of color duplex lie in its lack of
anatomic detail and operator dependence. It requires a
detailed knowledge of 3D vascular anatomy, as well as
expertise in the handling of the devise. While it provides
dynamic information about blood flow, this may lead to
a false sense of security because humeral and nervous
stimuli can affect the microcirculation and cause fluctua­
tions in vessel flow. Hence, flow rates do not always
correlate with the size of the perforator.
In addition to preoperative imaging, it is possible to
use a unidirectional hand-held pencil probe for identi­
fication of superficial vessels in the operating theatre.
The perforators identified can be marked on the patient’s
skin to allow accurate flap design and aid intraoperative
dissection. This is a simple and inexpensive technique,
which provides a useful intraoperative adjunct.32 There
can, however, be false-negative and false-positive
signals as a result of interference from axial vessels or
perforators that run parallel to the fascia, before enter­
ing their suprafascial course.
CT imaging
Multidetector-row helical CT is a recent innovation that
permits rapid delineation of an anatomic area of inter­
est, giving excellent resolution and low artifact rating.
It takes less than 10 min to perform and is well tolerated
by patients. This has become the modality of choice for
the identification of abdominal wall perforators.33–35 The
use of magnetic resonance imaging (MRI) to avoid the
high X-ray dose is promising but still needs further
refinement.36
The scanning is performed in conjunction with intra­
venous contrast medium and allows evaluation of
the donor and recipient vessels. Information collected
includes the exact location and intramuscular course of
the vessels and adequate recipient vessel length. One
can also limit the dissection and exposure to the removal
of only the intercostal muscles. Wider exposure can be
obtained by nibbling away the lower border of the
superior rib and the upper border of the inferior rib.
At the level of the second and third intercostal space,
large perforators sometimes emerge from between the
intercostal muscles to perforate the medial part of the
pectoralis major muscle. The size of these vessels is
variable, and it is estimated that they can only be used
as recipient vessels for free flaps in about 5–10% of
cases. These vessels can be identified and evaluated
above and below the pectoralis during preparation of
the recipient site. If no adequate perforators are found,
the internal mammary artery and the accompanying
veins are then prepared.25
Patient presentation
When designing a DIEAP flap, the main factor is the
amount of viable tissue that can be harvested on a
particular perforator. The most accurate indicator of
this is preoperative localization of the dominant source
of blood inflow by duplex Doppler or computed
tomography (CT) imaging. In addition to defining the
“safe” flap territory, these techniques provide a degree
of reassurance by avoiding intraoperative surprises,
and considerably reduce operative time. A reduction
of operative costs significantly decreases the overall
expense of the reconstructive procedure.
More recently, magnetic resonance angiography has
shown promise in the imaging of perforators. In
Fig. 20.2.6  The internal mammary artery and two common veins on the right side
after removing a small part of the costal cartilage of the third rib.
Intercostal muscles
Sternum
Pectoralis major muscle
II
III

328
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
the surgeon him/herself and correlated to intraoperative
findings (Figs. 20.2.7 & 20.2.8).
Patient selection
Patients eligible for an autologous breast reconstruction
with a DIEAP or SIEA flap are mainly those with suf­
ficient lower abdominal subcutaneous fat tissue. In
Western society, many women are good candidates, but
cultural differences can apply. For example, Asian
women are generally slimmer and may prefer other
donor sites such as the anterolateral thigh area. The
lower abdomen is, however, first preference for autolo­
gous breast reconstruction. Only in very slender women,
or in cases where scarring of the abdominal wall
vessels from their origin, the caliber of the perforators,
and also identifies the dominant vessel. Delineation of
the relative dominance of the deep and superficial
systems allows the surgeon to consider different options
preoperatively. Not only can this modality be used to
select suitable patients preoperatively but also operative
times are reduced by a mean of 21%, with the obvious
associated cost benefits.37
The disadvantages of multidetector-row helical CT lie
in the X-ray dosage and use of intravenous contrast
media, with the resultant risk of anaphylaxis. The X-ray
dose, albeit significant, is less than a conventional liver
CT scan and can be combined with staging investiga­
tions to reduce the overall exposure. Interpretation of
the images can be done before and during surgery by
Fig. 20.2.7  Different views and 3D reproductions of a perforator on the right side of the abdominal wall. The sagittal view shows the course of the vessel through the rectus
abdominis muscle. The location of the perforator is described in relation to the umbilicus.

329
Surgical technique
or those with a limited life span because of age or concur­
rent disease. In addition, patients objecting to donor site
scars, those refusing complex surgery, or those unable to
accept the possible microsurgical complications are seen
as candidates for implant-based surgery.
Surgical technique
Preoperative marking
For this surgical technique,38 the patient is marked in a
standing position. A fusiform skin island is drawn on
the abdomen, similar to the one used for breast recon­
struction with a free TRAM flap, but the bulk of the flap
endangers the normal blood circulation of the free flap
or the abdominoplasty flap, secondary options, such as
gluteal perforator flaps or internal thigh flaps, are con­
sidered. Pedicled latissimus dorsi or thoracodorsal
artery perforator flaps in combination with an implant
are further down the reconstructive ladder and implant
basic techniques are avoided if possible.
Severe obesity, uncontrolled diabetes, debilitating
cardiovascular disease, and uncontrollable coagu­
lopathies are the most frequent examples of absolute
contraindications to DIEP flap reconstruction. Smokers
and unmotivated patients are advised to postpone their
surgery if oncologically possible. Implant reconstruction
is only recommended in patients with a poor prognosis
Fig. 20.2.8  CT-angiograms of a supraumbilical lateral perforator on the left side, symmetrical to a similar perforator on the right side, vascularizing only the most lateral
parts of the lower abdomen. The sagittal view shows a relatively easy dissection as the vessel penetrates directly in the muscle, but choosing this perforator means that
tissue beyond the midline will not be vascularized.

330
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
Dissection of the vascular pedicle of a DIEAP flap can
be divided into three different technical stages: supra­
fascial, intramuscular, and submuscular. The most
demanding stage is the intramuscular dissection of the
vascular pedicle.
Suprafascial dissection
Dissection begins laterally in the flanks and progresses
medially with the aid of cutting and coagulating dia­
thermy. The skin and subcutaneous fat are lifted off the
external oblique fascia up to the lateral border of the
rectus abdominis muscle. At this point, dissection pro­
ceeds more cautiously as the perforators are identified.
Gentle traction on the flap helps provide good exposure
of the vessels. Again, if imaging data is available, the dis­
section can progress rapidly to the preselected perfora­
tor, with ligation of the more laterally placed perforators
(Fig. 20.2.9B). If only a unidirectional Doppler probe
was used, one can try to visualize as many perforators
as possible before selecting the largest one. This method
needs some expertise, can be time-consuming, and does
not allow evaluation of all the medial perforators.
If the caliber of one vessel is estimated to be insuffi­
cient, an adjacent perforator located on the same vertical
line can also be dissected. The abdominal wall muscles
must be relaxed at all times and the perforating vessels
kept moist with normal saline. No antispasmodic agents
are routinely used. When dissecting a perforator from
the lateral side, it is important to realize that a side
branch may be located more medially. Extra care must
be taken when dissecting the full circumference of a
vessel, but complete dissection helps prevent vessel
damage when raising the flap from the contralateral
side (Fig. 20.2.9C,D).
The anterior rectus fascia is then incised with a pair
of scissors following the direction of the rectus abdomi­
nis muscle fibers at the rim of the tiny gap in the fascia
through which the perforating vessel passes (Fig.
20.2.9E). If more than one perforator is dissected, the
different gaps can be connected with each other. A small
cuff of fascia may be left around the perforator if the
vessel is small or if the surgeon feels more comfortable
doing so.
Lifting the fascia helps mobilize the perforator, which
can be freed by blunt dissection, gently pushing away
the loose connective tissue. The perforator can be adher­
ent to the deep surface of the anterior rectus fascia for
a variable distance before it plunges into the muscle.
The division of the fascia is continued superiorly for a
distance of 3–4 cm and inferiorly to the lateral border of
the rectus abdominis muscle in an oblique line towards
the inguinal ligament (Fig. 20.2.9F). At this point, the
is centered over the selected perforator. Although the
size and shape may vary slightly, the borders of a DIEAP
flap are generally located at the level of the suprapubic
crease, the umbilicus, and both anterior superior iliac
spines, but the flap may be extended laterally to the
midaxillary lines.
A DIEAP flap generally measures 12–15 cm in height
and 30–45 cm in width. However, the tension of the
donor site following closure should be estimated, as this
ultimately limits the size of the flap that can be har­
vested. A horizontal line is drawn just above the umbi­
licus and another one marked 12–15 cm below this. At
a level 2 cm below the umbilicus, the lateral limits of the
flap are marked 15–23 cm on either side of the midline.
The amount of subcutaneous fat present in the flanks is
assessed, as this can be included in the flap if required
(Fig. 20.2.9A). All the outer markings are connected by
a continuous line placed in natural skin creases.
Operative procedure (see Video 20.2.1 )
The patient is placed in a supine position with the arms
positioned beside the trunk. If available, imaging data
is drawn on the patient’s abdomen using a 1 cm grid
system based on the umbilicus. Two intravenous lines,
an indwelling urinary catheter, and antithrombotic
stockings are applied. A warming blanket is used to
keep the patients core body temperature at 37°C. The
proposed incision lines are infiltrated with a dilute solu­
tion of local anesthetic and adrenaline (40 mL 1%
xylocaine with 1/100 000 adrenaline in 40 mL sterile
water), except in the region of the superficial epigastric
veins. Three separate stab incisions are then placed
around the umbilicus and connected with the aid of skin
hooks. The umbilicus is incised circumferentially down
to the fascia. While making the inferior incision, care is
taken to preserve the superficial epigastric veins. If the
venous drainage of the flap is insufficient or thrombosis
of the perforating vein(s) occurs after the anastomosis,
the superficial epigastric veins can be used as an addi­
tional venous conduit. Two or three veins may be
present, but they commonly unite further down the
abdominal wall. The veins are dissected over a length
of 2–3 cm and ligated with clips to make them easily
retrievable later, if needed. If the caliber of the superficial
epigastric artery is noted to be large enough, a similar
skin island to the DIEAP flap can be harvested on these
two vessels. The incisions are continued down to the
fascia. Beveling is avoided unless extra volume is
required, as this may later lead to a depressed scar in
the lower abdomen. Laterally however, the flap may be
beveled to include more fat and reduce residual
“dog-ears”.

