Operative Technique in Plastic Surgery – Kevin C.Chung

experienced nursing care on the ward.
■ Hourly flap monitoring (color, capillary refill, temperature, turgor, and
Doppler) for first 24 hours in step-down unit or ICU
■ Bed rest for the first night, up to chair the next day, and walking on
postoperative day (POD) 2
■ NPO the first night with progression of diet the next day if no flap concerns
■ Enoxaparin 40 mg SC daily while in hospital, started POD 0
■ Aspirin 81 mg daily for the first 6 weeks, started POD 1
■ Abdominal binder applied for 6 weeks
■ The typical discharge date is POD 3 for unilateral reconstructions and POD 4
for bilateral or immediate reconstructions.
OUTCOMES
■ Several studies have reported abdominal donor site morbidity, including bulge
or hernia and functional weakness, to be higher in free TRAM vs DIEP
patients.11,12
■ However, a recent multicenter, patient-reported outcomes study found no
significant difference in BREAST-Q scores for physical well-being of the
abdomen between free TRAM and DIEP flap reconstruction.11
■ With regard to other outcomes, the literature has shown that the risk of fat
necrosis is lower in free TRAM flaps when compared to DIEP flaps.12
COMPLICATIONS
■ Early complications
■ Hematoma or seroma (donor site or flap site)
■ Venous congestion
■ Flap loss (partial or total)
■ DVT/PE
■ Infection
■ Mastectomy flap necrosis
■ Abdominal skin or umbilical necrosis
■ Late complications
■ Fat necrosis (flap)
■ Delayed wound healing
■ Abdominal bulge or hernia
■ Aesthetic (asymmetry, malposition)

REFERENCES
1. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction
with the free TRAM or DIEP flap: patient selection, choice of flap, and
outcome. Plast Reconstr Surg. 2002;110(2):466-475.
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(3):423-427.
3. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric system. Plast
Reconstr Surg. 1988;82(5):815-832.
4. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior
epigastric artery perforator flap: a systematic review. Plast Reconstr Surg.
2014;134(5):810e-821e.
5. Rozen WM, Palmer KP, Suami H, et al. The DIEA branching pattern and its
relationship to perforators: the importance of preoperative computed
tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg.
2008;121:367-373.
6. Mathes DW, Neligan PC. Current techniques in preoperative imaging for
abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr
Microsurg. 2010;26(1):3-10.
7. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and free. J
Surg Oncol. 2006;94(6):532-537.
8. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in
patients undergoing free TRAM flap breast reconstruction. Plast Reconstr
Surg. 2000;105(7):2374-2380.
9. Karanas YL, Santoro TD, Da Lio AL, Shaw WW. Free TRAM flap breast
reconstruction after abdominal liposuction. Plast Reconstr Surg.
2003;112(7):1851-1854.
10. Jandali S, Nelson JA, Wu LC, Serletti JM. Free transverse rectus abdominis
myocutaneous flap for breast reconstruction in patients with prior abdominal
contouring procedures. J Reconstr Microsurg. 2010;26(9):607-614.
11. Macadam SA, Zhong T, Weichman K, et al. Quality of life and patient-
reported outcomes in breast cancer survivors: a multicenter comparison of four
abdominally based autologous reconstruction methods. Plast Reconstr Surg.
2016;137(3):758-771.
12. Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or
DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr

Surg. 2009;124:752-764.

21
CHAPTER
Muscle-Sparing Free
Transverse Rectus
Abdominis Myocutaneous
(TRAM) Flap
Arash Momeni and Liza C. Wu
DEFINITION
■ Acquired amastia following mastectomy is associated with significant
psychological distress.1
■ Breast reconstruction following prophylactic mastectomy or mastectomy for
breast cancer has been demonstrated to improve health-related quality of life
and patient-reported outcomes.2
■ Favorable long-term patient satisfaction is particularly associated with
autologous breast reconstruction using abdominal tissue.3–5
■ In contrast to the traditional free TRAM flap in which the entire width of the
rectus abdominis muscle is harvested, the muscle-sparing free TRAM flap only
incorporates a small amount of rectus abdominis muscle along with overlying
anterior rectus sheath, thus, reducing donor-site morbidity.
ANATOMY
■ The rectus abdominis muscles are flat muscles located on either side of the
midline that originate from the 6th to 8th costal cartilages and the xiphoid
process and insert on the pubic symphysis.
■ Each rectus abdominis muscle rests within a fascial sheath (ie, rectus sheath)
that is formed by the confluence of the aponeuroses of the oblique (external
and internal) and transversus abdominis muscles.
■ Above the arcuate line, the aponeurosis of the internal oblique splits, thus
contributing to the anterior and posterior rectus sheath by joining with the

external oblique aponeurosis and transversus abdominis aponeurosis,
respectively.
■ Below the arcuate line, all three aponeuroses form the anterior rectus sheath.
■ The rectus abdominis muscle has a dual blood supply via the superior and
deep inferior epigastric vascular arcade.
■ These vessels originate from the external iliac vessels.
■ Perforating vessels from these arcades pierce the rectus abdominis muscle to
perfuse the overlying skin and soft tissues.
■ The blood supply to the lower anterior abdominal skin via the superior
epigastric artery is indirect and relies on “choke” vessels located in the
midabdomen.
■ In contrast, perforators emanating from the deep inferior epigastric artery
represent a more direct source of blood supply to the lower anterior
abdominal skin.
• This represents the anatomic basis for the more robust blood supply of the
free muscle-sparing (MS) TRAM flap compared to the pedicled TRAM
flap.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation for patients presenting for autologous breast
reconstruction using an MS-TRAM flap includes a detailed history and focused
physical examination.
■ History
■ Preoperative smoking cessation is strongly encouraged in order to decrease
the risk of wound infection, mastectomy skin necrosis, and abdominal flap
necrosis.6
■ Pre-existing medical conditions, such as diabetes mellitus, hypertension, etc.,
need to be optimized preoperatively.
■ Obesity is a specific consideration that may lend itself to increased
intraoperative and postoperative complications such as increased blood loss,
wound healing issues, and hernia formation.7
■ Physical examination
■ The abdomen is inspected for pre-existing scars that may preclude MS-
TRAM flap harvest.
• Although appendectomy and Pfannenstiel scars do not pose clinical
problems (unless the deep inferior epigastric vessels were previously

ligated), subcostal incisions can be associated with a higher rate of delayed
wound healing due to compromised perfusion to the watershed area of the
abdominal flap.
• Midline scars are not necessarily problematic, particularly in bilateral
reconstructions.
• Merely unilateral reconstructions in patients with large breasts in whom
more than two perfusion zones are required may occasionally necessitate
raising the MS-TRAM flap as a bipedicled flap.
• Previous liposuction is not a contraindication; however, a true
abdominoplasty is.8
■ Palpation of the abdomen is performed to document the presence of ventral
and/or umbilical hernias.
• Repair of an umbilical hernia at the time of autologous breast reconstruction
risks the development of umbilical necrosis.
■ The height of the MS-TRAM flap is determined preoperatively and should
correspond to breast width.
• It may be helpful to determine the degree of abdominal tissue laxity by
having the patient flex at the waist, as this gives a reasonable estimate of
how much tissue can be harvested without subjecting the closure line to
undue tension.
■ Breast examination/palpation is important to assess preoperative beast
volume as this can necessitate modification of flap design to optimize a
volume match.
IMAGING
■ Preoperative imaging is not routinely required prior to MS-TRAM flap
harvest.
■ Only in select patients, ie, patients with previous abdominal procedures in
which the deep inferior epigastric vessels or its perforators were at risk for
injury, is a CT angiography obtained to confirm the presence of suitable
vessels.
SURGICAL MANAGEMENT
■ Parameters to consider include the following:
■ Timing of reconstruction
• Immediate vs delayed reconstruction
■ Immediate reconstruction has several advantages. These include the ability to

reconstruct a breast mound in a single procedure as well as ease of obtaining an
aesthetically appealing result due to the presence of the breast skin envelope.
■ Delayed reconstruction can be offered at anytime after mastectomy and
adjuvant chemotherapy. In cases of postmastectomy radiotherapy, we
recommend waiting 6 months after the end of radiation to allow for the
recovery of the soft tissues from radiation injury. Furthermore, scarred or
irradiated skin that prevents adequate ptosis should be excised and replaced
with abdominal skin.
■ Need for adjuvant radiotherapy
• Radiotherapy after MS-TRAM flap-based reconstruction can result in
volume loss, skin contracture, fat necrosis, and poor appearance.9
• Options to remedy the detrimental radiation-induced effects include a
“delayed-immediate” approach, in which a tissue expander is placed
immediately and eventually replaced with autologous tissue following
completion of radiotherapy, or immediate reconstruction with an MS-
TRAM flap that is designed approximately 10% to 15% larger than the
contralateral breast to account for the anticipated volume loss.
■ Recipient vessels
• The decision as to whether the ipsilateral or contralateral MS-TRAM flap is
used is predominantly determined by the choice of the recipient vessels (see
Techniques).
Preoperative Planning
■ Preoperative patient assessment should reveal the presence of adequate
amount of lower abdominal soft tissue for the purpose of breast reconstruction.
■ Clinical examination should rule out pre-existing abdominal scars that would
preclude the harvest of an MS-TRAM flap.
■ Preoperative landmarks include the umbilicus, anterior superior iliac spines
(ASIS), and the suprapubic crease.
■ The elliptical skin island of the MS-TRAM flap includes the areas between
the upper border of the umbilicus and the suprapubic crease and the ASIS
bilaterally.

