Gerd Fabre

Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction

&NA; The anatomic topography of the perforators within the rectus muscle and the anterior fascia largely determines the time needed to harvest the perforator free flap and the difficulty of the procedure. In 100 consecutive cases, the topographic patterns of the perforators were investigated. In 65 percent, a short intramuscular course was seen. In 16 percent, a perforator at the tendinous intersection was encountered. In 9 percent, the largest perforator was found to have a long intramuscular course. In 5 percent, a subfascial course was found, and in another 5 percent, a paramedian course was found. In 74 percent of flaps, just one perforator was used, whereas two perforators were dissected in 20 percent. Only in 6 percent of flaps were three perforators used. A long intramuscular course (>4 cm) lengthens the dissection substantially, especially when the intramuscular course is in a step‐wise pattern. The subfascial course requires precarious attention at the early stage of the perforator dissection when splitting the fascia. The perforators at the tendinous intersections are the most accessible and require a short but intense dissection in the fibrotic tissue of intersection. A paramedian perforator, medial to the rectus muscle, is a septocutaneous rather than a musculocutaneous perforator. The straightforward dissection almost extends up to the midline. Therefore, dissection always is performed at one side and, if no good perforators are present, continued at the intact contralateral side. The size of these perforators and their location in the flap determine the choice. One perforator with significant flow can perfuse the whole flap. If in doubt, two perforators can be harvested, especially if they show a linear anatomy so that muscle fibers can be split. The only interference with the muscle exists in splitting the muscle fibers. A perforator that lies in the middle of the flap is preferable. For a large flap, a perforator of the medial row provides better perfusion to zone 4 than one of the lateral row because of the extra choke vessel for the lateral row perforators. The clinical appearance of the perforators is the key element in the dissection of the perforator flap. Perforator topography determines the overall length and difficulty of the procedure. (Plast. Reconstr. Surg. 109: 1912, 2002.)

Fat necrosis in deep inferior epigastric perforator flaps: an ultrasound-based review of 202 cases.

Background: In autologous breast reconstruction after mastectomy, fat necrosis is a rather common complication that may lead to secondary corrective surgery. The understanding of fat necrosis until now has been limited because previous studies were based exclusively on physical examination and used diverse definitions. Methods: The authors retrospectively reviewed the incidence of fat necrosis and the correlation of several risk factors in 202 deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. The incidence of fat necrosis was based on both physical examination and ultrasound imaging. The following risk factors were studied: age, smoking, body mass index, timing of reconstruction, and timing and extent of radiation therapy fields. Results: Physical examination revealed a palpable mass or nodule in 14 percent of the DIEP flaps (28 of 202). Ultrasound examination added another 21 percent of DIEP flaps (42 of 202) with a firm area of scar tissue (diameter ≥5 mm). The overall ultrasound incidence of fat necrosis in this study was 35 percent (71 of 202). Although the overall ultrasound incidence of fat necrosis was very high, only 7 percent of the DIEP flaps (15 of 202) needed to undergo an extra surgical procedure for removal of this area. In contrast to previous studies, none of the risk factors studied was statistically significant for the occurrence of fat necrosis. Conclusions: These results suggest that there is no significant association between previously suspected risk factors and fat necrosis. The overall incidence of fat necrosis, however, is much higher than previously accepted, even though the need for corrective surgery is limited.