331
Surgical technique
direction of the division of the fascia is changed into the
direction of the fibers of the external oblique muscle.
This avoids a continuous area of weakness of the lower
abdominal wall, as closure of the fascia is performed on
top of the rectus abdominis muscle. Two separate
incisions, one around the perforator and one over the
deep inferior epigastric vessels at the lower lateral
border of the rectus muscle, can also be performed.
It is advisable to fully complete the dissection of the
DIEAP flap on one side before progressing to the other.
A
B
C
D
Fig. 20.2.9  (A) Incision of skin and subcutaneous tissue is extended towards the flanks if additional tissue is needed. The dominant perforator on the right side is marked
with an ‘x’ on the flap. (B) The flap is elevated from lateral to medial until the area around the preoperatively marked perforator is reached. Undermining is then continued
proximal and distal to the perforator. (C) Undermining continues around the perforator for a distance of about 2 cm. Lifting up the subcutaneous tissue is easier at this point
when the deep fascia is still closed. (D) Access to the perivascular loose connective tissue is found by incising the gap in the deep fascia and the tissues surrounding the
vessels.
Continued

332
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
E
F
G
H
I
(E) The deep rectus fascia is incised vertically following the
fibers of the rectus abdominis muscle both cranially and caudally. The perforator is
freed in its supramuscular course. (F) The deep fascia is opened all the way down to
the infralateral border of the rectus muscle and further distally along its lateral border
to create exposure of the deep inferior epigastric artery and vein. (G) The rectus
abdominis muscle is split following the muscle fibers until the posterior fascia or the
peritoneum can be seen. Sensory nerves coming from lateral and following the
perforator can be transected. Motor nerves are left intact (white arrow). (H) Wide
exposure is achieved with a self-retaining retractor. A bloodless field allows perfect
control of the dissection. The main branch of the deep inferior epigastric artery and
its veins is clipped distal to the perforator (white arrow). (I) Once the entire course
of the perforator and the main vessel is clear, the posterior part of the perforator and
the main vessel is dissected off the surrounding tissues. The distal part of the deep
inferior epigastric vessels can be dissected either through the same incision through
the rectus muscle or from laterally by pulling the rectus muscle medially.
Fig. 20.2.9, cont’d
This allows a “life boat” in the form of a contralateral
DIEAP flap or TRAM flap to be performed if the perfo­
rator is inadvertently damaged. It is important to
emphasize that the vessels must be protected at all
stages and complete muscle relaxation is necessary until
donor site closure is obtained. As dissection progresses,
the DIEAP flap should be secured to the abdominal wall
with the aid of staples.
Intramuscular dissection
The rectus abdominis muscle should be split in a longi­
tudinal direction in the perimysial plane through which

333
Surgical technique
pedicle diameter and length to enable a safe microsurgical
anastomosis.
If one is certain that the blood flow through the deep
inferior epigastric vessel is sufficient (an ultrasonic flow
meter can be used), the remainder of the flap can be
raised. In cases of midline scars, or when a large flap is
needed, the same vascular dissection can be performed
on the contralateral side. Otherwise, all the remaining
perforators are ligated, the umbilicus is released and the
entire skin flap is raised. The pedicle is finally transected
when the recipient vessels have been prepared. A hemo­
clip can be placed on the lateral comitant vein to help
orientate the pedicle.
After division of the pedicle, the flap is turned over
and the vessels placed carefully onto its undersurface.
One has to be meticulous about the position of the
pedicle, as it tends to rotate very easily, especially if only
one perforator has been harvested. The flap is then
weighed, photographed, and transferred. The ischemia
time is noted. The flap is placed on moist gauze at the
recipient site to prevent desiccation and again stapled
to the surrounding skin for security. The flap may be
rotated to facilitate microsurgery, provided a note of this
is made and the rotation reversed at the end of the
procedure.
the perforating vessel traverses. Splitting the muscle
fibers makes dissection easier as the vessel becomes
larger (Fig. 20.2.9G). The perforator is again liberated by
blunt dissection, staying close to the vessel at all times,
as it remains covered by a thin layer of loose connective
tissue. As a general rule, if resistance to dissection is
encountered, a side branch or a nerve will be identified.
Different muscular branches must be ligated with care,
and hemoclips are placed 1–2 mm away from the main
vessel so that if one inadvertently comes off, it can easily
be replaced. This technique avoids damage and spasm
of the main perforating vessel. Placing a vessel loop
around the vascular pedicle allows additional retraction
without any unnecessary tension being placed on the
vessel. Using bipolar coagulating diathermy and small
hemoclips, one continues to ligate all the side branches
until the origin of the perforator on the major branch
of the deep inferior epigastric vessel is reached at the
posterior surface of the rectus abdominis muscle (Fig.
20.2.9H).
If two perforators have been selected, the rectus
abdominis muscle must be widely separated. If the
perforators run in two adjacent perimysial planes, the
fibers may have to be cut. However, transection of large
parts of the rectus abdominis muscle or division at the
level where a motor nerve crosses from the lateral to the
medial side should be avoided.
Submuscular dissection
The lateral border of the rectus abdominis is raised
using non-crushing tissue forceps. Special care is taken
not to injure the mixed segmental nerves entering the
muscle laterally. The sensory nerve branch can be dis­
sected by epineural splitting.19 In this way, an additional
5–9 cm can be obtained, facilitating neural suturing at
the recipient site. If possible, all the motor branches are
left intact. However, in cases where a motor branch runs
between two perforators, then this nerve has to be cut.
Once the flap is harvested, it can be re-sutured.
Between the mixed segmental nerves, the plane
posterior to the rectus abdominis muscle is opened,
exposing the main deep inferior epigastric vessel. Side
branches of the main stem are ligated, and the dissec­
tion is continued by retracting the rectus abdominis
muscle medially until the proximal part of the pedicle
is completely liberated. The length of the pedicle can
be tailored to meet the needs of different recipient sites
or the demands of the shape of the flap (Fig. 20.2.9I).
The more distal the perforator is located in the flap,
the further the deep inferior epigastric vessels need to
be dissected into the groin. Frequently however, the
pedicle can be transected at the lateral border of the
rectus abdominis muscle. At this level, there is sufficient
Hints and tips
Ten golden rules in perforator flap surgery
1. Map the perforators preoperatively: identify the most
dominant vessels on each side.
2. Start dissection on one side of the flap: leave the
contralateral side intact until you have finished the entire
dissection of the pedicle.
3. Preserve every perforator until you encounter a larger one:
discard only the smaller ones that you are sure you will
not use. Select one or two perforators with the largest
diameter that correspond with your preoperative mapping.
4. Consider the best location of the perforator within the flap:
the more centrally located, the better blood flow to the
outer parts of the flap.
5. Consider the easiest dissection through the muscle: long
intramuscular dissections are more tedious, increase the
risk of damaging the vessels, and are more
time-consuming.
6. Dissect close to the vessels, remaining within the
perivascular loose connective tissue, thereby guaranteeing
a bloodless field.
7. Ensure wide exposure by splitting the rectus muscle along
its fibers (avoid digging a small hole).
8. Carefully ligate every side-branch at a distance of about
2 mm away from the main pedicle.
9. Avoid traction on the perforator: intima rupture is a frequent
cause of unexplained clotting of the perforator.
10. Transect the other perforators after the entire pedicle is
dissected.

334
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
Shaping of the DIEAP flap in secondary
autologous breast reconstruction
A systematic approach is applied to create easy and
reproducible results in shaping of autologous tissue by
using the “3-step principle”11,12 producing a 3D structure
from a flat piece of abdominal fat, and skin is broken
down into three essential steps: (1) redefining and rec­
reating the basis and borders of the footprint of the
breast (the interface of the posterior surface of the breast
gland and the thorax) at the right location on the chest
wall (Fig. 20.2.10); (2) molding the flap into a tear drop-
shaped conus on top of the footprint by means of specific
suturing (Fig. 20.2.11); and (3) repositioning the skin
envelope (Fig. 20.2.12) over the conus with the correct
tension (Fig. 20.2.13).
The breast footprint
Any previous scars or severely damaged tissue that lies
over the footprint of the new breast are excised. In
modified radical mastectomy cases, the new inframam­
mary fold is incised to a depth of approximately 1 cm
to allow easy suturing of the DIEAP flap. While the
position of the borders of the new footprint mirror the
position of the contralateral footprint, the new inframa­
mmary fold position needs to be placed 2–3 cm higher
Closure of the donor site and fashioning of
the umbilicus
As no fascia has been resected, primary tension-free
closure of the fascia with a running, non-absorbable 1-0
suture is always possible. The upper skin flap is under­
mined using cutting diathermy to the level of the xiphoid
and costal margin. Two suction drains are placed at the
upper and lower margins of the skin flaps and brought
out suprapubically on each side of the midline. The
lower border of the umbilicus is marked on the anterior
abdominal wall at the level of the anterior superior iliac
spines and a 2 cm vertical line is drawn above this point.
Only a vertical incision is performed. The anterior
abdominal wall is extensively thinned at the site of the
new umbilicus by trimming of the subcutaneous fat.
The umbilicus is then passed through the defect and
inset with an interrupted 4-0 absorbable sutures.
The operating table is put in a flexed position to
facilitate closure of the anterior abdominal wall. Scarpa’s
fascia is approximated with interrupted 1-0 absorbable
sutures with particular attention being paid to medial
advancement of the wound edges to reduce the dog-
ears in the flanks. Finally, interrupted 3-0 sutures are
placed intradermally to evert the skin edges and a skin
adhesive is applied. No further abdominal dressing is
used.
Fig. 20.2.10  (A) Coronal; (B) sagittal; and (C)
transverse view of the footprint of the breast.
A
B
C
Gland
Muscle
I
II
III
IV
V
VI
VII
Inframammary fold

335
Surgical technique
Fig. 20.2.11  (A) Coronal; (B) sagittal; and (C) transverse
view of the conus of the breast.
A
B
C
Gland
Muscle
I
II
III
IV
V
VI
VII
Inframammary fold
Fig. 20.2.12  (A) Coronal; (B) sagittal; and (C) transverse
view of the envelope of the breast.
A
B
C
Gland
Muscle
I
II
III
IV
V
VI
VII
Inframammary fold

336
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
muscle border. This first key suture recreates the anterior
axillary fold (Fig. 20.2.14B).
The lateral edge of the flap is then stapled to the most
lateral part of the inframammary fold under slight
tension to avoid excessive lateral fullness (see Fig.
20.2.14B). The transition from the lateral pectoral border
into the lateral portion of the flap also recreates a natural
lazy-S shape along the lateral border of the breast. The
exact position of the second key suture is determined
by moving the flap along the inframammary fold while
assessing the lazy-S contour. It is always better to have
minimal fullness in this location at the time of recon­
struction, as the flap will shift laterally and distally in
the postoperative period.
Medial to the second key suture, in the midclavicular
line, the skin of the flap is then bunched up (Fig.
20.2.14C). This, together with the triangular skin resec­
tion around the umbilicus, dramatically increases flap
projection. It also helps create a sharp angle between the
skin of the flap and the abdominal skin below the infra­
mammary fold.
The third key suture is placed at the medial end of
the inframammary fold. The flap is not bunched in this
location to avoid overfilling of the inferomedial quad­
rant of the new breast. However, one should be cautious,
as if the flap is not placed medially enough, it can be
difficult to achieve sufficient cleavage.
Two important components are then assessed: a
volume estimation of the DIEAP flap compared with the
contralateral breast; and the poorly vascularized tissue
in the flap that needs to be resected (previously zone IV,
see Fig. 20.2.14C). The latter can be accomplished either
by visual inspection of the skin, or by carving into the
dermal plexus with a Bistouri in the most distal corner.
Tissues that show mixed arterial and venous bleeding
can be kept. When a DIEAP flap with an ipsilateral
pedicle is used, poorly vascularized tissue is removed
before placing the first key suture. The authors recom­
mend making the reconstructed breast 5–10% larger
than the contralateral side, anticipating a postoperative
reduction in swelling.
The medial part of the flap is then rounded off, pro­
viding a smooth transition into the presternal region.
Overfilling of the superomedial regions of the breast is
also recommended (Fig. 20.2.14D), as gravity will be
pulling the flap caudally over the ensuing 6 months.
Excessive fat can be removed later, whereas a depres­
sion in this area can be very disturbing for the patient.
The breast envelope
Once the final volume of the flap is determined, one can
make a rough estimate of how much skin overlying the
than the contralateral inframammary fold depending on
the laxity of the mastectomy flap skin and tension
exerted on the abdominoplasty flap closure later in the
procedure. The skin in between the mastectomy scar
and the inframammary fold is de-epithelialized. In this
way, a layer of 1–2 cm of fat in the lower part of the
breast is preserved, improving projection. The skin
edges of the upper mastectomy flap are thinned down
to the dermis for the first 5 mm and then progressively
trimmed to obtain a seamless transition into the upper
skin edge of the DIEAP flap. The upper mastectomy flap
is then undermined on the lateral, cranial, and medial
borders of the breast footprint to subsequently accom­
modate the flap.
In cases of primary breast reconstruction, the edges
of the footprint are assumed to be intact. If for oncologic
reasons the edges of the footprint need to be undermined
or resected, these borders will need to be repaired before
transferring the flap.
The breast conus
The authors prefer to use the contralateral DIEAP flap
in cases of delayed breast reconstruction. The flap is
rotated through 180° prior to transfer, and shaping
begins after the anastomosis has been completed (Fig.
20.2.14A).
A wedge of skin is removed around the site of the
umbilicus and closed in two layers. This simple maneu­
ver gathers more volume in the lower half of the flap.
The more skin that is removed, the more projection that
can be achieved, but it does result in compression of the
subdermal plexus in this area.
The tendon of the pectoralis major muscle is then
identified. The tip of the DIEAP flap is fixed just below
the pectoralis tendon by suturing Scarpa’s fascia to the
pectoralis fascia 2–3 cm medial to the lateral pectoral
Fig. 20.2.13  The nipple areolar complex is an integral part of the envelope of the
breast.