FIG 1 • A,B. Illustration of a free MS-TRAM flap based
on the deep inferior epigastric vessels with limited
rectus abdominis muscle attached to the skin island
(Courtesy of D.W. Low, MD).
Positioning
■ The patient is positioned supine on the operating table with bilateral upper
extremities abducted.
■ The operating table should allow hip flexion to decrease tension during donor-
site closure.
Approach
■ The lower abdominal skin can be harvested in a variety of different ways
based on the amount of rectus muscle included as well as its vascular pedicle.
■ Options include
• Pedicled TRAM flap (see Chapter 32)
• Free TRAM flap—Full width of rectus abdominis muscle is harvested (see
Chapter 34)
• Free MS-TRAM flap—Part of the rectus abdominis muscle is harvested

(FIGS 1 and 2)
• Free deep inferior epigastric perforator (DIEP) flap—No rectus abdominis
muscle is harvested (see Chapter 36)
• Free superficial inferior epigastric artery (SIEA) flap—The anterior rectus
sheath is not violated and the abdominal flap is raised based on the
superficial epigastric vessels (see Chapter 37)
FIG 2 • Clinical image of a free MS-TRAM flap. Note the
small segment of rectus abdominis muscle harvested
with the flap.
T E C H N I Q U E S
■ Free MS-TRAM Flap Harvest
■ Landmarks: Umbilicus, anterior superior iliac spines (ASIS), suprapubic
crease
■ Skin incision is made along the upper border of the flap.
■ Dissection is carried down to the abdominal wall fascia followed by
undermining of the upper abdominal skin and soft tissues to the level of the
xiphoid and costal margin.
■ It is critical to spare perforating vessel in the subcostal region to maximize
perfusion to the abdominal skin flap.
■ The patient is temporarily sat up and the superior abdominal skin is draped

over the MS-TRAM flap island to confirm the ability to obtain donor-site
closure at the completion of the procedure.
■ The lower border of the MS-TRAM flap is incised followed by identification
of the superficial inferior epigastric (SIE) vessels.
■ The SIE vein (SIEV) is found approximately 4 to 5 cm lateral to the
midline. The SIEA is approximately 2 to 3 cm lateral to the SIEV.
■ At this point, the surgeon should determine if the SIE vessels are suitable
to apply a SIEA flap.
■ If the SIEA is of inappropriate caliber (less than 1.5 mm) or not present,
the SIEV is dissected over the course of 4 to 5 cm and ligated. This
provides for an additional outflow vein or a source of vein graft.
■ Next, flap dissection proceeds from lateral to medial until the lateral row of
perforators emanating from the anterior rectus sheath is visualized.
■ In unilateral breast reconstruction, the skin island opposite the vascular
pedicle is dissected off of the abdominal wall, across the midline, and up to
the medial row of perforators.
■ In bilateral breast reconstruction, the skin island is transected in the
midline followed by medial-to-lateral dissection until the medial row of
perforators is identified.
■ Once the decision is made on which perforators to include, the anterior
rectus sheath is incised below to the inferior-most perforator. The anterior
rectus sheath is divided inferolaterally toward the vascular pedicle of the flap.
■ The deep inferior epigastric vessels are identified along the lateral edge of
the rectus abdominis muscle and followed all the way to their origin, ie, the
external iliac vessels.
■ Superiorly, the anterior rectus sheath incision is extended to incorporate the
chosen perforators. It is critical to keep the amount of fascial harvest to a
minimum.
■ The amount of muscle divided in a MS-TRAM flap is dependent on the
topography of perforators.
■ The lateral- and medial-most perforators determine the width of rectus
abdominis muscle that is divided.
■ The rectus abdominis muscle is split along its fibers at the level of the
lateral-most perforator and the medial-most perforator, respectively.
• It is important to confirm that the main vascular pedicle is located within
the harvested segment of rectus abdominis muscle.

• Small vascular branches traveling away from the perforator-carrying
central muscle segment are carefully ligated and divided.
• In order to reduce the width of rectus abdominis muscle that is sacrificed,
it is critical to stay close to the perforators and to follow their
intramuscular course (TECH FIG 1).
■ After recipient vessel dissection and confirmation of adequate recipient
vessels, the deep inferior epigastric vessels are ligated close to their origin,
followed by transection of the central rectus abdominis muscle segment
inferiorly and superiorly.
TECH FIG 1 • A. Donor-site defect following MS-
TRAM flap harvest. B. Donor-site defect following MS-
TRAM flap harvest. Note, preservation of rectus
abdominis muscle medially and laterally.
■ Recipient Vessel Dissection
■ The most common recipient vessels are the internal mammary artery (IMA)
and vein (IMV) (TECH FIG 2).
■ The pectoralis major muscle is divided along its fibers at the level of the 3rd
rib.
■ After identification of the 3rd rib, the intercostal space between the 3rd and
4th rib is assessed for the possibility of a rib-sparing approach to the IM
vessels.
■ If the intercostal space is adequately wide (greater than 2 cm), a rib-sparing
approach is chosen.

■ The pectoralis major muscle is divided along its fibers between the 3rd and
4th rib.
• The intercostal muscles are divided lateral to the level of the IM vessels
vertically beginning inferolaterally at the level of the cartilaginous and
bony junction. Next, in a lateral to medial direction, the intercostal muscle
cuff is excised at the level of the pleura until the IM vessels are visualized
encased in adipose tissue.
• Completion IM vessel dissection follows after removal of the adipose
tissue and lymphatics surrounding the IMA and V in the space between
the 3rd and 4th rib.
■ If a rib-sparing approach is not possible, the cartilage of the 3rd rib is most
commonly removed for the purpose of IM vessel dissection.
■ The perichondrium of the 3rd rib is incised transversely on its anterior
surface from its junction with the sternum to approximately 1 cm medial to
the costochondral junction.
■ Subperichondrial dissection follows anteriorly, superiorly, and inferiorly.
Complete posterior dissection is not mandatory.
■ The costal cartilage is then removed with a rongeur.
■ The posterior perichondrium is incised vertically lateral to the IM vessels
followed by lateral-to-medial dissection.
• Meticulous dissection with ligation of small intercostal branches is critical
to maintain a bloodless field.
TECH FIG 2 • Recipient vessel dissection: The
pectoralis major muscle is split and the right internal
mammary vessels are dissected.

■ After identification of the IM vessels, the soft tissues between the superior
border of the 4th rib and the inferior border of the 2nd rib are excised, thus,
providing for a long vascular segment that facilitates microsurgical
anastomosis.
■ Other possible recipient vessels include the thoracodorsal vessels, the
circumflex scapular vessels, the thoracoacromial vessels, and the axillary
artery and vein.
■ Abdominal Donor-Site Closure
■ Meticulous donor-site closure is critical if abdominal hernias and bulges are
to be avoided.
■ Inferiorly primarily fascial closure is performed with figure-of-eight
polypropylene sutures with buried knots.
■ Fascial closure is routinely reinforced with polypropylene mesh.
■ The polypropylene mesh is placed between the rectus abdominis muscle and
the anterior rectus sheath.
■ It is critical to ensure that the mesh is positioned inferiorly within the
rectus sheath so as to buttress the fascial repair site.
■ Size 0 polypropylene sutures are used to secure the mesh.
■ The mesh is secured with buried mattress sutures: first, inferiorly; then
superiorly and medially; and, finally, laterally.
■ In cases on minimal fascial excision with MS-TRAM flap harvest, primary
fascial closure is performed. However, in cases of moderate (greater than 2–3
cm) fascial excision, a bridging mesh technique of anterior rectus sheath
closure is preferred to minimize postoperative abdominal discomfort
secondary to an overly tight fascial closure.
■ Next, the patient is raised to facilitate skin closure.
■ The superior abdominal skin flap is temporarily stapled into place and the
site of the umbilical transposition is marked.
■ An opening in the abdominal skin flap is created, followed by removal of a
core of subcutaneous tissue.
■ The umbilicus is sutured into place with interrupted deep dermal 4-0
absorbable monofilament sutures followed by a subcuticular closure with a
5-0 absorbable monofilament suture.
■ Two suction drains are placed exiting the abdominal wound laterally.

