Breast Reconstruction With The Diep Flap: Anatomical Study And Clinical Applications

Among the many donor sites available for autogeneous breast reconstruction, the transverse rectus abdominis myocutaneous (TRAM) flap is most popular and has been regarded as the "Gold standard" for breast reconstruction. The TRAM flap may be transferred as a pedicled flap or a free flap. However, donor site morbidity is very severe in both cases since they require the harvesting of part of the rectus abdominis muscle and the anterior rectus fascia. Many attempts have been made to decrease the donor site morbidity. Koshima and Soeda developed the deep inferior epigastric artery skin flap without rectus abdominis muscle in 1989, which was then introduced to autogenous breast reconstruction in 1994 and named as the deep inferior epigastric perforator (DIEP) flap by Allen and Treece. This technique decreased the donor site complications. Since the year 2000, we have performed several breast reconstructions with the DIEP flap and the results were satisfying. Since the anatomic knowledge associated with the DIEP flap, especially for the nerve repaired in the breast reconstruction with the DIEP flap is very limited, it is critical to further investigate the anatomic nature of the vessel and nervous system of the lower abdominal wall and breast that is involved in breast reconstruction with the DIEP flap.ObjectivesAnatomic study: To further investigate the anatomy of the deep inferior epigastric artery, and their perforatore, the lower intercostals nerve trunks, and their branches associated with the DIEP flap to facilitate selecting the appropriate perforator vessel and protecting the intercostals nerve during dissecting the pedicle. At the same time, to study the innervations of the DIEP flap and the female breast to evaluate the feasibility of the breast reconstruction using the senate DIEP flap.Clinical study: To review the available breast reconstruction cases with the DIEP flaps, assess its reliability and safety, evaluate the necessity of the sensory reinnervation of the DIEP flaps, and monitor the cutaneous blood flow in the DIEP flap in order to evaluate microcirculation of this flap.Methods1. Anatomic studies of the abdominal wall were carried out on 9 fixed cadavers (18 sides). Gelatin injections and microdissections were employed to investigate the anterior lower abdominal wall. The architecture of the DIEA and the lower intercostals nerve was established.2. Several pieces of the perforator bundles were obtained from the resected abdominal tissues of three patients who underwent abdominoplasty to confirm the presence of never fibers within the vascular perforator bundles histologically.3. Anatomic studies of the female breast were carried out on one fixed cadaver (2 sides). Microdissections were examined in the chest wall to detect the neural architecture of the lower intercostals nerve.