337
Surgical technique
Fig. 20.2.14  (A) The deep inferior epigastric artery perforator (DIEAP) flap is turned 180° after performing the microsurgical anastomosis of the vessels and then (B)
sutured with two key sutures to the pectoral fascia at the anterior axillary fold and the lateral part of the new inframammary fold making sure to avoid any fullness of the
inferolateral quadrant of the new breast. (C) A triangular excision of skin around the umbilical area and gathering of the skin at the inframammary fold around the
midclavicular line will create projection of the flap and a sharp angle between the lower part of the breast and the abdominal wall. (D) The least vascularized part of the flap
is then resected making sure to preserve enough tissue to fill the upper medial quadrant of the breast.
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338
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
planes will cause excessive bleeding and slow the
surgeon down. Two golden rules apply to any type of
perforator flap surgery: a bloodless field and wide
exposure of the vessels. A common mistake made is to
follow the perforator vessels into a deep hole. Muscle,
septum, and other tissues through which the perfora­
tors travel should be opened widely to get a clear view
and help deal with any bleeding encountered.
A number of technical considerations are important
in the planning and execution of the dissection. The
wrong choice of perforator can have disastrous compli­
cations. With the help of imaging and direct intra­
operative visualization, the most dominant perforator
can be identified. Unusual courses of perforators such
as those rounding the medial or lateral edge of the
rectus abdominis muscle must be taken into account.
Dominance of the superficial system should be recog­
nized at the beginning of flap harvest, at the time of
incision of the lower edge of the flap.
During dissection of the pedicle overstretching of the
vessels should be avoided. The use of vessel loops is
limited to the actual dissection and should not be left in
place as they accidentally can come under traction in a
later phase of the operation.
Ligation of side branches should be performed at a
distance of 2–3 mm away from the pedicle. When a
vascular clip or a ligating suture is placed too close to
the main pedicle, it can interrupt the arterial or venous
flow. Care should be taken during the motor nerve dis­
section. Excessive traction or crushing of the nerve can
permanently affect its function.
In case of a free flap, torsion of the pedicle can easily
occur during transfer of the flap. Exact orientation
with the help of vascular clips can avoid this problem.
Following anastomosis, kinking of the pedicle can
be avoided by placing the pedicle in smooth curves
once the shaping has finished. During the shaping
of the flap, excessive defatting can lead to areas of
partial flap necrosis or fat necrosis.41 Delayed defat­
ting using liposuction is a safer procedure. Poorly
vascularized areas should be resected during the initial
procedure to reduce the amount of postoperative
complications.
In inexperienced hands, the DIEAP flap dissection
will require a longer operating time than a conventional
myocutaneous flap. After a number of cases, operating
time will fall back and be comparable with myocutane­
ous flap harvesting, or even shorter if a limited pedicle
length is needed.
Abdominal scarring is probably the most important
risk factor for raising a DIEAP flap. It can cause major
problems during the dissection of the perforators and
the epigastric vessels. Intramuscular scarring is not
DIEAP flap will be required. The flap can be pushed up
into the pocket or pulled down, leaving more or less
vertical skin height, respectively, on the skin paddle of
the flap. The more skin left, the more ptosis can be
achieved. Also, the more skin resected in the lateral part
of the flap, the more the flap will be pushed medially.
Once again, the clinical and aesthetic assessment of the
contralateral breast is key in fine-tuning the shape of the
DIEAP flap. Finally, the upper part of the skin paddle
covered by the mastectomy flap is de-epithelialized.
Postoperative care
The postoperative care is simplified as the function of
the rectus muscle is preserved. Preserving the integrity
of the muscle also significantly decreases postoperative
abdominal wall pain, facilitates rehabilitation, and
therefore reduces hospitalization time.
Flap monitoring is mainly clinical. Frequency of
evaluation is hourly during the first 24 h, 2-hourly in
the second 24 h, and every 4 h during the following 2
days. Adhesive thermometer-strips are stuck to the skin
island of the flap and the high sternal region. Differ­
ences of more than 2°C are reported to the physician
on-call. In addition to temperature, color, consistency of
the flap, and capillary refill are registered on a specific
microsurgical follow-up sheet. Unidirectional Doppler
flowmetry and other more sophisticated devices are not
used, as they can produce false-positive signals.39,40
Patients are mobilized within 24 h after removing the
urinary catheter. Systemic antibiotics are given for 24 h.
Except for daily subcutaneous prophylactic doses of
low-molecular heparin, no other anticoagulants are
given. Besides paracetamol as pain relief and anti-
inflammatory, no other drugs are given unless a specific
medical condition requires it. Drinking starts 12 h post­
operatively. Drains are left for 3–7 days depending on
their daily output. Dressing changes are not necessary
with the use of skin adhesives. A sterile towel covers the
breast(s) and the abdomen to keep the flap warm for the
first 5 days. After that, a soft and elastic bra is adjusted.
No compressive garments are applied.
Outcomes, prognosis,
and complications
The dissection of a DIEAP flap has a steep learning
curve, involving a specific technique. Dissection is
performed close to the perforating vessels in the plane
of loose connective tissue surrounding the pedicle,
allowing side branches and crossing nerves to be easily
identified and preserved. Dissection through other

339
Secondary procedures
During the second operation, the contralateral breast
can also be corrected in case of unilateral reconstruction.
Any preferred technique of breast augmentation, reduc­
tion, or mastopexy can be performed as long as sym­
metry of shape and volume can be achieved.
Finally, bilateral tattooing of the nipple areolar
complex is performed under local anesthesia. Even if
the contralateral breast has not been operated on, the
nipple areolar complex is tattooed to obtain a perfect
color match and create an optical effect of camouflaging
the reconstruction.
Primary reconstructions will always yield better
aesthetic results than secondary or tertiary reconstruc­
tions as the natural footprint and skin envelope remain
intact, especially if postoperative radiotherapy is
avoided. If the conus is properly shaped during the first
procedure, secondary procedures can be less complex
and less frequent. For that reason, prophylactic mastec­
tomies are performed more routinely today as a risk-
reducing operation in hereditary breast cancer for
BRCA-1 and -2 mutations (Fig. 20.2.16) or for oncologic
reasons (i.e., invasive lobular carcinoma). Prophylactic
mastectomy and immediate breast reconstruction
without adjuvant radiotherapy should also be consid­
ered instead of a wide segmentectomy combined with
aggressive radiotherapy, as this can lead to significant
deformity of the breast mound.
Secondary (Fig. 20.2.17) and specifically tertiary
(implant crippled or failed previous autologous
attempts) reconstruction is more complex, as it involves
correction and adjustment of all three essential parts of
the “3-step” principle. Applying this principle, however,
allows the surgeon to not only analyze the problem but
also provides an opportunity to develop a clear preop­
erative strategy. In tertiary reconstructions, the surgeon
is often left with no other choice but to remove all previ­
ous tissue, implants, and scarring and to start the entire
reconstructive process again.
always diagnosed on preoperative ultrasound and can
spread out farther than suspected from the place and
length of a previous incision.
Smoking is considered a relative contraindication to
raising a DIEAP flap. The authors’ impression is that the
area most distant from the vascular pedicle of smokers
is not well perfused, with prolonged vascular spasm.
Additionally, wound healing problems and wound
infections have been observed more frequently in
smokers. Smokers who request elective, delayed recon­
structions are asked to stop smoking at least 3 months
before becoming a candidate for surgery. This is an
additional way to test the motivation of the patient. An
unmotivated patient or poor general medical health are
the only absolute contraindications to DIEAP flap breast
reconstruction.38,42,43
Secondary procedures
The free flap transfer and initial shaping is just the first
step in achieving a full and natural breast reconstruc­
tion. Following the principles of a sculptor, the authors
try to create a breast in the first stage that is slightly
bigger than the desired volume but resembles the final
result as closely as possible. Obtaining a definite result
in one procedure is impossible. As removing tissues is
so much easier than adding, specific areas of the flap
can be aspirated or resected during the second opera­
tion 6 months later to achieve symmetry, which is the
final goal of this procedure. If more tissue is needed, the
flap can be augmented by lipofilling in specific spots to
improve the shape or throughout the flap if pure volume
augmentation is necessary. Augmentation by implants
is possible as well but performed less and less as results
of lipofilling become more predictable and successful.
Nipple reconstruction is performed using the modified
CV flap (Fig. 20.2.15). Scar revisions and adjustments of
the borders of the footprint can easily be performed.
Fig. 20.2.15  (A–D) The modified CV-flap technique for nipple reconstruction.
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340
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
Fig. 20.2.16  (A) Preoperative image of a 46-year-
old-woman, carrier of a BRCA-2 mutation, following
tumorectomy through a horizontal racquet incision at
the right breast. (B) Intermediate phase after bilateral
areola-sparing mastectomy, using the same scar on
the right breast, a more conventional vertical scar on
the left breast, and bilateral autologous reconstruction
by means of a bilateral free deep inferior epigastric
artery perforator flap. (C–E) At 2-year-postoperative
after bilateral nipple reconstruction using the
interposed skin island of the flap and bilateral tattoo.
A
B
C
D
E

A
B
C
D
Fig. 20.2.17  (A) Preoperative image of a 62-year-old woman following modified radical mastectomy of the
right breast with breast hypertrophy/ptosis of the left breast. (B) Intermediate phase after secondary
autologous breast reconstruction by means of a unilateral free deep inferior epigastric artery perforator flap.
(C–E) Final result, 1 year postoperatively, after right nipple reconstruction (and later tattoo) and left breast
reduction.
E