■ Layered closure is performed with approximation of Scarpa fascia followed
by deep dermal and subcuticular closure.
■ Sterile dressings are applied.
■ MS-TRAM Flap Inset
■ Whenever the internal mammary vessels are chosen as recipient vessels, the
contralateral MS-TRAM flap is used for reconstruction.
■ The MS-TRAM flap is rotated 90 degrees with the umbilicus positioned
inferolaterally (TECH FIG 3).
■ The ipsilateral MS-TRAM flap is used whenever the thoracodorsal vessels
are chosen as recipient vessels.
■ Here, the umbilicus is positioned inferomedially after rotating the flap 90
degrees.
■ After performing microsurgical anastomoses, the flap is secured in place
with 2-0 absorbable sutures.
■ The flap is secured medially at the level of the 3rd rib as well as along the
superomedial, superior, and superolateral borders of the breast footprint.
■ A suction drain is placed and wound closure performed with interrupted
absorbable sutures for deep dermal closure following by subcuticular
closure.
■ Finally, Doppler examination is performed and the site with an audible
Doppler signal is marked with a 5-0 polypropylene suture.
■ TECH FIG 4 displays a case example of bilateral immediate breast
reconstruction with free MS-TRAM flaps.

TECH FIG 3 • Illustration demonstrating anastomosis
of the deep inferior epigastric vessels to the internal
mammary vessels. Note that the left MS-TRAM flap
has been transferred to the right chest with the flap
being rotated 90 degrees so that the umbilicus is
positioned inferolaterally (Courtesy of D.W. Low, MD).

TECH FIG 4 • Preoperative (A), early postoperative
(prior to nipple-areola reconstruction) (B) and late
postoperative (after nipple-areola reconstruction) (C)
images of a patient who underwent bilateral
immediate breast reconstruction with free MS-TRAM
flaps.
PEARLS AND PITFALLS
Indications
■ Patients with adequate amount of lower abdominal soft tissue for the
purpose of breast reconstruction.
■ Absence of abdominal scars precluding MS-TRAM flap harvest.
Imaging
■ Routine use of preoperative imaging is not indicated.
■ Merely in cases in which prior abdominal surgery places the deep
inferior epigastric vessels or its perforators at risk is preoperative CT
angiography warranted.
Flap
dissection
■ Minimize abdominal wall morbidity by having the lateral- and
medial-most perforators determine the width of rectus abdominis
muscle that is divided.
■ Minimize fascial excision.
■ Preserve the SIEV as an additional drainage source or potential vein
graft.
Donor-site
■ Meticulous fascial closure is paramount to minimize the risk of

closure
abdominal hernia or bulge formation.
■ Routinely use polypropylene mesh in donor-site closure, even if
primary fascial closure is performed.
■ Avoid an overly tight fascial closure; use bridging mesh in cases of
moderate fascial excision (>2–3 cm).
Flap inset
■ The contralateral MS-TRAM flap is used whenever the IM vessels are
chosen as recipient vessels.
■ The ipsilateral MS-TRAM flap is used in cases in which the
thoracodorsal vessels are used as recipients.
POSTOPERATIVE CARE
■ Following extubation and transfer to the PACU, the patient is admitted to a
step-down unit.
■ Flap checks are performed via a combination of clinical and Doppler
examination hourly for the first 48 hours, followed by every 4 hours until
discharge.
■ The patient is kept NPO until the morning of postoperative day (POD) 1 and is
then started on a clear liquid diet. Diet is advanced to a regular diet on POD 2.
■ Activity restrictions include out of bed to chair on POD 1 followed by
ambulation on POD 2.
■ No specific anticoagulation is indicated. Patients merely receive heparin 5000
U subcutaneously every 8 hours for the duration of the hospitalization.
■ The patient is typically discharged home on POD 3 to 4. Instructions are
provided regarding incision and drain care.
OUTCOMES
■ The issue of donor-site morbidity associated with MS-TRAM flap harvest was
investigated in a matched-pair analysis of a total of 104 patients.10
■ Fifty-two MS-TRAM flap patients were matched with 52 abdominoplasty
patients.
■ Postoperative complication rate, including the rate hernia and abdominal
bulge formation were similar in both groups.
■ A higher degree of patient satisfaction with the appearance of the abdominal
scar was noted among TRAM flap patients.10
■ Using the BREAST-Q, Macadam et al. performed a multicenter study
including 1790 patients and did not detect any significant difference in patient-
reported outcomes between patients undergoing reconstruction with DIEP flaps

vs MS-TRAM flaps.11
COMPLICATIONS
■ Wound-related complications can be as high as 30% to 50%9 and include
■ Simple infections
■ Seromas
■ Hematomas
■ Skin flap necrosis
■ Delayed wound healing
■ Additional complications include
■ Fat necrosis
■ Flap loss (approximately 1%)12
■ Abdominal bulge/hernia formation
REFERENCES
1. Gomez-Campelo P, Bragado-Alvarez C, Hernandez-Lloreda MJ.
Psychological distress in women with breast and gynecological cancer treated
with radical surgery. Psychooncology. 2014;23(4):459-466.
2. Koslow S, Pharmer LA, Scott AM, et al. Long-term patient-reported
satisfaction after contralateral prophylactic mastectomy and implant
reconstruction. Ann Surg Oncol. 2013;20(11):3422-3429.
3. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic satisfaction with
breast reconstruction during the long-term survivorship Period. Plast Reconstr
Surg. 2009;124(1):1-8.
4. Liu C, Zhuang Y, Momeni A, et al. Quality of life and patient satisfaction after
microsurgical abdominal flap vs staged expander/implant breast
reconstruction: a critical study of unilateral immediate breast reconstruction
using patient-reported outcomes instrument BREAST-Q. Breast Cancer Res
Treat. 2014;146(1):117-126.
5. Atisha DM, Rushing CN, Samsa GP, et al. A national snapshot of satisfaction
with breast cancer procedures. Ann Surg Oncol. 2015;22(2):361-369.
6. Selber JC, Kurichi JE, Vega SJ, et al. Risk factors and complications in free
TRAM flap breast reconstruction. Ann Plast Surg. 2006;56(5):492-497.
7. Fischer JP, Nelson JA, Sieber B, et al. Free tissue transfer in the obese patient:
an outcome and cost analysis in 1258 consecutive abdominally based
reconstructions. Plast Reconstr Surg. 2013;131(5):681e-692e.
8. Jandali S, Nelson JA, Wu LC, Serletti JM. Free transverse rectus abdominis

myocutaneous flap for breast reconstruction in patients with prior abdominal
contouring procedures. J Reconstr Microsurg. 2010;26(9):607-614.
9. Serletti JM, Fosnot J, Nelson JA, et al. Breast reconstruction after breast
cancer. Plast Reconstr Surg. 2011;127(6):124e-135e.
10. Momeni A, Kim RY, Heier M, et al. Abdominal wall strength: a matched-pair
analysis comparing muscle-sparing TRAM flap donor-site morbidity with the
effects of abdominoplasty. Plast Reconstr Surg. 2010;126(5):1454-1459.
11. Macadam SA, Zhong T, Weichman K, et al. Quality of life and patient-
reported outcomes in breast cancer survivors: a multicenter comparison of four
abdominally based autologous reconstruction methods. Plast Reconstr Surg.
2016;137(3):758-771.
12. Pannucci CJ, Basta MN, Kovach SJ, et al. Loupes-only microsurgery is a safe
alternative to the operating microscope: an analysis of 1,649 consecutive free
flap breast reconstructions. J Reconstr Microsurg. 2015;31(9):636-642.

