Autogenous Breast Reconstruction With the Deep Inferior Epigastric Perforator Flap
Clinics In Plastic Surgery | July 2003 | Vol. 30 | Num. 3
James E. Craigie, MDa, Robert J. Allen, MDb, Frank J. DellaCroce, MD, Scott K. Sullivan, MD
"East Cooper Plastic Surgery, 1300 Hospital Drive, Suite 120, Mt. Pleasant, SC 29464, USA Division of Plastic Surgery, LSU Health Sciences Center; 4429 Clara Street, Suite 440, New Orleans, LA 70115, USA
The perfect method for breast reconstruction would be safe, reliable, reproducible, applicable to all patients, and have no donor site morbidity. The ideal reconstructed breast would provide symmetric, permanent, and natural results. The pursuit of these goals has fueled the development and refinement of autogenous methods of breast reconstruction. In 1976, Fugino et al  described the gluteus maximus myocutaneous flap for breast reconstruction. This was followed in 1979 by Holmstrom's  use of the rectus abdominus myocutaneous free flap, and in the early 1980s, Hartrampf et al [3,4] popularized the pedicled transverse rectus abdominus flap (TRAM).
The TRAM flap remains the most popular method of autogenous reconstruction. This popularity is due to the relative ease with which the procedure is performed and the fact that no microsurgical expertise is required. Proponents also argue that the pedicled TRAM is quicker to perform, and, thus, saves operative time and expense; this has not been borne out in the literature . The pedicled TRAM has proven to be a basically reliable method of reconstruction but the rate of partial flap necrosis may approach 25% . This can be a problem when open wounds cause delays in chemotherapeutic protocols, and, later, when the differentiation of fat necrosis from a recurrent tumor is required. The high rate of partial flap necrosis is the result of a basic anatomic problem with the flap, which requires reversal of flow through intramuscular choke vessels into the inferior vasculature. This, combined with folding and tunneling of the pedicle at its pivot point, can compromise vascular exchange within the flap. Tunneling may also affect the medial breast contour . The free TRAM flap has been used in an effort to increase flap perfusion but it suffers from the same limitation of rectus muscle sacrifice. When patients with rectus sacrifice are compared with those in which it is preserved, the importance of this consideration is clear.
The deep inferior epigastric arttery perforator (DIEP) flap for breast reconstruction was innovated to improve the donor site morbidity that is associated with the TRAM flap [7). Patients who are reconstructed with the DIEP flap experience substantially less postoperative pain than those who are subjected to muscle sacrifice (TRAM) . Muscle sacrifice in pedicle flaps is also responsible for abdominal asymmetries, hernias, pain, and impaired ability to perform daily, occupational, and sporting activities. Kroll et al  and Mizgala et al  reported that abdominal wall morbidity was significant and proportional to the amount of muscle that was removed after TRAM flap breast reconstruction. The "muscle sparing" free TRAM is considered less morbid to the abdominal wall. Some studies indicated, however, that the integrity of the remaining rectus muscle is lost if a small portion is removed with the flap [11-13]. Weakness and atrophy of the remaining muscle occur when the insertion is sacrificed and the quality of the abdominal wall after the free TRAM has been described as comparable to a pedicle TRAM donor site .
W.B. SAUNDERS COMPANY A Division of Elsevier Inc.
The Curtis Center. Independence Square West. Philadelphia, Pennsylvania 19106 http://www.wbsaunders.com
CLINICS IN PLASTIC SURGERY July 2003
Editor: Molly Jay
Volume 30, Number 3 ISSN 0094-1298
Copyright @ 2003 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information retrieval system, without written permission from the publisher.
Single photocopies of single articles may be made for personal use as allowed by national copyright laws. Permission of the publisher and payment of a fee is required for all other photocopying, including multiple or systematic copying, copying for advertising or promotional purposes, resale, and all forms of document delivery. Special rates are available for educational institutions that wish to make photocopies for non-profit educational classroom use. Permissions may be sought directly from Elsevier Inc. Rights & Permissions Department, PO Box 800, 9xford OX5 IDX, UK; phone: (+44) 1865 843830, fax: (+44) 1865 853333, e-mail: email@example.com. You may also contact Rights & Permissions directly through Elsevier's home page (http://www.elsevier.com), selecting first 'Customer Support', then 'General Information', then 'Persmissions Query Form'. In the USA, users may clear permissions and make payments through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA; phone: (978) 750-8400; fax: (978) 750-4744, and in the UK through the Copyright Licensing Agency Rapid Clearance Service (CLARCS), 90 Tottenham Court Road, London W1P OLP, UK; phone: (+44) 171 4365931; fax: (+44) 171436 3986. Others countries may have a local reprographic rights agency for payments.
Reprints. For copies of 100 or more, of articles in this publication, please contact the Commercial Reprints Department, Elsevier Inc., 360 Park Avenue South, New York, New York 10010-1710. Tel. (212) 633-3813 Fax: (212) 633-3820 email: firstname.lastname@example.org
The ideas and opinions expressed in Clinics in Plastic Surgery do not necessarily reflect those of the
Publisher. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosage, the method and duration of administration, or contra indications. It is the responsibility of the treating physician or other health care professional, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Mention of any product in this issue should not be construed as endorsement by the contributors, editors, or the Publisher of the product or manufacturers' claims.
Clinics in Plastic Surgery (ISSN 0094-1298) is published quarterly by W.B. Saunders Company. Corporate and editorial offices: The Curtis Center, Independence Square West, Philadelphia, PA 19106- 3399. Accounting and circulation offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Periodicals postage paid at Orlando, FL 32862, and additional mailing offices. Subscription prices are $224.00 per year for US individuals, $325.00 per year for US institutions, $112.00 per year for US students and residents, $259.00 per year for Canadian individuals, $372.00 per year for Canadian institutions, $277.00 per year for international individuals, $372.00 per year for international institutions and $139.00 per year for Canadian and foreign students/residents. To receive student/resident rate, orders must be accompanied by name of affiliated institution, date of term, and the signature of program/residency coordinator on institution letterhead. Orders will be billed at individual rate until proof of status is received. Foreign air speed delivery is included in all Clinics subscription prices. All prices are subject to change without notice. POSTMASTER: Send address changes to Clinics in Plastic Surgery, W.B. Saunders Company, Periodicals Fulfillment, Orlando, FL 32887-4800. Customer Service: 1-800-654- 2452 (US). From outside of the US, call 1-407-345-4000. E-mail: email@example.com
Clinics in Plastic Surgery is covered in Current Contents, EMBASE/Excerpta Medica, Science Citation Index,Index Medicus, ASCA, and ISI/BIOMED.