342
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without
rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648. The rectus
abdominis musculocutaneous flap has many advantages, but its
disadvantages are also well-known. These are the possibility of abdominal
herniation and, in certain situations, its bulk. To overcome these problems,
an inferior epigastric artery skin flap without rectus abdominis muscle,
pedicled on the muscle perforators and the proximal inferior deep
epigastric artery, was used. A large flap without muscle can survive on a
single muscle perforator.
5. Reid AW, Szpalski C, Sheppard NN, et al. An international
comparison of reimbursement for DIEAP flap breast reconstruction.
J Plast Reconstr Aesthet Surg. 2015;68:1529–1535. Results demonstrate
that DIEAP flap breast reconstruction is inconsistently funded.
Unfortunately, it appears that the current reimbursement offered by many
countries may dissuade institutions and surgeons from offering this
procedure. However, substantial evidence exists supporting the cost-
effectiveness of perforator flaps for breast reconstruction and the long-term
clinical benefits make this investment of time and money essential.
8. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg. 1994;32:32–38.
9. Blondeel PN, Boeckx WD. Refinements in free flap breast
reconstruction: the free bilateral deep inferior epigastric perforator
flap anastomosed to the internal mammary artery. Br J Plast Surg.
1994;47:495–501. Besides the enormous advantages of reconstructing the
amputated breast by means of a conventional TRAM flap, the main
disadvantage remains the elevation of small (free TRAM) or larger
(pedicled TRAM) parts of the rectus abdominis muscle. In order to
overcome this disadvantage, the free deep inferior epigastric perforator
(DIEP) skin flap has recently been used for breast mound reconstruction,
with excellent clinical results. After achieving favorable results with eight
unilateral DIEP-flaps, the authors were challenged by an abdomen with a
midline laparotomy scar. By dissecting a bilateral DIEP flap and making
adjacent anastomoses to the internal mammary artery, we were able to
achieve sufficient flap mobility for easy free flap positioning and breast
shaping. Intraoperative segmental nerve stimulation, postoperative
functional abdominal wall tests, and CT-scan examination showed normal
abdominal muscle activity. On the basis of a case report, the technical
considerations and advantages of anastomosing the bipedicled DIEP flap
to the internal mammary artery are discussed.
10. Blondeel PN. One hundred free DIEP flap breast reconstructions: a
personal experience. Br J Plast Surg. 1999;52:104–111. This study
summarizes the prospectively gathered data of 100 free DIEP flaps used
for breast reconstruction in 87 patients. Primary reconstructions were
done in 35% of the patients. Well-known risk factors for free flap breast
reconstruction were present: smokers 23%, obesity 25%, abdominal
scarring 28%, and previous radiotherapy 45%. Mean operating time was
6 h 12 min for unilateral reconstruction and mean hospital stay was 7.9
days. These data indicate that the free DIEP flap is a new but reliable and
safe technique for autologous breast reconstruction. This flap offers the
patient the same advantages as the TRAM flap and discards the most
important disadvantages of the myocutaneous flap by preserving the
continuity of the rectus muscle.
11. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Plast Reconstr Surg. 2009;123:455–462.
12. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Part II. Breast reconstruction after total mastectomy. Plast
Reconstr Surg. 2009;123:794–805. This is Part II of four parts describing
the 3-step principle being applied in reconstructive and aesthetic breast
surgery. Part I explains how to analyze a problematic breast by
understanding the three main anatomic features of a breast and how they
interact: the footprint, the conus of the breast, and the skin envelope. This
part describes how one can optimize his/her results with breast
reconstructions after complete mastectomy. For both primary and
secondary reconstructions, the authors explain how to analyze the
postmastectomy breast and the deformed chest wall before giving
step-by-step guidelines on how to rebuild the entire breast with either
autologous tissue or implants. The differences in shaping unilateral or
bilateral breast reconstructions with autologous tissue are clarified.
Regardless of timing or method of reconstruction, it is shown that by
breaking down the surgical strategy in three easy (anatomic) steps, the
reconstructive surgeon is able to provide more aesthetically pleasing and
reproducible results.
20. Taylor GI, Daniel RK. The anatomy of several free flap donor sites.
Plast Reconstr Surg. 1975;56:243–253.
25. Al-Dhamin A, Bissell MB, Prasad V, et al. The use of retrograde
limb of internal mammary vein in autologous breast reconstruction
with DIEAP flap: anatomical and clinical study. Ann Plast Surg.
2014;72:281–284. It is also worth noting that the retrograde limb of the
internal mammary vein seems to be a safe second recipient vein in DIEAP
flap reconstruction.
37. Uppal RS, Casaer B, Van Landuyt K, et al. The efficacy of
preoperative mapping of perforators in reducing operative times
and complications in perforator flap breast reconstruction. J Plast
Reconstr Aesthet Surg. 2009;62:859–864.
39. Lie KH, Barker AS, Ashton MW. A classification system for partial
and complete DIEP flap necrosis based on a review of 17,096 DIEP
flaps in 693 articles including analysis of 152 total flap failures. Plast
Reconstr Surg. 2013;132:1401–1408. In documented DIEAP flap losses,
40% involved venous problems, 28% arterial, and 21% were mechanical
(pedicle kinking, hematoma).
40. Wormald JC, Wade RG, Figus A. The increased risk of adverse
outcomes in bilateral deep inferior epigastric artery perforator flap
breast reconstruction compared to unilateral reconstruction: a
systematic review and meta-analysis. J Plast Reconstr Aesthet Surg.
2014;67:143–156. A systematic review of the literature has also confirmed
that bilateral DIEP flap breast reconstruction is associated with a
significantly higher risk of total flap failure compared with unilateral
DIEP flap breast reconstruction.
41. Bozikov K, Arnez T, Hertl K, et al. Fat necrosis in free DIEAP flaps:
incidence, risk, and predictor factors. Ann Plast Surg. 2009;63:138–
142. DIEAP flaps harvested on a single perforator, obese patients with a
body mass index ≥30, and revision operations all have significantly higher
amounts of fat necrosis.
43. Massey MF, Spiegel AJ, Levine JL, et al. Perforator flaps: recent
experience, current trends, and future directions based on 3974
microsurgical breast reconstructions. Plast Reconstr Surg.
2009;124:737–751. Perforator flap breast reconstruction is an accepted
surgical option for breast cancer patients electing to restore their body
image after mastectomy. Since the introduction of the deep inferior
epigastric perforator flap, microsurgical techniques have evolved to support
a 99% success rate for a variety of flaps with donor sites that include the
abdomen, buttock, thigh, and trunk. Recent experience highlights the
perforator flap as a proven solution for patients who have experienced
failed breast implant-based reconstructions or those requiring irradiation.
Current trends suggest an application of these techniques in patients
previously felt to be unacceptable surgical candidates, with a focus on
safety, aesthetics, and increased sensitization. Future challenges include
the propagation of these reconstructive techniques into the hands of future
plastic surgeons with a focus on the development of septocutaneous flaps
and vascularized lymph node transfers for the treatment of lymphedema.
Access the complete reference list online at

342.e1
References
References
1. Boyd JB, Taylor GI, Corlett R. The vascular territories of the
superior epigastric and the deep inferior epigastric systems.
Plast Reconstr Surg. 1984;73:1–16.
2. Holmström H. The free abdominoplasty flap and its use in breast
reconstruction. An experimental study and clinical case report.
Scand J Plast Reconstr Surg. 1979;13:423–427.
3. Robbins TH. Rectus abdominis myocutaneous flap for breast
reconstruction. Aust N Z J Surg. 1979;49:527–530.
4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without
rectus abdominis muscle. Br J Plast Surg. 1989;42:645–648. The rectus
abdominis musculocutaneous flap has many advantages, but its
disadvantages are also well-known. These are the possibility of abdominal
herniation and, in certain situations, its bulk. To overcome these problems,
an inferior epigastric artery skin flap without rectus abdominis muscle,
pedicled on the muscle perforators and the proximal inferior deep
epigastric artery, was used. A large flap without muscle can survive on a
single muscle perforator.
5. Reid AW, Szpalski C, Sheppard NN, et al. An international
comparison of reimbursement for DIEAP flap breast reconstruction.
J Plast Reconstr Aesthet Surg. 2015;68:1529–1535. Results demonstrate
that DIEAP flap breast reconstruction is inconsistently funded.
Unfortunately, it appears that the current reimbursement offered by many
countries may dissuade institutions and surgeons from offering this
procedure. However, substantial evidence exists supporting the
cost-effectiveness of perforator flaps for breast reconstruction and the
long-term clinical benefits make this investment of time and money
essential.
6. Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical
perforator-based flaps. Ann Plast Surg. 1992;29:12–17.
7. Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of
the blood supply of the contralateral side of the free transverse
rectus abdominis musculocutaneous flap. Ann Plast Surg.
1993;31:123–127.
8. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg. 1994;32:32–38.
9. Blondeel PN, Boeckx WD. Refinements in free flap breast
reconstruction: the free bilateral deep inferior epigastric perforator
flap anastomosed to the internal mammary artery. Br J Plast Surg.
1994;47:495–501. Besides the enormous advantages of reconstructing the
amputated breast by means of a conventional TRAM flap, the main
disadvantage remains the elevation of small (free TRAM) or larger
(pedicled TRAM) parts of the rectus abdominis muscle. In order to
overcome this disadvantage, the free deep inferior epigastric perforator
(DIEP) skin flap has recently been used for breast mound reconstruction,
with excellent clinical results. After achieving favorable results with eight
unilateral DIEP-flaps, the authors were challenged by an abdomen with a
midline laparotomy scar. By dissecting a bilateral DIEP flap and making
adjacent anastomoses to the internal mammary artery, we were able to
achieve sufficient flap mobility for easy free flap positioning and breast
shaping. Intraoperative segmental nerve stimulation, postoperative
functional abdominal wall tests, and CT-scan examination showed normal
abdominal muscle activity. On the basis of a case report, the technical
considerations and advantages of anastomosing the bipedicled DIEP flap
to the internal mammary artery are discussed.
10. Blondeel PN. One hundred free DIEP flap breast reconstructions: a
personal experience. Br J Plast Surg. 1999;52:104–111. This study
summarizes the prospectively gathered data of 100 free DIEP flaps used
for breast reconstruction in 87 patients. Primary reconstructions were
done in 35% of the patients. Well-known risk factors for free flap breast
reconstruction were present: smokers 23%, obesity 25%, abdominal
scarring 28%, and previous radiotherapy 45%. Mean operating time was
6 h 12 min for unilateral reconstruction and mean hospital stay was 7.9
days. These data indicate that the free DIEP flap is a new but reliable and
safe technique for autologous breast reconstruction. This flap offers the
patient the same advantages as the TRAM flap and discards the most
important disadvantages of the myocutaneous flap by preserving the
continuity of the rectus muscle.
11. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Plast Reconstr Surg. 2009;123:455–462.
12. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Part II. Breast reconstruction after total mastectomy. Plast
Reconstr Surg. 2009;123:794–805. This is Part II of four parts describing
the 3-step principle being applied in reconstructive and aesthetic breast
surgery. Part I explains how to analyze a problematic breast by
understanding the three main anatomic features of a breast and how they
interact: the footprint, the conus of the breast, and the skin envelope. This
part describes how one can optimize his/her results with breast
reconstructions after complete mastectomy. For both primary and
secondary reconstructions, the authors explain how to analyze the
postmastectomy breast and the deformed chest wall before giving
step-by-step guidelines on how to rebuild the entire breast with either
autologous tissue or implants. The differences in shaping unilateral or
bilateral breast reconstructions with autologous tissue are clarified.
Regardless of timing or method of reconstruction, it is shown that by
breaking down the surgical strategy in three easy (anatomic) steps, the
reconstructive surgeon is able to provide more aesthetically pleasing and
reproducible results.
13. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Part III – reconstruction following breast conservative
treatment. Plast Reconstr Surg. 2009;124:28–38.
14. Blondeel PN, Hijawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step
principle. Part IV – aesthetic breast surgery. Plast Reconstr Surg.
2009;124:372–382.
15. Kikuchi N, Murakami G, Kashiwa H, et al. Morphometrical study
of the arterial perforators of the deep inferior epigastric perforator
flap. Surg Radiol Anat. 2001;23:375–381.
16. Heitmann C, Felmerer G, Durmus C, et al. Anatomical features of
perforator blood vessels in the deep inferior epigastric perforator
flap. Br J Plast Surg. 2000;53:205–208.
17. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in
the planning of perforator flaps. Br J Plast Surg. 1998;51:202–209.
18. Vandevoort M, Vranckx JJ, Fabre G. Perforator topography of the
deep inferior epigastric perforator flap in 100 cases of breast
reconstruction. Plast Reconstr Surg. 2002;109:1912–1918.
19. Blondeel PN, Demuynck M, Mete D, et al. Sensory nerve repair in
perforator flaps for autologous breast reconstruction: sensational or
senseless? Br J Plast Surg. 1999;52:37–44.
20. Taylor GI, Daniel RK. The anatomy of several free flap donor sites.
Plast Reconstr Surg. 1975;56:243–253.
21. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion
and blood flow in free transverse rectus abdominis myocutaneous
and deep inferior epigastric perforator flaps. Plast Reconstr Surg.
2000;106:1295–1299.
22. Carramenha e Costa MA, Carriquiry C, Vasconez LO, et al. An
anatomic study of the venous drainage of the transverse rectus
abdominis musculocutaneous flap. Plast Reconstr Surg.
1987;79:208–217.
23. Felmerer G, Muehlberger T, Berens von Rautenfeld D, et al. The
lymphatic system of the deep inferior epigastric artery perforator
flap: an anatomical study. Br J Plast Surg. 2002;55:335–339.
24. Dupin CL, Allen RJ, Glass CA, et al. The internal mammary artery
and vein as a recipient site for free-flap breast reconstruction: a
report of 110 consecutive cases. Plast Reconstr Surg. 1996;98:685–692.
25. Al-Dhamin A, Bissell MB, Prasad V, et al. The use of retrograde
limb of internal mammary vein in autologous breast reconstruction
with DIEAP flap: anatomical and clinical study. Ann Plast Surg.
2014;72:281–284. It is also worth noting that the retrograde limb of the
internal mammary vein seems to be a safe second recipient vein in DIEAP
flap reconstruction.
26. Alonso-Burgos A, García-Tutor E, Bastarrika G, et al. Preoperative
planning of DIEP and SGAP flaps: preliminary experience with
magnetic resonance angiography using 3-tesla equipment and
blood-pool contrast medium. J Plast Reconstr Aesthet Surg.
2010;63:298–304.
27. Voet DAM, Petrovic M. Ultrasound evaluation of perforator vessels.
In: Blondeel PN, Morris SF, Hallock GG, et al., eds. Perforator Flaps:
Anatomy, Technique & Clinical Applications. St. Louis: Quality
Medical; 2005:92–102.