22
CHAPTER
DIEP Flap Breast
Reconstruction
Pierre M. Chevray
DEFINITION
■ Breast reconstruction following mastectomy can be accomplished with
prosthetic breast implants, autologous tissue flaps, or a combination of the two.
■ Autologous tissue flaps from the lower abdomen are capable of creating the
most natural, lasting, and maintenance-free reconstructed breasts with the
highest long-term patient satisfaction when compared to other methods of
breast reconstruction.1
■ Autologous tissue flaps have donor-site morbidity and require longer and more
complex surgery, with a longer recovery period, compared to implant-based
breast reconstruction.
■ Techniques to harvest lower abdominal flaps of skin and subcutaneous tissue
for breast reconstruction have evolved from the pedicled TRAM flap, to the
free TRAM flap, to the muscle-sparing free TRAM flap, to the DIEP flap, to
the SIEA flap, in order to minimize donor-site morbidity.2
■ The DIEP (Deep Inferior Epigastric Perforator) flap has become the most
popular lower abdominal free flap used for breast reconstruction because of its
balance of sparing rectus abdominis muscle function while still providing a
well-vascularized and reliable flap of skin and subcutaneous tissue.3–5
ANATOMY
■ The vascular pedicle of the DIEP flap is the deep inferior epigastric (DIE)
artery and veins, and their branches which perforate through the rectus
abdominis muscle (perforators), into the subcutaneous fat of the anterior
abdominal wall.
■ The DIE vessels originate from the external iliac vessels in the pelvis, course

anteriorly and superiorly, in the retroperitoneal plane, to the inferolateral
border of the rectus abdominis muscle. The DIE vessels continue superiorly,
within the rectus sheath, on the deep surface of the rectus abdominis muscle,
from which branches to the muscle and perforators into the overlying flap
tissue originate. Terminal branches of the DIE vessels coalesce with the
terminal branches of the deep superior epigastric vessels (FIG 1).
■ The single most common branching pattern of the DIE artery is that it
bifurcates into two parallel branches that course superiorly on the underside of
the rectus abdominis muscle. One branch runs along the medial side of the
muscle, giving rise to the “medial row” of perforators, and the other runs along
the lateral side of the muscle, giving rise to the “lateral row” of perforators.
However, this branching pattern is variable.
■ Generally, lateral row perforators pierce the muscle perpendicular to the plane
of the flat, straplike, rectus abdominis muscle and are easier to dissect
compared to medial row perforators, which tend to travel obliquely, from
medial to lateral, and superior to inferior, through the muscle and require
dissection along greater distances within the muscle when compared to lateral
row perforators.
FIG 1 • A. Deep inferior epigastric artery (DIEP) flap
anatomy showing a right hemiabdominal DIEP flap skin
paddle overlying the right rectus abdominis muscle
containing the medial and lateral branches of the deep
inferior epigastric (DIE) artery, which gives off the
medial and lateral row of perforators. B. The left

hemiabdominal DIEP flap is reflected laterally, as it
would be during exposure of the medial row of
perforators.
■ The limits of the DIEP flap skin paddle are several centimeters superior to the
superior edge of the umbilicus, inferiorly to the level of the pubic bone, and
laterally to the anterior axillary line. It is possible, usually in younger and
thinner patients, to transfer this entire lower abdominal flap based on the
perforators from one DIE vascular pedicle.
■ The skin paddle of lower abdominal flaps has been divided into zones.6Zone 1
is the paramedian region of the flap skin paddle overlying the rectus abdominis
muscle and is the best perfused area of the flap. Zone 2 is lateral to Zone 1.
Zone 3 is the mirror image of Zone 1, on the opposite side of the vertical
midline. Zone 4, lateral to Zone 3, is the furthest from the perforators and thus
the least well-perfused zone and most likely to suffer fat necrosis.
■ Selecting which perforators to keep, and which are not necessary and can be
sacrificed, is one of the critical decisions during this operation and requires the
most experience and judgment.
■ Generally, the single largest perforator will perfuse Zone 1 of a DIEP flap.
However, in most breast reconstructions, Zones 1 and 2 are necessary to
reconstruct a large enough breast.
■ Zones 1, 2, and 3, and sometimes Zone 4, can be perfused by including more
perforators.
■ The rectus abdominis muscle is segmentally innervated, and the skin paddle of
the DIEP flap receives sensory innervation from the thoracoabdominal
branches of the intercostal nerves T7-T11, which run between the internal
oblique and transversus abdominis muscles and then enter the lateral border of
the anterior rectus sheath.
■ These thoracoabdominal nerves run roughly transversely, just deep, and within
the rectus abdominis muscle along with the accompanying vascular branches
of the intercostal arteries and veins to anastomose with the DIE vessels, which
run roughly vertically.
■ The sensory nerve fibers run with the perforators through the rectus abdominis
muscle and anterior rectus sheath, into the overlying subcutaneous tissue of the
DIEP flap, to innervate the skin. The motor fibers branch into the substance of
the rectus abdominis muscle to innervate it.

■ These motor and sensory nerves run superficial to the DIE vessels, and for all
practical purposes, must be divided to harvest and transfer the DIEP flap.
Some surgeons repair the nerves that are divided.
PATHOGENESIS
■ The DIEP flap is most commonly used for breast reconstruction following
mastectomy for treatment of breast cancer, or risk reduction in patients with a
genetic increased risk of breast cancer such as BRCA 1 or 2 gene mutations.
NATURAL HISTORY
■ Rates of breast reconstruction have been slowly rising over the past 40 years.
However, in the United States, less than half of patients who are treated with
mastectomy have breast reconstruction,7,8 and rates of breast reconstruction are
substantially lower elsewhere in the world.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The DIEP flap can be used for total, or partial, breast reconstruction in patients
who have had a mastectomy or partial mastectomy (lumpectomy, segmental
mastectomy), respectively.
IMAGING
■ CT and MR angiography is used by some surgeons to visualize the DIE
vascular pedicle and perforators preoperatively. Some believe this can decrease
operative times; however, the author does not use preoperative imaging of any
kind.
NONOPERATIVE MANAGEMENT
■ Breast reconstruction has been shown to improve the quality of life of patients
who have had a mastectomy.
■ The Women’s Health and Cancer Rights Act of 1998, a federal law in the
United States, mandates commercial health insurance companies to cover
breast reconstruction after a mastectomy, surgery on the opposite breast to
improve breast symmetry, and breast prostheses. Despite this law, less than half
of patients who have a mastectomy in the United States have breast
reconstruction.
■ Nonsurgical treatment would include using an external breast prosthesis,
which fits into a brassiere cup or is part of a custom-made brassiere.
SURGICAL MANAGEMENT

Preoperative Planning
■ The objective of the operation is to improve the quality of life of the
mastectomy patient by reconstructing a breast mound that is as similar to a
natural breast as possible.
■ Absolute contraindications for this operation are prior full abdominoplasty or
uncorrectable hypercoagulable state.
■ Relative contraindications are a body mass index greater than 40 kg/m2,
hypercoagulable state, previous abdominal liposuction, and prior abdominal
surgery that may compromise the flap or abdominal wall.
■ The risks of the surgery to be discussed with the patient include the risks of
surgery in general (infection, bleeding, pain, scarring, hematoma, seroma, and
delayed healing) and the specific risks of this surgery, which are abdominal
hernia, bulge, weakness, and partial or total flap loss.
■ For immediate breast reconstruction, the incisions for the mastectomy are
discussed with the breast surgeon. A common issue is, should a patient with
ptotic breasts who would like smaller or more lifted reconstructed breasts have
a nipple-sparing mastectomy (NSM), even if it is oncologically acceptable? If
yes, how long after the NSM and DIEP flap reconstruction will you perform a
mastopexy that involves a periareolar incision?
■ Anecdotally, the author likes to wait at least 6 months.
■ Alternatively, the patient may be treated with a lumpectomy and oncoplastic
mastopexy and complete any adjuvant treatments and then undergo NSM and
DIEP flap breast reconstruction.
■ A third option, in patients without breast cancer such as patients with BRCA
mutations, is to have a mastopexy or breast reduction first and then, 6 or more
months later, undergo NSM and DIEP flap reconstruction.
Preoperative Markings
■ Preoperatively, with the patient standing upright, mark the anterior midline
from the sternal notch down to the pubis. Mark both inframammary folds
(IMFs). Then draw a horizontal line from the most inferior point of each IMF
across the midline to the opposite IMF to determine if one side is lower or
higher than the other side (FIG 2).
■ Also with the patient standing, mark the superior flap incision line. This is
typically about 2 cm superior to the superior border of the umbilicus but can
vary from the level of the superior border of the umbilicus, up to about 5 cm

above this.
■ This transverse line curves inferiorly as it is extended laterally in both
directions, and generally ends several centimeters lateral and superior to the
anterior superior iliac spine (ASIS).
■ The lower this incision is made, the lower and more easily concealed, the
longer the transverse abdominal donor-site scar will be, but the less flap skin
surface area and less flap subcutaneous fat volume that is harvested (see FIG
2; FIG 3).
■ The lower transverse abdominal incision is also marked preoperatively with
the patient standing. This is typically drawn in the natural suprapubic crease
and extends laterally, curving gently upward to meet the superior incision line
several centimeters superior and lateral to the ASIS (see FIG 2 and 3).
FIG 2 • Patient prepared and draped with arms
abducted at 90 degrees on arm boards. The vertical
midline, bilateral inframammary folds (IMF), horizontal
extension of the nadir of both IMF, and the proposed
DIEP flap skin paddles have been marked
preoperatively with the patient standing. Bilateral nipple-
sparing mastectomies via IMF incisions have been
completed.

