Deep Inferior Epigastric Artery Perforator Flap Harvest after Abdominoplasty with the Use of Computed Tomographic Angiography

Sir:FigurePrevious abdominal surgery has long been thought to be detrimental to flap survival in patients undergoing transverse abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap surgery. In particular, a previous abdominoplasty has been considered a contraindication because of the likely interruption of the perforating vessels essential in flap design and survival. This reasoning was hypothesized by Hartrampf et al. in their first article describing the TRAM flap in 1982,1 and although based on a theoretical assumption, it has remained poorly studied since. In recent times, several case reports have described the survival of a TRAM flap after abdominoplasty2,3; however, the same undertaking in a DIEP flap has not been described. With the need to isolate a single perforator, such an undertaking is clearly more precarious than in a musculocutaneous flap. The recent ability to map perforators preoperatively with computed tomographic angiography may change such presumptions, and the use of contemporary technologies of this type has allowed the plastic surgeon to offer patients reliable procedures that would not have been considered in the past.4,5 We present a case report of a patient who successfully underwent a DIEP flap breast reconstruction 6 years after a full abdominoplasty. To our knowledge, this is the first reported case of this type. A 58-year-old woman presented for a delayed postmastectomy breast reconstruction. She was otherwise well but had undergone a full abdominoplasty 6 years previously, with “limited” undermining of the upper flap having been performed. The patient sought an autologous reconstruction, and although other autologous options were considered, her abdominal wall was sought as a potential option. Given her previous abdominoplasty, preoperative computed tomographic angiography was performed to assess the presence and location of any remaining deep inferior epigastric artery perforators. Computed tomographic angiography demonstrated, as expected, the absence of all infraumbilical deep inferior epigastric artery perforators. However, there were several deep inferior epigastric artery perforators immediately above the umbilicus that remained intact and were highly suitable for a DIEP flap. As shown in Figure 1, a large, 2-mm, right perforator was selected. By designing the DIEP flap paddle to incorporate this perforator and its subcutaneous ramifications, the flap was raised and transferred in the usual fashion for breast reconstruction. The flap was well perfused throughout the postoperative period, and there were no flap-related or donor-site complications (Fig. 2).Fig. 1: Computed tomographic angiogram of the abdominal vasculature in a 58-year-old woman who had undergone previous abdominoplasty. Although there were no infraumbilical perforators, several large supraumbilical perforators were present, with a large, 2-mm, right perforator (blue arrow) selected (above and center). The perforators were shown to arise from the deep inferior epigastric arteries (white arrows, below).Fig. 2: Twelve-month postoperative photograph of a left DIEP flap breast reconstruction after previous abdominoplasty.It is important for plastic surgeons to offer patients reconstruction only when flap anatomy is both predictable and reliable. Breast reconstruction using the TRAM flap and its variations in patients with preexisting abdominal scars is controversial; however, such scars are not a contraindication with appropriate planning and flap design.5 Particularly with the use of preoperative imaging, DIEP flap surgery can be performed on patients in the presence of abdominal scarring. Standard procedures can affect the abdominal wall vasculature in variable ways, and imaging can highlight not only the preserved vasculature but also new vessels that may be present following revascularization or neovascularization. Traditionally, a DIEP flap would not normally be considered following a full abdominoplasty and umbilical repositioning; however, the current case highlights the importance of both an individualized approach and the adequate investigation and planning of perforator flap options. Warren M. Rozen, M.B.B.S., B.Med.Sc., Ph.D. Iain S. Whitaker, M.A.Cantab., M.B.B.Chir., Ph.D. Jeannette W. C. Ting, M.B.B.S., Grad.Dip.Surg.Anat. G. Gleda Ang, M.B.B.S., B.Med.Sc. Rafael Acosta, M.D. Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia DISCLOSURE There was no source of funding for this article. The authors declare that there is no source of financial or other support or any financial or professional relationships that might pose a competing interest.