342.e2
SECTION II
CHAPTER 20.2 • The deep inferior epigastric artery perforator (DIEAP) flap
28. Giunta RE, Geisweid A, Feller AM. The value of preoperative
Doppler sonography for planning free perforator flaps. Plast
Reconstr Surg. 2000;105:2381–2386.
29. Hallock GG. Doppler sonography and color duplex imaging
for planning a perforator flap. Clin Plast Surg. 2003;30:
347–357.
30. Iida H, Ohashi I, Kishimoto S, et al. Preoperative assessment of
anterolateral thigh flap cutaneous perforators by colour Doppler
flowmetry. Br J Plast Surg. 2003;56:21–25.
31. Pacifici A, Tinti A, Flamini FO, et al. Colour flow duplex scanning:
an accurate, non-invasive technique for preoperative evaluation of
the vascular supply of the rectus abdominis myocutaneous flap.
Scand J Plast Reconstr Surg Hand Surg. 1995;29:319–324.
32. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry
in the planning of perforator flaps. Br J Plast Surg. 1998;51:
202–209.
33. Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row
computed tomography in the planning of abdominal perforator
flaps. J Plast Reconstr Aesthet Surg. 2006;59:594–599.
34. Masia J, Larrañaga J, Clavero JA, et al. The value of the
multidetector row computed tomography for the preoperative
planning of deep inferior epigastric artery perforator flap: our
experience in 162 cases. Ann Plast Surg. 2008;60:29–36.
35. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, et al. Planning and
optimising DIEAP flaps with virtual surgery: the Navarra
experience. J Plast Reconstr Aesthet Surg. 2010;63:289–297.
36. Greenspun D, Vasile J, Levine JL, et al. Anatomic imaging of
abdominal perforator flaps without ionizing radiation: seeing is
believing with magnetic resonance imaging angiography. J Reconstr
Microsurg. 2010;26:37–44.
37. Uppal RS, Casaer B, Van Landuyt K, et al. The efficacy of
preoperative mapping of perforators in reducing operative times
and complications in perforator flap breast reconstruction. J Plast
Reconstr Aesthet Surg. 2009;62:859–864.
38. Blondeel P, Morrison C. The deep inferior epigastric artery
perforator flap. In: Blondeel PN, Morris SF, Hallock GG, et al., eds.
Perforator Flaps: Anatomy, Technique & Clinical Applications. St Louis:
Quality Medical; 2005:385–404.
39. Lie KH, Barker AS, Ashton MW. A classification system for partial
and complete DIEP flap necrosis based on a review of 17,096 DIEP
flaps in 693 articles including analysis of 152 total flap failures. Plast
Reconstr Surg. 2013;132:1401–1408. In documented DIEAP flap losses,
40% involved venous problems, 28% arterial, and 21% were mechanical
(pedicle kinking, hematoma).
40. Wormald JC, Wade RG, Figus A. The increased risk of adverse
outcomes in bilateral deep inferior epigastric artery perforator flap
breast reconstruction compared to unilateral reconstruction: a
systematic review and meta-analysis. J Plast Reconstr Aesthet Surg.
2014;67:143–156. A systematic review of the literature has also confirmed
that bilateral DIEP flap breast reconstruction is associated with a
significantly higher risk of total flap failure compared with unilateral
DIEP flap breast reconstruction.
41. Bozikov K, Arnez T, Hertl K, et al. Fat necrosis in free DIEAP flaps:
incidence, risk, and predictor factors. Ann Plast Surg. 2009;63:138–
142. DIEAP flaps harvested on a single perforator, obese patients with a
body mass index ≥30, and revision operations all have significantly higher
amounts of fat necrosis.
42. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of
758 DIEP flaps for breast reconstruction. Plast Reconstr Surg.
2004;113:1153–1160.
43. Massey MF, Spiegel AJ, Levine JL, et al. Perforator flaps: recent
experience, current trends, and future directions based on 3974
microsurgical breast reconstructions. Plast Reconstr Surg.
2009;124:737–751. Perforator flap breast reconstruction is an accepted
surgical option for breast cancer patients electing to restore their body
image after mastectomy. Since the introduction of the deep inferior
epigastric perforator flap, microsurgical techniques have evolved to support
a 99% success rate for a variety of flaps with donor sites that include the
abdomen, buttock, thigh, and trunk. Recent experience highlights the
perforator flap as a proven solution for patients who have experienced
failed breast implant-based reconstructions or those requiring irradiation.
Current trends suggest an application of these techniques in patients
previously felt to be unacceptable surgical candidates, with a focus on
safety, aesthetics, and increased sensitization. Future challenges include
the propagation of these reconstructive techniques into the hands of future
plastic surgeons with a focus on the development of septocutaneous flaps
and vascularized lymph node transfers for the treatment of lymphedema.

SECTION II • Reconstructive Breast Surgery
20.3 
Superficial inferior epigastric
artery (SIEA) flap
Julie Park, Deana S. Shenaq, and David H. Song
SYNOPSIS
■ The superficial inferior epigastric artery (SIEA) flap has the least donor
site morbidity of the flaps available from the lower abdomen for
autologous tissue breast reconstruction.
■ SIEA-specific challenges include short pedicles, vessel size mismatch,
and the propensity for arterial spasm.
■ Preoperative, intraoperative, and postoperative strategies are
described.
Access the Historical Perspective section online at

Introduction
The use of the lower abdominal tissue for autologous
breast reconstruction has been as a gold standard since
Hartrampf popularized the rotational transverse rectus
abdominis myocutaneous (TRAM) flap.1 Advances in
microsurgical technique have heralded an evolution
whereby flap perfusion is optimized while donor site
morbidity is minimized. This progression is well illus­
trated by the free TRAM, muscle-sparing free TRAM
(MS-fTRAM), and deep inferior epigastric perfora­
tor (DIEP) flap. While all of these flaps compromise
essentially the same island of lower abdominal skin
and subcutaneous fat, each iteration further minimizes
donor site morbidity. The superficial inferior epigastric
artery (SIEA) has the least donor site morbidity and
is the most muscle-sparing as the dissection is com­
pletely subcutaneous and does not violate the fascia.
This chapter will discuss anatomy and dissection tech­
nique. Challenges particular to the SIEA flap include
vessel size mismatch, short pedicles, and the tendency
towards arterial spasm. Preoperative, intraoperative,
and postoperative prevention strategies will be
described.
Patient selection
When assessing a patient preoperatively for the SIEA
flap, the same criteria applies as when determining the
suitability of a patient for a DIEP or free TRAM flap.
The patient needs sufficient redundant lower abdomi­
nal skin and fat in order to approximate final desired
breast volume and allow for a primary donor site
closure analogous to an abdominoplasty. Specific to
the SIEA flap, perfusion across the midline of the
abdomen, although reported, is not reliable.8 Therefore,
if the patient requires more than a hemi-abdomen for
either skin or volume to reconstruct the breast, it is
not advised to plan on using the SIEA flap. The excep­
tion to this is when a bilateral hemi-abdominal flap is
planned for a unilateral reconstruction, such as a
stacked flap (Fig. 20.3.1).9–11 In these cases, the use of
the SIEA, if available, is an excellent method to reduce
donor site morbidity.
Preoperative vascular imaging such as computed
tomography angiography (CTA) or magnetic resonance
angiography may be used to assess the deep and super­
ficial vascular systems.12–14 However, this is not essential,
and a reliable intraoperative algorithm will be described
below.
  Access video lecture content for this chapter online at expertconsult.com

343.e1
Historical perspective
Historical perspective
Autologous tissue reconstruction using the lower
abdominal tissue was pioneered by Carl Hartrampf in
1982 with the pedicled transverse rectus abdominis
myocutaneous (TRAM) flap.1 The rotational TRAM
relied on the superior epigastric vessels as a pedicle
and sacrifices a rectus muscle for vascular perfusion.
As microsurgical techniques evolved, the free TRAM
was advocated for breast reconstruction.2 While still
sacrificing the rectus muscle, the vascular pedicle was
based off the deep inferior epigastric artery and vein,
which is the dominant blood supply to the rectus
muscle and the lower abdominal tissues. The free
TRAM resulted in better perfusion and more freedom
in insetting and shaping the breast reconstruction. The
development of microsurgical perforator techniques led
to the understanding that the muscle was a conduit
for vascular supply and not essential for most flaps.
The pursuit to minimize donor site morbidity led to
the development of the deep inferior epigastric perfora­
tor (DIEP) flap as the next evolution of the TRAM
flap.3–5 The DIEP vascular pedicle is the deep inferior
epigastric system, but only the perforating vessels to
the subcutaneous fat and skin are harvested and the
rectus muscle is not sacrificed. The muscle-sparing free
TRAM (MS-fTRAM) is the cousin that bridges the DIEP
and free TRAM, in which a cuff of rectus muscle is
harvested to capture multiple perforators. The super­
ficial inferior epigastric artery (SIEA) flap is the most
muscle-sparing flap using the lower abdominal tissues
as the vessels course subcutaneous from the femoral
artery and vein and do not involve the rectus muscle
or fascia at all.6,7