FIG 3 • Initial DIEP flap harvest with patient supine.
(Note that in all intraoperative photos, the patient’s head
is to the right.) The umbilicus has been cored out from
the DIEP flaps, and the upper abdominal incision has
been made. The umbilicus has been tagged at its 12
o’clock position with a suture, which will be used later to
find the umbilicus and bring it out for insetting once the
abdominal donor site has been closed. Note that the
initial, more superior, upper and lower abdominal
incision markings, which were made preoperatively,
have both been lowered by about 2 cm based on an
intraoperative pinch/grab evaluation of the abdominal
donor site with the patient’s head and back raised to 45
degrees.
Positioning
■ The patient is positioned supine with the arms abducted 90 degrees on arm
boards. Alternatively, if no axillary lymph node surgery is planned, the arms
may be tucked. This allows for easier positioning of a dual head operating
microscope for two surgeons, but care must be taken not to injure the patient’s
hands and arms when raising the patient’s head and back to close the
abdominal donor site.
■ The operating table may be reversed (turned 180 degrees) underneath the
patient, in what is sometimes called a “C-arm position.” This allows the head
and back to be raised nearly to 90 degrees upright, which some surgeons desire

for evaluating insetting and shaping of the DIEP flap.
T E C H N I Q U E S
■ In immediate breast reconstruction, DIEP flap harvest can begin at the
abdomen at the same time the breast surgeon is performing the mastectomy at
the chest. Alternatively, the DIEP flap surgery can begin after the breast
surgeon is finished.
■ Typically, the patient cannot be paralyzed until the breast surgeon has
completed any axillary lymph node surgery, and this may make dissection of
perforators at the abdomen difficult due to the contraction of the rectus
abdominis muscle when stimulating the motor nerves with the electrocautery.
■ In a unilateral breast reconstruction, assess if a hemi-DIEP flap will provide
sufficient volume and skin surface for the reconstruction or if tissue across
the midline needs to be harvested.
■ Once the patient is under general anesthesia, raise the head and back of the
patient to about 45 degrees, or more, and perform a pinch/grab test to assess
if the abdominal donor site can be closed after flap harvest along the marked
incision lines. Raise or lower the upper abdominal incision line to adjust.
■ The upper abdominal incision is commonly at the level of the superior
border of the umbilicus or up to several centimeters superior to this. Return
the patient to the supine position. FIG 3 shows an example where the initially
marked upper and lower abdominal incision lines were both lowered
intraoperatively by about 2 cm after the pinch/grab test of the donor site.
■ DIEP Flap Harvest
Incision and Flap Elevation
■ The abdominal incisions are made. The superior incision is beveled
superiorly to capture more subcutaneous tissue volume with the flap and to
decrease the thickness of the cut edge of the upper abdominal donor-site flap.
This creates a better thickness match between the upper and lower cut edges
of the abdominal donor-site incision at closure.
■ The upper abdominal donor-site flap of skin and subcutaneous tissue is
elevated off the anterior rectus fascia for 5 to 10 cm to allow closure of the

donor site. Raising this abdominal skin flap superiorly to the xiphoid process
usually does not substantially increase mobility of the skin flap and will
decrease vascularity of the midline upper abdominal tissue.
■ The lower abdominal incision is made just barely through the dermis and
into the subcutaneous fat, in order to identify, and not injure, the superficial
inferior epigastric and/or the superficial circumflex iliac vessels. If there is a
large enough superficial artery, harvest of a superficial inferior epigastric
artery (SIEA) flap may be considered (see SIEA flap chapter). If there is a
large vein, it is dissected free inferiorly for 4 to 8 cm, ligated, and divided.
This is done to provide additional venous drainage or to be used as a vein
graft, if needed, in the case of venous congestion of the DIEP flap.
■ The umbilicus is cored out from the surrounding DIEP flap tissue and tagged
with a suture. Leave some fat around the stalk of the umbilicus to minimize
the risk of devascularization. Minimize the diameter or the umbilicus because
a smaller diameter umbilicus will draw surrounding upper abdominal skin
inward and deeply, resulting in a less visible circumferential scar (see FIG 3).
■ For bilateral DIEP flap reconstructions, or unilateral cases where a hemiflap
is sufficient, the vertical midline incision separating the right and left DIEP
flaps is made.
TECH FIG 1 • Left lateral view of patient just before
beginning elevation of the left abdominal DIEP flap to
expose and dissect vascular perforators. Note that the
surgical oncologist is performing the right mastectomy.
Note also that in this patient, the right IMF is about 2
cm lower than the left IMF. This is indicated by the

markings extending medially from the nadir of each
IMF, which were drawn preoperatively while the
patient was standing. This IMF asymmetry will be
corrected with sutures.
■ The DIEP flaps are elevated off the abdominal muscle fascia using
electrocautery at a low setting of 20 in the coagulation mode. The edge of the
flap tissue is grasped and is retracted and reflected at a greater than 90-degree
angle away from the abdominal wall in order to spread the plane between the
subcutaneous fat of the flap and the anterior rectus fascia so that vascular
perforators can be visualized (TECH FIG 2A).
Perforator Location and Selection
■ The DIEP flaps are raised from lateral to medial (TECH FIGS 1 and 2A,B)
to expose the lateral row of perforators, from medial to lateral to expose the
medial row of perforators, and from superior to inferior, and inferior to
superior.
■ Rarely are perforators located superior to the umbilicus used because they
are located at one corner of the flap and thus are less likely to perfuse a large
area of the flap, and they require incision and dissection through more rectus
abdominis muscle.

TECH FIG 2 • A. Left abdominal DIEP flap elevation
showing identification of two lateral row perforators. B.
Left abdominal DIEP flap elevation showing three
lateral row perforators. The anterior rectus abdominis
muscle fascia between the perforators has been
divided, and perforator dissection through the muscle
is about to begin. C. The left abdominal DIEP flap has
been raised on three lateral row perforators. The DIE
pedicle is visible and about to be dissected.
■ Perforators located more than 10 cm inferior to the umbilicus are rarely used
because they tether the pedicle to the underside of the flap and shorten the
effective length of the pedicle.
■ The largest perforator is most commonly in the medial row, located within
several cm of the umbilicus. However, sometimes the largest perforator is in
the lateral row. When harvesting a hemiabdominal DIEP flap, the one largest
perforator is often sufficient to perfuse the flap. This can be tested by
occluding the other perforators with Acland clamps for 5 to 10 minutes and
evaluating the color of the flap and arterial bleeding at the edges of the flap.
■ Two or three perforators may be necessary to adequately perfuse the flap.
■ It is advantageous to select perforators within the same medial or lateral row
as this minimizes the amount of rectus abdominis muscle fibers that are
divided during flap harvest (TECH FIG 2C).
Perforator Dissection
■ The selected perforators are dissected free from the anterior rectus fascia.
There is an opening in the fascia that each perforator passes through. The
edge of this hole in the fascia is exposed with the cautery, grasped with
toothed forceps, elevated to allow the underlying perforator to fall away, and
divided with the cutting cautery to enlarge the opening. These enlarged
openings around the selected perforators in the fascia are connected by
incising the fascia between them (see TECH FIG 2B).
■ The perforators are carefully dissected free from the rectus abdominis
muscle using bipolar cautery on a low setting, such as 20. It is important to
retract the muscle fibers away from the perforator vessels using “fish-hook”

or Weitlaner retractors and directly grasp the muscle fibers immediately
adjacent to the perforator vessels, pulling them away and dividing them with
bipolar cautery (see TECH FIG 2C).
■ Much of the muscle can be bluntly dissected (pushed) away from the
perforator vessels until a small vascular branch of the perforator into the
muscle is encountered. The smallest of these branches are divided using the
bipolar cautery. Others are clipped with small vascular clips and divided with
scissors.
■ Dissection of the selected perforators continues until they are freed from the
rectus abdominis muscle, and the junction with the DIE vascular pedicle is
reached (see TECH FIG 2C).
■ The DIE vessels are sometimes within the rectus abdominis muscle and have
to be dissected free from the muscle fibers like the perforators. Further
inferiorly, the DIE vessels will always be in a fatty or loose areolar plane
deep to the rectus abdominis muscle, between the muscle and the posterior
rectus sheath.
DIE Vessel Dissection
■ There are segmental intercostal neurovascular bundles entering the lateral
border of the rectus sheath. These run in a superolateral to inferomedial
direction and anastomose with the DIE vessels. The intercostal vessels must
be divided.
■ These intercostal nerves within these intercostal neurovascular bundles
continue over (superficial to) the DIE vessels and branch into the rectus
abdominis muscle to innervate the muscle and follow the perforator branches
of the DIE vessels through the muscle and into the flap to provide sensory
innervation to the abdominal flap skin. These intercostal nerves are divided
where they cross over the DIE vessels. If desired, these nerves can be
repaired, after transposing the ends deep to the DIE vessels.
■ Continue to dissect the DIE vessels inferiorly toward their origin from the
external iliac vessels. Deep to the inferior quarter of the rectus abdominis
muscle, the DIE vessels diverge from the underside of the muscle and run in
a deep and lateral direction through the preperitoneal fat to meet the external
iliac vessels (TECH FIG 3).
■ The pedicle vessels are dissected to within a few cm of their origin from the
external iliac vessels to ensure adequate pedicle length to reach the internal
mammary or thoracodorsal recipient vessels at the chest.

