Imaging of the superficial inferior epigastric vascular anatomy and preoperative planning for the SIEA flap using MDCTA.

The superficial inferior epigastric artery (SIEA) flap consists of skin and subcutaneous fat with limited donor-site morbidity and has the potential to be very versatile - either as a thin flap without excessive fat tissue or as a voluminous flap for breast reconstruction. However, anatomical inter-individual variability often makes the choice of a free SIEA flap difficult. Imaging of small-calibre vessels is possible with the multi-detector-row computed tomography angiography (MDCTA) and to obtain the characteristics of the superficial inferior epigastric vascular anatomy, we investigated the superficial inferior epigastric system using MDCTA. We investigated 17 patients who had abdominal wall MDCTA in preparation for a free flap procedure using either the deep inferior epigastric perforator (DIEP), SIEA or the groin flap. The visibility and anatomical characteristics including the branching pattern, the diameter, course of travel and layers were noted. The SIEA was visible in 64.7% and, of these, 36.4% had a common trunk formation with the superficial circumflex iliac artery (SCIA), while 63.6% arose independently. The measured diameters were SIEA 1.6 ± 0.4mm, SCIA 1.4 ± 0.4mm, deep circumflex iliac artery (DCIA) 2.4 ± 0.4mm, DIEA 2.9 ± 0.4mm and superficial inferior epigastric vein (SIEV) 3.1 ± 0.5mm. The SIEA consistently coursed lateral to and deeper than the SIEV and also lateral to the DIEA. MDCTA provided detailed three-dimensional information of the superficial inferior epigastric vascular system including the course and size of the SIEA. The information on vascular anatomy obtained with the MDCTA is valuable in the preoperative planning of the free SIEA flap and should be performed routinely.

Fukaya E ，Kuwatsuru R ，Iimura H ，Ihara K ，Sakurai H ... -  《-》

Preoperative computed tomography angiogram to predict patients with favorable anatomy for superficial inferior epigastric artery flap breast reconstruction.

Piorkowski JR ，DeRosier LC ，Nickerson P ，Fix RJ ... -  《-》

Anatomy of the arterial and venous systems of the superficial inferior epigastric artery flap: A retrospective study based on computed tomographic angiography.

This study was performed to investigate the arterial and venous anatomy of superficial inferior epigastric artery (SIEA) flaps using multidetector-row computed tomography angiography (MDCTA). We hypothesized that applicability of the SIEA flap has been underestimated in previous studies. We retrospectively analyzed the results of preoperative MDCTA of the bilateral lower abdominal walls in 72 consecutive patients. We assessed the presence and branching pattern of the superficial inferior epigastric artery, superficial inferior epigastric vein (SIEV), superficial circumflex iliac vein, and venae comitantes (VC) of the superficial inferior epigastric artery. We also assessed the internal diameter of the SIEA at its origin. The SIEA was present on 133 sides (92.4%), and the mean internal diameter was 2.0 mm. The internal diameter of the SIEA was ≥2.0 mm on 102 sides (70.8%). The VC drained into the superficial circumflex iliac vein on 68 sides (47.2%) and to the SIEV on 30 sides (20.8%). An internal diameter of the SIEA of ≥2.0 mm at its origin on preoperative imaging can be a good criterion for exploring the artery during lower abdominal flap harvest. The VC is the dominant drainage vein over the SIEV in some patients, and it communicates with the superficial circumflex iliac vein in almost half of patients. These findings can increase the safety of breast reconstruction with an SIEA flap.

Kita Y ，Fukunaga Y ，Arikawa M ，Kagaya Y ，Miyamoto S ... -  《-》

The efficacy of preoperative vascular mapping by MDCTA in selecting flap in abdominal flap breast reconstruction.