344
SECTION II
CHAPTER 20.3 • Superficial inferior epigastric artery (SIEA) flap
fat at the superior edge of the incision, rather than the
middle, will provide approximately 1 cm of extra tissue
to protect DIEP perforators (Fig. 20.3.2).
The lower incision is made judiciously as the superior
inferior epigastric vein can be very superficial in some
patients. The superior inferior epigastric vein (SIEV) is
typically found by marking the distance from the pubic
symphysis to the anterior superior iliac spine (ASIS) into
thirds. It is typically at the area approximately one-third
lateral from the pubic symphysis. The SIEA location is
more variable. The artery can travel directly lateral to the
vein. Alternatively, it can be deeper, just below Scarpa’s
layer. The SIEA can also travel separately, approximately
3 cm lateral to the SIEV. In this position, it travels with
two venae comitantes (Fig. 20.3.3). The venae comitantes
can sometimes be of such large caliber that they can be
used instead of the SIEV. Alternatively, sometimes the
venous perfusion depends on the venae comitantes in
addition to SIEV. Rozen et al. studied CTA imaging in
200 patients and found that in 40% of cases, there was a
medial and lateral SIEV branch, which arose from differ­
ent trunks altogether; and thus, the authors advocate
that both trunks be used to facilitate venous drainage in
these instances.15 Temporarily occluding the veins with
Acland clamps and assessing flap perfusion is the
Surgical technique
Patient marking
Patient marking is similar to that of the DIEP and free
TRAM flaps. A major difference is the location of the
transverse ellipse. Some surgeons center the transverse
ellipse around the umbilicus to capture periumbilical
perforators. To optimize the SIEA flap as an option, it is
recommended to lower the incision to encounter the
SIEA at a larger caliber. The periumbilical perforators
can still be captured if caution is taken with the dissec­
tion through the subcutaneous tissues.
Intraoperative technique
The patient is positioned and draped in the same manner
of a DIEP or free TRAM flap. When making the superior
incision, the majority of the periumbilical perforators
can still be preserved even with a more inferior skin
paddle with careful dissection through the subcutane­
ous fat. After sharply incising the superior incision, the
dermis is incised with cautery while obtaining hemosta­
sis. After the dermis is released, the tissues open up
approximately 1–1.5 cm. Dissection of the subcutaneous
Fig. 20.3.1  (A–D) The use of the SIEA with a DIEP
flap for a unilateral reconstruction with a bilateral
flap. In this case a bilateral flap was required to
provide adequate skin to reconstruct the breast
envelope as well as subcutaneous fat for volume.
The patient underwent a staged secondary
contralateral small reduction for symmetry
as well as nipple reconstruction.
A
B
C
D

345
Surgical technique
authors’ preferred method to establish the necessary
venous drainage of the flap (Fig. 20.3.4). It is important
to note that the anatomy of the SIEA and SIEV is not
necessarily symmetric on both sides of the abdomen.
Many papers have used SIEA caliber as a criterion for
suitability of flap use.15–17 However, in our experience,
if the SIEA is palpable at the incision and the SIEV is
≥1.5 cm, the SIEA flap can be utilized even if the SIEA
artery is <1 mm.18 We have found that further dissection
towards the femoral artery almost always yields a larger
diameter vessel when the SIEA is palpable at the lower
abdominal incision.
Intraoperative algorithm for
lower abdominal flap choice
A simple intraoperative algorithm is used to determine
which lower abdominal flap is used. Preoperative
imaging is not necessary. If the SIEV is present and
equal to or greater than 1.5 cm, then the SIEA is assessed.
If the SIEA is palpable and a hemi-abdomen is sufficient
for reconstruction, then a SIEA flap is used. If the SIEA
is not present or palpable, then the DIEP perforators are
assessed. If there is a dominant DIEP perforator, then a
DIEP is performed. If there is not, then the location of
the existing perforators is assessed and either a muscle-
sparing free TRAM or, rarely, a free TRAM is performed.
Fig. 20.3.2  (A) After dermis has been incised, the tissues open up approximately
1–1.5 cm. The subcutaneous dissection is carried out at the edge of the superior
margin instead of the center of the tissues. (B) This results in a cuff of
subcutaneous fat that protects any superiorly based deep inferior epigastric
perforators.
A
B
Fig. 20.3.3  Relationship of the superficial inferior epigastric artery (SIEA) to the
superior inferior epigastric vein (SIEV). The SIEA can travel along side of the SIEV
or lateral to the SIEV with two venae comitantes.

346
SECTION II
CHAPTER 20.3 • Superficial inferior epigastric artery (SIEA) flap
pedicle length, fully opening the cribriform fascia to
expose the SIEA at its origin is essential. Buchel et al.
advocate that pedicle length should be twice the thick­
ness of the flap.18 Any branches at this distal level are
clipped long for potential use if spatulation is required
at branch points to address vessel mismatch.
At this point, we have still not performed any poste­
rior dissection, and therefore, the pedicle remains pro­
tected by posterior tissue and less likely to spasm. Once
the anterior dissection is complete along the full length
of the vessel, we carefully dissect the posterior surface
of the arterial pedicle. If concomitant vascular lymph
node transfer is not planned, harvesting the fat and
lymph nodes that surround the SIEA is avoided. Once
the pedicle dissection is completed, the flap is essentially
ready for harvest after clipping any DIEP perforators.
Because of the SIEA’s short pedicle, it is recommended
to de-epithelialize the majority of the flap in situ on the
abdomen to avoid injury to the anastomosis. This is
particularly important for larger flaps with a small
aperture following skin-sparing mastectomy.
Recipient vessels
Typically the internal mammary artery (IMA) and vein
or the perforating branches emanating from the internal
mammary vessels are used for recipient vessels. To
simplify the anastomosis and maximize recipient vessel
length, it is imperative to clear the tissues completely in
the intercostal space above and below the harvested rib.
Approximately 4 cm of length can typically be prepared.
As the surgeon becomes more familiar and comfortable
with the flap, shorter recipient vessel length or a rib-
sparing technique for access to the internal mammary
vessels can be used.
If present, the internal mammary perforators off the
second or third rib provide an excellent size match for
the SIEA and SIEV.19–22 Good communication with the
breast surgeon is important to preserve these vessels.
Anastomosis
Because of the short SIEA pedicle, the anastomosis is
often vertically oriented rather than horizontal. The
complexity is compounded by size mismatch of the
pedicle and recipient vessels. A surgeon can get more
experience with short pedicle anastomosis to the inter­
nal mammary vessels by practicing rib-sparing tech­
niques with the DIEP flap.
The use of a venous coupler can facilitate the venous
anastomosis given the size mismatch and short pedicle.
There are a couple of caveats to the use of a venous
coupler. If the surgeon is not already adept with the
coupler, then a hand-sewn anastomosis is preferable.
If the SIEV is present, but not the SIEA, the SIEV is
preserved in consideration for possible venous super­
charging of the flap.
Harvesting the SIEA
Once the decision to pursue an SIEA flap is made, the
pedicle is dissected. In order to protect from traction
injury to the artery and prevent spasm, we recommend
non-circumferential dissection of the pedicle initially
and focus only on the anterior dissection of the SIEA.
This is important because a gentle cephalad traction of
the flap coupled with a vertical retraction on the lower
groin skin will give optimal access for pedicle dissec­
tion. The SIEV can now be easily and quickly dissected
to femoral vein. Initially, the SIEA will travel caudally
as well. However, prior to entering the femoral sheath,
it makes a sharp turn superomedially. To maximize
Fig. 20.3.4  (A) Acland clamps on the superior inferior epigastric vein (SIEV)
reveal the dependence of this deep inferior epigastric perforator flap on the
superficial system for venous drainage. (B) Once the clamps are removed, the SIEV
is drained, and the flap no longer appears congested. The reliability of specific
perforators can be assessed by clamping individual vessels assessing changes in
flap perfusion.
A
B

347
Postoperative care
recommend holding the superomedial mastectomy skin
with one hand and insetting the flap in the superome­
dial direction first, which removes tension off the
pedicle. The remainder of the mastectomy skin can then
be carefully draped around the flap. In a patient under­
going completion mastectomy following previous
lumpectomy and radiation therapy, the mastectomy
skin can be less compliant. Thus, in this scenario, incis­
ing the mastectomy skin at 6 o’clock (exact location
depending on the size of the flap) may facilitate inset
without pedicle disruption. As mentioned previously,
the authors recommend performing the majority of the
de-epithelialization on the abdomen to avoid the need
to deliver the flap through a small space, which places
more traction on the pedicle. If the flap must be
de-epithelialized on the chest, the surgeon should heed
caution again in the situation of a skin-sparing mastec­
tomy with a small aperture. The mastectomy skin
coupled with short pedicle length can disrupt the
anastomosis.
Avoidance of tension on the pedicle is important to
minimize arterial spasm. The mastectomy skin envelope
to flap relationship must be evaluated. If the flap is rela­
tively small in a large skin envelope, consider (1) a verti­
cal reduction for a better match; (2) anchoring sutures
from the flap to the chest wall; and (3) an external
support such as a surgical bra that is fitted carefully to
prevent compression while giving inferior and lateral
support.
It is also important to remember the superficial nature
of the SIEA when de-epithelializing, insetting, and
securing the flap, as to avoid injuring the pedicle as it
courses through the flap.
Postoperative care
Care for the SIEA flap is similar to the postoperative care
for the DIEP flap and other free tissue reconstructions
of the breast. Most surgeons follow a postoperative
pathway. At the authors’ institution, patients leave the
operating room with a tissue oximetry monitor attached
to the flap and are transferred to the flap unit after a
6-hour period of flap monitoring in the post-anesthesia
care unit. The flap is monitored for color, temperature,
capillary refill, turgor, arterial signal with hand-held
Doppler, and hourly continuous tissue oximetry.
Incentive spirometry and chemical and mechanical DVT
prophylaxis are initiated. Patients are kept NPO for
approximately the first 24 hours, although if the patient
and flap are doing well by the next morning, the diet
is advanced after evaluation on morning rounds. The
Foley catheter is removed and the patient is written to
get out of bed to chair and ambulate later in the day.
Redoing a venous coupler can result in loss of almost a
centimeter of vessel length, which typically cannot be
afforded with the SIEA flap. Additionally, when the
recipient vein is less than 2 mm in diameter, it is gener­
ally advocated to avoid using the venous coupler.
Another scenario to avoid using the venous coupler is
when the recipient vein is less than 2 mm in diameter.
The SIEV is typically large, sometimes with diameters
up to 4 mm or greater. It also has a very thick vessel wall
compared the DIEP vein and recipient veins. When
forced to use a venous coupler less than 2 mm, the
redundancy of the thick SIEV in the small aperture of
the coupler ring can cause occlusion.23 In these cases, it
is better to hand suture the anastomosis.
To address arterial size mismatch, we recommend
making a backcut on the anti-mesenteric side of the
vessel. Alternatively, if there were any distal branches,
the pedicle could be spatulated at a branch point to
increase vessel diameter (Fig. 20.3.5). The arterial anas­
tomosis is hand sewn with interrupted 9-0 nylon sutures
under surgical microscopic magnification. Early on in
our practice, we exclusively performed non-rib-sparing
dissections to access the IMA or IMA perforator but now
commonly use rib-sparing techniques.
Inset
When insetting the SIEA flap, care must be taken given
the shorter pedicle length, especially with an immediate
reconstruction following a skin-sparing mastectomy
that provides only a small aperture. The authors
Fig. 20.3.5  Spatulation of the vessels can aid with size mismatch between
recipient artery and the superficial inferior epigastric artery.
Spatulation
Cut at branch point