■ De-epithelialize as much of the flap skin as possible while the flap is still in
situ at the abdomen (see section below on Insetting the DIEP Flap).
TECH FIG 3 • Dissection of the left abdominal DIEP
flap pedicle continues to within 1 to 2 cm of its origin
from the external iliac vessels. Two Weitlaner
retractors are used for exposure. DIEA, deep inferior
epigastric artery. DIEV, deep inferior epigastric vein.
■ Exposure and Preparation of Internal Mammary
Recipient Vessels
■ The breast surgeon will typically have completed the unilateral or bilateral
mastectomy surgery by the time the DIEP flap dissection is completed, and
dissection of the recipient vessels can begin.
■ The internal mammary recipient vessels are preferred over the thoracodorsal
vessels as the arteries are larger in caliber and a better size match to the DIE
pedicle vessels and are more superficially and centrally located making
microsurgical vascular anastomosis technically easier and allowing improved
flap positioning.
■ The mastectomy skin flaps must be retracted sufficiently to expose the third
intercostal space adjacent to the sternum and to allow the operating
microscope a line of sight to this area perpendicular to the chest wall. The
mastectomy incision may have to be lengthened to achieve this exposure. A
combination of Weitlaner retractors and fishhook elastic retractors or
retaining sutures are used for this exposure (TECH FIG 4A). The tension,

pressure, and time of retraction of the mastectomy skin flaps should be
minimized to minimize the risk of mastectomy skin flap necrosis.
■ A small 3 × 5 cm trapezoidal flap of pectoralis major muscle is elevated off
the underlying third intercostal space and reflected laterally (TECH FIG
4B). It is important to divide the origins of the pectoralis major muscle of
this small flap far enough medially to expose the lateral border of the sternum
at the third intercostal space.
■ The perichondrium of the medial-most 2.5 cm of the third rib costochondral
cartilage is incised in the shape of an “H” and opened like window shutters
off of the cartilage using a freer elevator.
■ A rongeur is used to remove the medial-most 2.5 cm of the third
costochondral cartilage, being careful not to enter, tear, or avulse any of the
underlying posterior perichondrium.
■ Once the rib cartilage has been removed (TECH FIG 4C), the posterior
perichondrium is incised at the lateral end of the exposure and divided from
lateral to medial carefully avoiding injuring the internal mammary vessels,
which are immediately deep to the posterior perichondrium.
■ The internal mammary vein is medial to the internal mammary artery when
there is only one vein (TECH FIG 4D).
■ The posterior perichondrium and the third intercostal space soft tissue are
excised and discarded.
■ The internal mammary artery and vein are dissected free from each other,
and the surrounding soft tissue from the second intercostal space (just
superior to the excised third rib cartilage and perichondrium) inferiorly to the
superior border of the 4th rib (see TECH FIG 4D).

TECH FIG 4 • A. Exposure for left internal mammary
recipient vessel preparation following nipple-sparing
mastectomy via an inframammary incision. A
Weitlaner retractor and suture are used for this
exposure. The incisions along the lines of the muscle
fibers to raise a laterally based flap of pectoralis major
muscle are marked. B. Left internal mammary
recipient vessel preparation. The trapezoidal flap of
pectoralis major muscle overlying the third
costochondral cartilage has been reflected laterally. C.
Left internal mammary recipient vessel preparation.
The left third costochondral cartilage has been
removed with a rongeur, leaving the perichondrium. D.
Left internal mammary recipient vessel preparation.
The third rib perichondrium and portions of the second
and third intercostal muscles have been removed. The
left internal mammary artery and vein are exposed
and dissected free circumferentially from the second
intercostal space (ICS) down to the superior border of
the fourth rib. IMA, internal mammary artery. IMV,

internal mammary vein. ICS, intercostal space.
■ Control of the Footprint of the Reconstructed
Breast
■ Two 15 French fluted closed suction drains are exited from the chest wall
lateral to the lower lateral border of the breast. One drain is placed along the
inframammary fold (IMF) of the reconstructed breast, and the second drain is
placed superficial to the pectoralis major muscle in the upper breast.
■ The IMF is fixed in the desired position using three to four simple
interrupted 2-0 PDS sutures placed through the pectoralis major muscle
fascia and into rib periosteum.
■ In delayed breast reconstructions, the skin and subcutaneous tissue lateral to
the breast is dissected free from the underlying chest wall and axillary
contents. In immediate reconstructions, this dissection will have been done
by the breast surgeon performing the mastectomy.
■ This lateral breast and subaxillary lateral chest wall skin and subcutaneous
tissue is advanced anteriorly (in the anatomic position) and sutured into
position using several simple interrupted 2-0 PDS sutures. If this is not done,
this tissue tends to fall posteriorly and inferiorly, creating a roll of excess
tissue, and/or the DIEP flap can migrate laterally into this space.
■ The skin of the DIEP flap that is not needed is de-epithelialized while the
flap is still in situ at the abdomen. This way, the flap does not need to be
removed from within the mastectomy skin envelope once it is placed there.
■ For immediate reconstructions with a nipple-sparing mastectomy, a small
elliptical segment of skin paddle measuring 1.5 × 6 cm is kept to be brought
out along the IMF (TECH FIG 5). For immediate reconstructions with a
skin-sparing mastectomy, a 9-cm-diameter circular skin paddle in the middle
of the DIEP flap is kept initially. Later, once the flap is transferred, a 5-cm-
diameter skin paddle is made for future nipple reconstruction. For delayed
breast reconstructions, only the lateral-most few cm of the DIEP flap is de-
epithelialized while the flap is still in situ at the abdomen.

TECH FIG 5 • Abdominal donor site and flap insetting.
The anterior rectus fascia is closed primarily, and two
drains are placed at the abdominal donor site.
■ Harvest, Transfer, and Revascularization of the
DIEP Flap
■ The operating microscope is prepared, brought into position over the internal
mammary recipient vessels, and adjusted (TECH FIG 6). Note that some
surgeons use loupes only and do not use an operating microscope.
■ The DIEP flap is harvested by ligating the DIE artery and vein(s) with metal
clips and dividing them with scissors.
■ The DIE artery and vein(s) are flushed with 2 cc each of 100 mg/mL
heparinized saline.
■ The flap is transferred to the chest wall and secured with two or three simple
interrupted 3-0 Vicryl sutures to the chest wall skin if needed.
■ The internal mammary vein (IMV) is ligated with a metal clip and divided
with scissors. The microvenous anastomosis is created using a flow-coupler
device. Most commonly, 2.5 or 3.0 mm diameter couplers are used for the
larger right IMV, and 2.0 or 2.5 mm couplers are used for the smaller left
IMV.
■ The arterial anastomosis is completed after the venous microanastomosis.
The IMA is ligated with a metal clip and divided with scissors. The IMA and
DIEP flap artery are placed in a double approximating Acland clamp and the
anastomosis completed with typically eight simple interrupted 9-0 nylon
sutures.

TECH FIG 6 • Setup of the surgeon, assistant
surgeon, and microscope for DIEP flap
revascularization to the internal mammary recipient
vessels at the chest. The ipsilateral patient arm is
lowered so the surgeon can stand by the ipsilateral
patient shoulder. The assistant surgeon stands below
the contralateral abducted patient arm. This allows
both surgeons to stand close enough to the
microsurgical field and be 180 degrees apart to be
able to simultaneously use a dual head operating
microscope.
■ Insetting the DIEP Flap and Shaping a Breast

■ It is important that the flap volume matches the footprint of the reconstructed
breast and mastectomy skin flap volume. If the DIEP flap is not wide enough,
or not large enough in volume to fill out the mastectomy skin envelope, it
will leave a depression or hollow at the superomedial reconstructed breast.
Suspending the flap to the superomedial mastectomy pocket with sutures will
result in flattening of the flap and loss of projection of the reconstructed
breast. Therefore, if the flap volume is inadequate to fill out the mastectomy
pocket, it is best to reduce the perimeter of the reconstructed breast by
elevating the IMF and closing down the lateral mastectomy pocket with 2-0
PDS sutures. See Section “Control of the footprint of the reconstructed
breast” above.
■ The thickest part of the flap, which is usually the vertical midline cut edge, is
placed along the IMF. In other words, a right abdominal DIEP flap is turned
90 degrees clockwise to inset, whereas a left abdominal DIEP flap is turned
90 degrees counterclockwise to inset, for either the left or right breast. The
DIEP flap is placed within the mastectomy skin envelope.
■ The vascular pedicle, anastomoses, internal mammary vessels, and flow-
coupler wire are examined by retracting the DIEP flap and carefully arranged
to avoid kinks or twists.
■ In immediate reconstruction with a nipple-sparing mastectomy, I leave a
small skin paddle within the mastectomy incision. For an inframammary
incision, I leave a 1.5 × 6 cm fusiform-shaped ellipse of skin within this
incision (see TECH FIG 5). For a vertical infra-areolar incision, I leave a
smaller, 1.5 × 3 cm fusiform-shaped ellipse of DIEP flap skin. Both of these
small narrow skin paddles are usually excised at the revision/touch-up
surgery done 3 or more months after the DIEP flap breast reconstruction.
■ In immediate reconstruction with a skin-sparing mastectomy, I usually leave
a 4.5 to 5 cm circular DIEP flap skin paddle to replace the excised nipple-
areolar complex. This diameter allows future nipple reconstruction with a C-
V flap entirely within the flap skin paddle, which will eventually be tattooed.
■ The dermal edges of the DIEP flap are sutured to the mastectomy skin
envelope with a single layer of inverted dermal 3-0 Monocryl and dressed
with antibacterial ointment and Xeroform gauze. No brassiere or other
dressings, or support, are used.
■ Closure of the Abdominal Donor Site