Current methods of breast reconstruction using abdominal tissue include the transverse abdominal myocutaneous (TRAM) flap, deep inferior epigastric arterial perforator (DIEP) flap, superficial inferior epigastric arterial (SIEA) flap, and some other composite flaps. Because of the variant vascular anatomy in abdominal region, it is hard to choose an appropriate flap for a specific patient without accurate preoperative vascular mapping. This study was drawn to address the efficacy of preoperative vascular mapping by multidetector-row computed tomographic angiography (MDCTA) in selecting flap in abdominal flap breast reconstruction. A total of 34 breast reconstructions using abdominal flap from December 2006 to July 2009 were included. In all the patients included, MDCTA was performed preoperatively. Three indexes were obtained including choice of flaps, operation time, and flap complication rate. Then, these data were compared with the former data stored in the databank of our hospital from January 2004 to December 2006, before MDCTA was introduced in our center. Among the 34 patients, the flap selection was: SIEA flaps 11.8%, DIEP flaps 61.8%, TRAM flaps 11.8%, and bilateral flaps 14.7%. The correlate indexes from the data bank were as follows: SIEA flap 0; DIEP flaps 51.7%; TRAM flaps 32.8%; bilateral flaps 15.5%. p < 0.05 occurred between the comparison of SIEA, DIEP, and TRAM flap choice in the two groups. The operation time in the study group was as follows: SIEA flap (4.02 ± 0.46) hours, DIEP flap (6.23 ± 1.42) hours, TRAM flap (4.72 ± 1.53) hours, Bilateral flap (7.86 ± 1.16) hours; while the former correlate data were: DIEP (9.67 ± 1.74) hours, TRAM flap (6.64 ± 1.83) hours, bilateral flap (11.83 ± 1.35) (all the three comparison p < 0.05). The total flap complication rate was about 5.9% in the test group; while in the databank, it was 12.1% (p < 0.05). With the accurate mapping of vascular territory in abdomen by MDCTA, we could easily select a suitable abdominal flap for breast reconstruction, and we can also simplify the procedure to save operation time and make the process more safely.

Xin M ，Luan J ，Mu L ，Zhao Z ，Mu D ，Chen X ... -  《-》

[Significance of abdominal wall CT-angiography in planning DIEA perforator flaps, TRAM flaps and SIEA flaps].

Muscle sparing TRAM flaps and DIEA perforator flaps are standard procedures for breast reconstruction. Recently CT-angiography has been established to evaluate perforator vessels pre-operatively. CT-angiography was introduced to our department in July 2009. In a retrospective analysis data of the last 20 patients (altogether 22 flaps) before CT-angiography introduction and the following 20 (also 22 flaps) patients after introduction of CT-angiography were analysed with regard to the ratio of TRAM to DIEP flaps, and the time required to raise the flaps. The same surgeon raised all flaps. As different surgeons performed dissection of the recipient site, anastomoses, and insertion of flaps, and patients received primary (with sentinel or complete lymphadenctomy) or secondary reconstructions, only the time required harvesting the flap was compared. Thus other influences on raising the flap were eliminated. DIEP flaps were harvested with one single perforator. If perfusion or was considered not to be safe via one single perforator a muscle sparing TRAM flap (ms2) was raised. Angiography was performed using a 64-slice multi-detector CT scanner. CT-angiography did not lead to an increased rate of DIEP flaps in relation to ms2-TRAM flaps. Harvesting time of all flap types with CT-angiography on average was 121 min, without CT-angiography 135 min. This was not significantly different. However, separate analysis of DIEP flaps and ms2-TRAM flaps revealed a significant advantage of CT-angiography based harvesting of DIEP flaps of 26 min: with CT-angiography 101 min vs. 127 min without CT-angiography (p<0.028). There were no significant differences for ms2-TRAM flaps. All scans showed course and branching, diameter and size of the inferior epigastric artery. If evident the superficial inferior epigastric artery (SIEA) was marked. Dosage was 292 mGy-606 mGy×cm dependent on body weight. CTDI was 6.8-14.7 mGy. CT-angiography is a reproducible and observer independent procedure that reliably demonstrates the inferior epigastric artery and its perforating branches. Sensitivity is considered to be 99,6%. Additionally the superficial inferior epigastric artery can be evaluated. In our patients the ratio of ms2-TRAM flaps to DIEP flaps was not affected by introducing CT-angiography. However, DIEP flap harvesting was significantly accelerated. Harvesting of ms2-TRAM flaps was not affected. It remains to be seen whether the observed time advantage is really essential for this operation. Preoperative imaging of the perforators allows establishing a detailed, observable and comprehensible operation strategy, which particularly facilitates surgical training and learning of perforator dissection.

Fansa H ，Schirmer S ，Frerichs O ，Gehl HB ... -  《-》