348
SECTION II
CHAPTER 20.3 • Superficial inferior epigastric artery (SIEA) flap
■ Maximize recipient vessel length
■ Backcut or spatulate the SIEA for improved vessel
mismatch
■ Careful external support of the flap to prevent
ptosis
■ Postoperative care focused on warming the patient
and reducing pain and anxiety.
We recommend caution in patients who are heavy and
active smokers, not so much out of concern for fat
necrosis, but for increased vasospasm risk. Intraopera­
tively, papaverine is particularly useful to address any
arterial spasm.
Outcomes, prognosis, complications
Patients who have had SIEA flaps do well with few
donor site complications (Fig. 20.3.6). The decreases in
donor site morbidity correlate to the decrease in rectus
muscle harvested.21,22,24,25 Anecdotally, in our practice
we have observed decreased postoperative pain and
time to ambulation. There are no risks of hernia or
Postoperative day two is spent with continuation of
ambulation and converting all pain control to oral
medications. Patients are discharged on postoperative
day three.
Specific consideration to the postoperative monitor­
ing of the SIEA flap revolves around arterial spasm.
Ptosis of the flap can cause stretch on both the venous
and arterial anastomosis. Arterial spasm, in addition to
resulting in an absent Doppler signal and a cool, pale
flap, is often manifested on tissue oximetry as a steady
drop of 15–20 points and leveling off, even at levels that
may otherwise seem normal, whereas in venous com­
promise the oxygen saturation continues to drop, often
to levels below 30%. Therefore, the trend in tissue oxim­
etry rather than just the absolute value is important to
prompt flap evaluation.
Maneuvers to avoid arterial vasospasm include
controlling pain and anxiety, warming the patient,
and preventing dehydration with intravenous fluids.
Mechanical measures to help prevent spasm revolve
around keeping the flap stable, such as using a surgical
bra in those patients with a loose mastectomy skin
envelope.
If a patient’s flap does go into spasm, often external
measures can be tried initially. If the patient has not
been wearing a bra, a surgical bra is placed to give
support. Medications are adjusted to treated pain, and
anti- anxiolytics are added if the patient exhibits
anxiety. Calcium channel blockers can be tried if the
blood pressure will tolerate it. If the spasm does not
break on its own after these measures, operative explo­
ration is warranted. Of course, if there is any surgical
concern, such as a difficult anastomosis and the index
of suspicion is higher, operative re-exploration is
always indicated.
Pitfalls and techniques to avoid them
The main pitfalls of the SIEA flap focus on the predilec­
tion of the artery to spasm, vessel size mismatch, and
short pedicle. Throughout the chapter, we have dis­
cussed strategies to avoid these and will highlight them
here.
■ Lower the abdominal incision to encounter the SIEA
at a larger caliber
■ Perform the anterior dissection first rather than
circumferential dissection of the artery to protect the
artery from vasospasm
■ Dissect the artery completely to the femoral artery
■ Avoid unnecessary peri-arterial lymph node harvest
to increase pedicle length
■ De-epithelialize the flap on the abdomen
Fig. 20.3.6  (A,B) A patient who underwent bilateral skin-sparing mastectomy with
immediate reconstruction with bilateral superficial inferior epigastric artery flaps.
She had bilateral immediate autologous reconstructions with abdominal donor site
morbidity analogous to an abdominoplasty.
A
B

349
Secondary procedures
Secondary procedures
Staged secondary procedures are the same as
any abdominally based autologous tissue breast
reconstruction.
bulge since the rectus fascia and motor nerves to the
rectus muscles are not disturbed. If, during the dis­
section, one harvests lymph nodes with the flap or
does not adequately clip lymphatics, there is a risk
for lymphatic leaks and potentially lymphedema,
although rare.
15. Rozen WM, Chubb D, Whitaker IS, Ashton MW. The importance of
the superficial venous anatomy of the abdominal wall in planning a
superficial inferior epigastric artery (SIEA) flap: case report and
clinical study. Microsurgery. 2011;31:454–457. This case report and
review of CTA data demonstrates the variability in the number as well as
source of regional drainage of SIEV trunks, and advocates that all separate
trunks should be maximally dissected in the event that multiple venous
anastomoses are needed to optimize drainage in SIEA free flaps. In 40% of
cases illustrated in this anatomical study, two SIEV branches arose from
different trunks altogether, and the authors advocate that both trunks be
used in these instances.
16. Chevray PM. Breast reconstruction with superficial inferior
epigastric artery flaps: a prospective comparison with TRAM and
DIEP flaps. Plast Reconstr Surg. 2004;114:1077–1083, discussion
1084–1085. Chevray conducted a prospective study on the reliability and
outcomes of SIEA vs. TRAM and DIEP flaps for breast reconstruction,
and found that the SIEA flap was usable in 30% of cases. There was a
higher rate of reoperation with SIEA flaps, which he attributed to smaller
pedicle diameter (1.5 mm or smaller) and significant size mismatch with
recipient vessels.
17. Spiegel AJ, Khan FN. An intraoperative algorithm for use of the
SIEA flap for breast reconstruction. Plast Reconstr Surg.
2007;120:1450–1459. This is one of the first reports suggesting an
intraoperative algorithm for SIEA flap selection, which advocates for
utilization of this flap if arterial caliber is >1.5 mm with a palpable pulse.
Although our criteria for SIEA flap selection is only a palpable pulse, this
paper set the stage for future studies with higher numbers of patients.
20. Dorafshar AH, Januszyk M, Song DH. Anatomical and technical
tips for use of the superficial inferior epigastric artery (SIEA) flap in
breast reconstructive surgery. J Reconstr Microsurg. 2010;26:381–389.
This paper set forth a simple approach to harvest of the SIEA flap and
demonstrated that favorable results could be achieved with even smaller
caliber vessels (average arterial pedicle diameter in this series was
0.96 mm).
Access the complete reference list online at

349.e1
References
References
1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg.
1982;69:216–225.
2. Arnez ZM, Smith RW, Eder E, Solinc M, Kersnic M. Breast
reconstruction by the free lower transverse rectus abdominis
musculocutaneous flap. Br J Plast Surg. 1988;41:500–505.
3. Blondeel PN, Boeckx WD. Refinements in free flap breast
reconstruction: the free bilateral deep inferior epigastric perforator
flap anastomosed to the internal mammary artery. Br J Plast Surg.
1994;47:495–501.
4. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
morbidity of free DIEP flaps and free TRAM flaps for breast
reconstruction. Br J Plast Surg. 1997;50:322–330.
5. Blondeel PN. One hundred free DIEP flap breast reconstructions: a
personal experience. Br J Plast Surg. 1999;52:104–111.
6. Arnez ZM, Khan U, Pogorelec D, Planinsek F. Breast reconstruction
using the free superficial inferior epigastric artery (SIEA) flap. Br J
Plast Surg. 1999;52:276–279.
7. Chevray PM. Update on breast reconstruction using free TRAM,
DIEP, and SIEA flaps. Semin Plast Surg. 2004;18:97–104.
8. Holm C, Mayr M, Höfter E, et al. Interindividual variability of the
SIEA angiosome: effects on operative strategies in breast
reconstruction. Plast Reconstr Surg. 2008;122:1612–1620.
9. Beahm EK, Walton RL. The efficacy of bilateral lower abdominal
free flaps for unilateral breast reconstruction. Plast Reconstr Surg.
2007;120:41–54.
10. Hamdi M, Khuthaila DK, Van Landuyt K, et al. Double-pedicle
abdominal perforator free flaps for unilateral breast reconstruction:
new horizons in microsurgical tissue transfer to the breast. J Plast
Reconstr Aesthet Surg. 2007;60:904–912, discussion 913–914.
11. Figus A, Fioramonti P, Ramakrishnan V. Stacked free SIEA/DIEP
flap for unilateral breast reconstruction in a thin patient with an
abdominal vertical midline scar. J Reconstr Microsurg.
2007;23:523–525.
12. Rozen WM, Anavekar NS, Ashton MW, et al. Does the preoperative
imaging of perforators with CT angiography improve operative
outcomes in breast reconstruction? Microsurgery. 2008;28:516–523.
13. Alonso-Burgos A, García-Tutor E, Bastarrika G, et al. Preoperative
planning of deep inferior epigastric artery perforator flap
reconstruction with multislice-CT angiography: imaging findings
and initial experience. J Plast Reconstr Aesthet Surg. 2006;59:585–593.
14. Mathes DW, Neligan PC. Current techniques in preoperative
imaging for abdomen-based perforator flap microsurgical breast
reconstruction. J Reconstr Microsurg. 2010;26:3–10.
15. Rozen WM, Chubb D, Whitaker IS, Ashton MW. The importance of
the superficial venous anatomy of the abdominal wall in planning a
superficial inferior epigastric artery (SIEA) flap: case report and
clinical study. Microsurgery. 2011;31:454–457. This case report and
review of CTA data demonstrates the variability in the number as well as
source of regional drainage of SIEV trunks, and advocates that all separate
trunks should be maximally dissected in the event that multiple venous
anastomoses are needed to optimize drainage in SIEA free flaps. In 40% of
cases illustrated in this anatomical study, two SIEV branches arose from
different trunks altogether, and the authors advocate that both trunks be
used in these instances.
16. Chevray PM. Breast reconstruction with superficial inferior
epigastric artery flaps: a prospective comparison with TRAM and
DIEP flaps. Plast Reconstr Surg. 2004;114:1077–1083, discussion
1084–1085. Chevray conducted a prospective study on the reliability and
outcomes of SIEA vs. TRAM and DIEP flaps for breast reconstruction,
and found that the SIEA flap was usable in 30% of cases. There was a
higher rate of reoperation with SIEA flaps, which he attributed to smaller
pedicle diameter (1.5 mm or smaller) and significant size mismatch with
recipient vessels.
17. Spiegel AJ, Khan FN. An intraoperative algorithm for use of the
SIEA flap for breast reconstruction. Plast Reconstr Surg.
2007;120:1450–1459. This is one of the first reports suggesting an
intraoperative algorithm for SIEA flap selection, which advocates for
utilization of this flap if arterial caliber is >1.5 mm with a palpable pulse.
Although our criteria for SIEA flap selection is only a palpable pulse, this
paper set the stage for future studies with higher numbers of patients.
18. Buchel EW, Dalke KR, Hayakawa TE. Rethinking the superficial
inferior epigastric artery flap in breast reconstruction: video
demonstration of a rapid, reliable harvest technique. Can J Plast
Surg. 2013;21:99–100.
19. Ulusal BG, Cheng M-H, Wei F-C, et al. Breast reconstruction using
the entire transverse abdominal adipocutaneous flap based on
unilateral superficial or deep inferior epigastric vessels. Plast
Reconstr Surg. 2006;117:1395–1403, discussion 1404–1406.
20. Dorafshar AH, Januszyk M, Song DH. Anatomical and technical
tips for use of the superficial inferior epigastric artery (SIEA) flap in
breast reconstructive surgery. J Reconstr Microsurg. 2010;26:381–389.
This paper set forth a simple approach to harvest of the SIEA flap and
demonstrated that favorable results could be achieved with even smaller
caliber vessels (average arterial pedicle diameter in this series was
0.96 mm).
21. Wu LC, Bajaj A, Chang DW, Chevray PM. Comparison of donor-site
morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for
breast reconstruction. Plast Reconstr Surg. 2008;122:702–709.
22. Selber JC, Samra F, Bristol M, et al. A head-to-head comparison
between the muscle-sparing free TRAM and the SIEA flaps: is the
rate of flap loss worth the gain in abdominal wall function? Plast
Reconstr Surg. 2008;122:348–355.
23. Bank J, Teng E, Song DH. Microvascular coupler-induced intimal
crimping causing venous thrombosis. J Reconstr Microsurg.
2015;31:157–158.
24. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing
the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: part II. Bilateral reconstruction.
Plast Reconstr Surg. 2010;126:1438–1453.
25. 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;124:752–764.