■ The anterior rectus fascia is closed with buried interrupted figure-of-eight 0
PDS sutures. The rectus abdominis muscle is not sutured (see TECH FIG 5).
■ The upper abdominal skin and subcutaneous tissue flap is elevated off the
fascia for several cm superiorly. It is not necessary to elevate this all the way
to the xiphoid process.
■ Fluted 15-Fench round drains are brought out from each end of the
abdominal donor-site incision and secured with 2-0 nylon sutures. The left
drain is placed transversely along the lower donor site, and the right sided
drain is placed transversely across the upper donor site, superior to the
umbilicus (see TECH FIG 5).
■ The head and back of the patient are raised sufficiently to be able to close the
donor site without excessive tension. With the patient flexed at the hips, the
bed is placed in Trendelenburg to bring the back of the patient parallel to the
floor.
■ The upper and lower abdominal skin flaps are closed with multiple simple
interrupted 2-0 clear PDS sutures to reapproximate the superficial fascia and
subcutaneous fat. The skin is closed with a running subcuticular 2-0
Monoderm Quill suture.
■ A 20 × 8 mm ellipse of skin and underlying cylindrical core of fat are
excised from the upper abdominal skin flap overlying the umbilicus. The
umbilicus is brought out through this hole, and inset using multiple inverted
dermal 4-0 Monocryl sutures.
■ The umbilicus and abdominal donor-site incision are dressed with antibiotic
ointment, Xeroform gauze, dry sterile gauze, and tape.
PEARLS AND PITFALLS
Perforator
selection
■ Lateral row perforators, in general, have a more direct course
through the rectus abdominis muscle to the DIE pedicle and are
easier to dissect, compared to medial row perforators, which often
run diagonally through greater amounts of the rectus abdominis
muscle. The largest perforators are more commonly in the medial
row, but medial row perforators are not required, unless a DIEP
flap including tissue across the midline is being harvested.
Congested
■ Occasionally, a DIEP flap will become venous congested during

flap during
harvest
flap harvest, while still in situ at the abdomen. If this is mild, it
will often resolve over 1–2 hours as venous interconnections
within the flap “open up” and venous outflow redistributes.
Venous
insufficiency
■ Venous insufficiency, manifest by venous congestion of the DIEP
flap, is more common and more difficult to detect than arterial
insufficiency. I recommend using an internal venous Doppler
probe, especially one where the Doppler probe is integrated into a
venous anastomotic coupling device. You cannot leave the
operating room if the flap skin paddle is at all blue in hue and has
less than 1-second capillary refill. This is venous congestion and
must be addressed. On the other hand, a free flap can appear very
pale, and without detectable capillary refill, as long as there is an
arterial Doppler flow signal present.
Insetting
■ Set the perimeter/footprint of the reconstructed breast, and de-
epithelialize the DIEP flap before transfer, so that the flap is placed
within the mastectomy skin envelope only once, and does not have
to be removed for de-epithelializing the periphery or adjusting the
perimeter of the mastectomy pocket. This will avoid the risks of
taking the flap in and out of the mastectomy skin envelope, and it
will save time.
Flap
orientation
■ A typical DIEP flap pedicle is long enough to allow the ipsilateral
or contralateral flap to be used to reconstruct a breast. All else
being equal, it is advantageous to use an ipsilateral flap, especially
in delayed breast reconstruction, because this places the least well-
perfused tissue, and most likely portion to suffer partial flap loss or
fat necrosis, at the lateral and inferior region of the reconstructed
breast.
Postoperative
■ No postoperative anticoagulation regimen has been proven more
effective than others. I give patients 325 mg of aspirin daily while
they are inpatients starting as soon as the patient is awake enough
to swallow. I also give patients 40 mg of low molecular weight
heparin subcutaneously daily while they are inpatients, starting at 5
PM on the 1st postoperative day.

FIG 4 • A. Preoperative frontal view of patient shown in
FIG 2 and TECH FIG 6. B. Postoperative frontal view of
patient shown in FIG 2 and TECH FIG 6, 8 months after
bilateral nipple-sparing mastectomies, and bilateral
immediate breast reconstruction with DIEP flaps.
Bilateral 190-cc smooth silicone implants were added to
augment the reconstructed breast volume.
POSTOPERATIVE CARE
■ Patients have perfusion of the DIEP flap monitored hourly for the first 24
hours and then every 2 hours for the next 48 hours by the nurses.
■ Patients are not allowed to eat or drink, except for ice chips to moisten their
mouths, until viability of the DIEP flap is confirmed on the morning of the 1st
postoperative day, at which time a regular diet is allowed.
■ Patients are given aspirin 325 mg orally daily starting immediately
postoperatively and as long as they are inpatients.
■ Patients are given 40 mg of low molecular weight heparin subcutaneously
daily starting at 24 hours after completion of the surgery.
■ On the morning of the 1st postoperative day, patients transfer with assistance
from their bed into a chair for 15 minutes to 3 hours.
■ On the 2nd postoperative day, patients ambulate with assistance outside of
their hospital room at least once.
■ On the 3rd postoperative day, intravenous fluids and the Foley catheter are
discontinued in the morning, and patients are asked to ambulate with assistance
outside of their hospital room at least three times.
■ Starting of the 3rd postoperative day, patients are asked to shower and wash all

surgical sites with soap and water daily.
■ Some patients are discharged home in the afternoon of the 3rd postoperative
day. Most patients are discharged home on the 4th postoperative day.
■ Patients are asked not to wear a brassiere, not to sleep prone or on their sides,
and not to raise their elbows higher than their shoulders for the first 2 weeks
after surgery.
■ Patients are asked not to submerge any surgical wound underwater (so no
bathtub, hot tub, or swimming) and not to perform any activity which causes
impact, or jarring of their body, for 4 to 5 weeks postoperatively.
■ Patients are given prophylactic intravenous antibiotics as long as they have an
I.V. in the hospital, and then Bactrim DS twice daily until removal of the last
drain.
■ Drains are removed once the output has fallen to less than, or equal to, 30
mL/d, for 2 consecutive days. Occasionally, one or two drains are removed
before discharge from the hospital. Typically, some of the drains are removed
at the first office visit 5 to 10 days after discharge from the hospital, and the
remaining drains are removed at the second postoperative office visit 1 week
later.
■ An outpatient surgery to improve reconstructed breast shape and symmetry,
repair abdominal donor-site dog-ears, and for nipple reconstruction is typically
done, at the earliest, 3 months after the initial DIEP flap reconstruction surgery.
OUTCOMES
■ Autologous tissue flaps from the lower abdomen are capable of producing the
best, long-lasting, and most maintenance-free reconstructed breasts of any
method of breast reconstruction.1
■ A reconstructed breast, which looks and feels like a natural breast, can be
achieved with a DIEP flap and nipple-sparing mastectomy done via an
inframammary incision (FIG 4).
COMPLICATIONS
■ With experience, the DIEP free flap loss rate, and emergent take-back rate,
should be at or below 1% and 5%, respectively.
■ Partial flap loss and fat necrosis are more common in obese patients and
patients who smoke. Both of these are usually managed nonoperatively.
■ A true hernia at the abdominal donor site is exceedingly rare, with a frequency
of a fraction of a percent of patients.