SECTION II • Reconstructive Breast Surgery
20.4 
The free TRAM flap
Maurice Y. Nahabedian
SYNOPSIS
■ The free transverse rectus abdominis myocutaneous (TRAM) can be
classified as a muscle-sparing flap that includes the medial and lateral
segments of the rectus abdominis muscle (MS-2), the medial or lateral
segments (MS-1), or the full width (MS-0).
■ The free TRAM has a reliable and predictable blood supply based off
the inferior epigastric artery and vein.
■ Functional outcomes of the muscle-sparing free TRAM and deep
inferior epigastric perforator flap (DIEP) flap are equivalent.
■ Preoperative and intraoperative imaging studies can predict the
vascular architecture and perfusion patterns.
■ The free TRAM may provide more predictable outcomes in obese and
morbidly obese patients compared with the DIEP flap.
■ Free TRAM can result in excellent aesthetic outcomes with low
complication rates.
Introduction
The abdomen is the most common donor site for autolo­
gous breast reconstruction. There are various flaps that
are derived from the abdomen including the pedicle
TRAM, free TRAM, DIEP, and the superficial inferior
epigastric artery flap (SIEA). The evolution of these
flaps has been based on improving breast aesthetics and
reducing abdominal morbidity. Breast aesthetics are
related to volume of abdominal tissue, ability to opti­
mally position the flap on the chest wall, properly shape
the flap, and ensure adequate vascular inflow and
outflow to optimize perfusion. Donor aesthetics are
related to adequate closure of the abdominal soft tissues,
continuity and innervation of the rectus abdominis
muscles, and maximal preservation of the anterior
rectus sheath. The relative risk ratio of these flaps with
respect to breast outcome is highest with the SIEA flap
followed by the DIEP flap, free TRAM flap, and pedicle
TRAM flaps. The relative risk ratio with respect to donor
or abdominal outcome is highest with the pedicle TRAM
flap followed by the free TRAM, DIEP flap, and the
SIEA flap.
The free TRAM flap has been a prominent method of
breast reconstruction using autologous tissue since the
early 1990s. Advantages of the free TRAM compared
with alternative flaps are ultimately related to predict­
ability and reproducibility. This is because the blood
supply to the free TRAM is optimized based on the
larger caliber deep inferior epigastric perforator vessels
as well as inclusion of multiple perforators. In addition,
the continuity and innervation of the rectus abdominis
muscles are usually preserved with minimal violation
of the anterior rectus sheath.
Basic science/anatomy
Patients should have a sufficient quantity of abdominal
skin and subcutaneous fat in order to reconstruct a breast.
The fat is separated into a subcutaneous and a subscarpal
layer separated by Scarpa’s fascia. The thickness of these
layers varies from 2–8 cm. The anterior rectus sheath is
comprised of the aponeurosis of the external and internal
oblique muscles and characterized as an interwoven
collagen lattice. It is considered the principal support
structure for the anterior abdominal wall. Disruption or
attenuation of the lattice without proper closure can
result in bulge or hernia. There is a loose areolar layer of
tissue over the anterior sheath that contains a plexus of
vessels that should be preserved to ensure vascularity
and viability following the operation.
  Access video lecture content for this chapter online at expertconsult.com

351
Classification of free TRAM flaps
20.4.2). Preservation of the rectus abdominis muscle is
based on subdivision into three vertical segments:
medial, central, and lateral.1,2 Preservation of the entire
muscle is classified as an MS-3 (DIEP) flap. Preservation
of the medial and lateral segment is classified as an
MS-2 (muscle-sparing TRAM) flap (Fig. 20.4.3). Preser­
vation of the lateral or medial segment is classified as
an MS-1 (muscle-sparing TRAM) flap (Fig. 20.4.4). A
modification of this particular classification is based on
whether the medial (M) or lateral (L) segment of the
rectus abdominis muscle is preserved. If the medial and
central segments of the muscle are harvested with the
flap, the free TRAM would be classified as an MS-1L,
signifying that the lateral segment was preserved. Sac­
rifice of the entire width of the muscle is classified as an
MS-0 (TRAM) flap (Fig. 20.4.5). MS-1 and MS-2 flaps
will preserve the continuity of the rectus abdominis
muscle and therefore provide varying degrees of muscle
function.
The zones of the free TRAM flap are the same as the
zones of all abdominally based flaps and are comprised
of four segments (Fig. 20.4.6). Zone 1 represents the
adipocutaneous territory over the dominant blood
supply. Zone 2 is based on unilateral or bilateral flaps.
With unilateral flaps, zone 2 is opposite the midline.
Zone 3 is lateral to zone 1, and zone 4 is lateral to zone
3. With bilateral flaps, zone 2 is lateral to zone 1 and
zone 3 and 4 do not exist.
Current concepts with free flap
breast reconstruction
When considering autologous breast reconstruction
with a free TRAM flap, an appreciation of ideal breast
aesthetics is important. This incorporates three essential
elements: the breast footprint, skin envelope, and conus.
This three-step principalization of breast reconstruction
was described by Phillip Blondeel and is the basis for
achieving ideal breast aesthetics.3,4 The footprint is
unique for each woman and defined and fixed for each
breast (Fig. 20.4.7). The borders of the footprint include
the clavicle, lateral edge of the sternum, anterior axillary
line, and the inframammary fold. It is important to
The rectus abdominis muscle is a type 3 muscle that
is perfused by the superior and inferior deep epigastric
vessels (Fig. 20.4.1). It is segmentally innervated at
various levels throughout its length. The free TRAM
flap receives its blood supply from the deep inferior
epigastric artery and vein, as well as the perforating
branches traversing through the anterior rectus sheath.
The intramuscular course of the deep inferior epigastric
vessels is complex and classified as type 1, 2, or 3 based
on the number of dominant branching patterns. The
number of perforators emanating from these vessels is
variable with the preponderance of perforators located
in the periumbilical region. The intercostal motor nerves
typically innervate the muscle along the posterior
surface at the junction of the lateral and central segment.
Proper function of the rectus abdominis muscle requires
that these motor nerves remain intact because each
nerve controls a different arc of muscle flexion. The
intramuscular course of these motor nerves may cross
over the dominant source vessels supplying the flap.
Sensory nerves are identified along the surface of the
anterior rectus sheath and traverse through the subcu­
taneous layer to the skin.
Classification of free TRAM flaps
Classification of the abdominal flaps is based on the
degree of muscle preservation (Table 20.4.1 and Fig.
Fig. 20.4.1  Vascular anatomy of the rectus abdominis muscle.
Table 20.4.1  The classification and definition of the various
abdominally based free flaps
Muscle-sparing
technique
Definition (rectus abdominis)
MS-0
Full width, partial length
MS-1
Preservation of lateral segment
MS-2
Preservation of lateral and medial segment
MS-3 (DIEP)
Preservation of entire muscle

352
SECTION II
CHAPTER 20.4 • The free TRAM flap
20.4.9). In the setting of immediate reconstruction, the
quality and quantity of skin is important. Skin quality
is affected by previous surgery, radiation, scar, and
vascularity. With immediate reconstruction, it is impor­
tant to ensure that the flap volume approximates the
skin envelope volume. With delayed reconstruction,
this is not a factor because the shape of the breast is
determined by the amount of skin and fat from the flap,
as well as the useable skin from the chest.
Plastic surgeons typically learn the fundamentals of
breast shaping during residency or fellowship. This is
usually achieved with the apprentice or mentorship
appreciate that the footprint is stable and does not
change with weight gain or loss. The footprint repre­
sents the foundation for the conus. The conus is repre­
sentative of the 3D shape, volume, projection, and
contour of the breast (Fig. 20.4.8). This will vary with
weight gain or loss. The conus is typically characterized
with a lower pole prominence. In general, ideal breast
proportion is based on the ratio of the distance along
the breast meridian with separation into upper and
lower distances based on the location of the nipple
areolar complex. Ideally, the upper to lower pole ratio
is 45 : 55. The final component is the skin envelope (Fig.
A
B
06,
Fig. 20.4.2  (A–D) Schematic illustrations of the MS-1, MS-2, and MS-3 flaps based on the amount of muscle spared. DIEP, deep inferior epigastric perforator flap.
C
06,,
D
',(3

353
Patient selection
developing breast cancer. Some patients will present
following a mastectomy and are interested in delayed
reconstruction. These patients may have had prior
radiation therapy or complications related to prosthetic
reconstruction. To be considered a good candidate for a
free TRAM flap, patients should have sufficient tissue
in the lower abdomen to create a breast that will meet
expectations.
Proper patient selection and good outcomes are inti­
mately related.5,6 Although many women may express
an interest in autologous breast reconstruction, not all
Fig. 20.4.3  The rectus abdominis muscle following harvest on an MS-2 free TRAM
flap.
Fig. 20.4.4  The rectus abdominis muscle following harvest of an MS-1 free TRAM
flap.
Fig. 20.4.5  An MS-0 free TRAM flap incorporating the full width of the rectus
abdominis muscle.
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Fig. 20.4.6  The standard zones of the free TRAM flap based on the proximity of
the primary blood supply. The unilateral and bilateral variations are shown.
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model. Initially the technical aspects of the operation are
the most important and require mastery; however, with
surgical maturation, the aesthetic aspects become as
important, and the artistry of breast reconstruction
comes to fruition. The ultimate goal is to create sym­
metry, proportion, and contour. When positioning a free
TRAM flap on the chest wall, the width and height of
the tissues should match the desired footprint of the
breast. The natural shape or cone of the breast should
be appreciated to estimate the amount of skin that will
be required to achieve ideal proportions. The relation­
ship of the torso to the breast is assessed to reconstruct
a breast that will be appropriate for the patient’s frame
and body habitus.
Patient selection
Patients who are considered for breast reconstruction
with the free TRAM in the immediate setting are usually
those diagnosed with breast cancer or at high risk for

354
SECTION II
CHAPTER 20.4 • The free TRAM flap
Fig. 20.4.7  The footprint of the breast is illustrated in
(A) coronal; (B) sagittal; and (C) transverse views.
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Fig. 20.4.8  The conus of the breast is illustrated in
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