■ A lower abdominal bulge, to some degree, occurs in about 5% of patients.
Abdominal bulges are not a health risk and are repaired if the patient desires by
plication and polypropylene mesh overlay.
■ The most common reasons for emergent take back are venous
insufficiency/congestion of the DIEP flap and hematoma at the reconstructed
breast. Venous congestion can cause a hematoma secondarily and can be
mistaken for a hematoma by the inexperienced surgeon. A breast hematoma
does not cause venous occlusion of the DIEP flap pedicle or anastomosis, but
can result from venous congestion.
REFERENCES
1. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic satisfaction with
breast reconstruction during the long-term survivorship period. Plast Reconstr
Surg. 2009;124:1-8.
2. 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.
3. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus
abdominis muscle. Br J Plast Surg. 1989;42:645-648
4. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg. 1994;32:32-38.
5. Chevray PM. Update on breast reconstruction using free TRAM, DIEP, and
SIEA flaps. Semin Plast Surg. 2004;18:97-104.
6. Holm C, Mayr M, Hofter E, Ninkovic M. Perfusion zones of the DIEP flap
revisited: a clinical study. Plast Reconstr Surg. 2006;117:37-43.
7. Jagsi R, Jiang J, Momoh AO, et al. Trends and variation in use of breast
reconstruction in patients with breast cancer undergoing mastectomy in the
United States. J Clin Oncol. 2014;32:919-926.
8. Howard-McNatt MM. Patients opting for breast reconstruction following
mastectomy: an analysis of uptake rates and benefit. Breast Cancer. 2013;5:9-
15.

23
CHAPTER
Abdominal Breast
Reconstruction Using a
SIEA Flap Approach
Adrian S. H. Ooi, Deana Shenaq, Julie E. Park, and David H.
Song
DEFINITION
■ Abdominal-based flaps for breast reconstruction can be divided into pedicled
and free flaps based on their arterial supply.
■ Pedicled
• Transverse rectus abdominis myocutaneous (TRAM) flap
■ Free
• TRAM flap
• Muscle-sparing TRAM (MS-TRAM) flap
• Deep inferior epigastric perforator (DIEP) flap
• Superficial inferior epigastric artery (SIEA) flap
■ The free TRAM, MS-TRAM, and the DIEP flaps are based on a deep inferior
epigastric vascular pedicle arising directly from the external iliac vessels.
■ In the free TRAM flap, the entire width of rectus muscle is taken to capture
all the perforators within that segment.
■ In the MS-TRAM flap, a cuff of rectus muscle is harvested to capture
multiple perforators from the deep inferior epigastric pedicle.
■ In the DIEP flap, only the perforating vessels to the subcutaneous fat and
skin are harvested and the rectus muscle is not sacrificed.
■ The SIEA flap is based on the subcutaneous superficial inferior epigastric
vascular pedicle arising from the femoral vessels in the femoral triangle.
Harvest of the flap does not involve any rectus muscle or fascia.
ANATOMY

■ The SIEA flap is a Mathes and Nahai fasciocutaneous type A flap, harvested
from the lower abdomen.
■ The skin island for the SIEA flap extends laterally to the anterior superior
iliac spine (ASIS), medially to the midline or just past it, and from the level of
the umbilicus superiorly to the pubic tubercle inferiorly.
■ Vascular anatomy
■ Arterial
• The SIEA is a branch of the femoral artery and arises from the femoral
artery 2 to 3 cm below the inguinal ligament (FIG 1).
• It is present in 49% to 91% of patients.1,2
• The average size of the SIEA is 1.2 to 1.6 mm and average length 4 to 6
cm.3
• It is present in both groins in 58% of patients.4

FIG 1 • Vascular anatomy of the superficial inferior
epigastric system.
• In about 75% of cases, it arises from a common origin with the superior
circumflex iliac artery (SCIA).5
• The course of the artery is variable in relation to the superficial inferior
epigastric vein (SIEV), usually arising up to 3 cm lateral to the SIEV and
deep to the Scarpa fascia.
• After piercing the cribriform fascia, the SIEA courses inferolaterally for a
short distance immediately above the deep fascia.
• It runs in a superolateral direction before crossing the inguinal ligament at
roughly the midpoint between the pubic tubercle and the ASIS.
• The SIEA then pierces the Scarpa fascia to run in the superficial fatty later
of the abdomen before arborizing with the periumbilical perforators of the
deep inferior epigastric artery.
■ Venous drainage
• The venous drainage of the flap is through up to two venae comitantes of
the epigastric artery and/or the SIEV (see FIG 1).
• Diameter: 1.3 to 4 mm1
• The surface marking of the SIEV is one-third of the way between the pubic
symphysis and the ASIS.
• The SIEV directly drains the subcutaneous plexus and is usually located
superficial and medial to the SIEA in the superficial fatty layer of the
abdomen.
• The venae comitantes of the SIEA typically drain into SIEV.6
• Occasionally, the superficial circumflex iliac vein (SCIV) and SIEV join
into a common branch before draining into the femoral vein and if taken
together can be used to enhance venous drainage of the flap (FIG 2).
■ Flap vascular territory
• The literature consists of varying reports using different measurement
parameters stating flap perfusion can range from the hemiabdomen to 100%
of the entire abdominal flap.1,2,6
• We have found harvesting of the tissue across the midline to be unreliable,
and would not advocate going past the hemiabdomen without testing
perfusion either clinically with clamping off all other vascular input on the

contralateral side or utilizing intraoperative fluorescence imaging.
■ The flap receives sensory innervation via the segmental intercostal nerves
T10-T12.
PATHOGENESIS
■ Breast defects requiring SIEA flap reconstruction can be partial or total
mastectomy defects and can arise from a variety of pathologies including:
■ Postcancer resection
FIG 2 • The left superficial inferior epigastric (SIEV) and
superficial circumflex iliac veins (SCIV) draining into a
common branch.
■ Prophylactic resection
■ Failed implants
■ A single large mastectomy defect may require a complete abdominal flap for
coverage. An SIEA flap can be used together with the contralateral SIEA,
DIEP, or MS-TRAM flap.
■ The SIEA flap has been used for coverage of other defects including:
■ Head and neck
■ Upper extremity and hand
■ Lower extremity
NATURAL HISTORY
■ Holmström reported the first use of a free abdominoplasty flap based on the
deep inferior epigastric vessels in 1979.7

■ Hartrampf pioneered the use of the pedicled TRAM flap for breast
reconstruction in 1982.8
■ While sacrificing rectus muscle, the free TRAM gained increasing popularity
for breast reconstruction due to the use of the dominant blood supply to the
rectus muscle, the deep inferior epigastric pedicle, to perfuse the abdominal
tissue. It also allowed for more freedom in insetting and shaping the breast.9
■ To minimize donor-site morbidity from harvest of the rectus muscle, the free
MS-TRAM and DIEP flaps were developed following improvements in
microsurgical knowledge and technique. Varying amounts of rectus muscle are
left behind after harvest to maintain abdominal wall integrity and strength.
■ Further evolution of the abdominal tissue flaps led to the development of the
SIEA flap. The flap, first used by Antia and Buch for facial reconstruction in
1971 and further elucidated by Taylor and Daniel in their cadaveric studies of
1975, is based on a subcutaneous pedicle and completely spares the rectus
fascia and muscle. Grotting first reported on its use in breast reconstruction in
1991, and owing to its obvious donor-site benefits has rapidly gained
popularity ever since.10–12
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A focused history and examination relevant to any form of free flap
reconstruction should be performed. In particular, the following should be
elucidated and corrected if possible:
■ History of tobacco use
■ Obesity
■ Previous irradiation
■ Prothrombotic conditions
■ Anticoagulant use
■ Similar criteria are applied to the SIEA flap as when determining the
suitability of a patient for a free DIEP, MS-TRAM, or TRAM.
■ Sufficient redundant lower abdominal skin and fat
• Approximates final desired breast volume
• Allows for primary donor-site closure analogous to an abdominoplasty
■ Abdominal scars
• Transverse lower abdominal scars such as in a Pfannenstiel incision may
preclude the use of the SIEA or even deep inferior epigastric pedicles.
• Midline laparotomy scars limit the abdominal tissue use to a single

hemiabdomen as the perfusion across the midline is no longer reliable.
IMAGING
■ Though not essential, several preoperative investigative techniques can be
used to elucidate the vascular anatomy of the abdominal flap.
■ Doppler ultrasound
• Can be used pre- and intraoperatively to locate perforators and pedicle
position.
• Used postoperatively for flap monitoring
■ CT-angiogram and MR-angiogram
• Used preoperatively to elucidate location of abdominal perforators and the
route of the source vessels
• Can be used to select cases where the SIEA is suitable for use
■ Fluorescence imaging
• Intraoperative administration of ICG via a peripheral vein after the
hemiabdominal flap has been isolated on its pedicle and imaging with an
infrared camera can help to assess the flap vascular territory.
DIFFERENTIAL DIAGNOSIS
■ Reconstructive options for breast defects include but are not limited to:
■ Implant-based reconstruction +/− acellular dermal matrix
• Immediate implant
• Primary expander with implant exchange
• Expander-implant
■ Pedicled flaps
• Latissimus dorsi (LD)
• TRAM
■ Free flaps
• LD
• TRAM
• MS-TRAM
• DIEP
• SIEA
• Superior gluteal artery perforator (SGAP) flap
• Inferior gluteal artery perforator (IGAP) flap