From the Guidelines
The vessels most at risk of injury during a mastectomy reconstruction using the rectus abdominis muscle are the deep inferior epigastric vessels, specifically the deep inferior epigastric artery (DIEA) and its perforators, as well as the superior epigastric vessels. The primary vessels at risk include the deep inferior epigastric vessels (both artery and vein), which serve as the main blood supply to the rectus abdominis muscle flap 1. The superficial epigastric vessels may also be compromised during dissection. Additionally, the superior epigastric vessels at the superior portion of the muscle can be injured, particularly when creating the tunnel for flap transposition. Perforating vessels that connect the deep system to the overlying skin and subcutaneous tissue are also vulnerable during the procedure. Some key points to consider when evaluating the risk of vascular injury during this procedure include:
- The anatomy of the perforators used in DIEP flap is variable, and lack of preoperative imaging can lead to increased operative times 1
- The ideal perforator is the largest caliber and is medially located within the flap with an extended vascular territory beyond the midline to provide optimal perfusion 1
- Dissection of the selected perforator should preserve muscle 1
- Preoperative imaging such as CT angiography can be used to map these vessels before surgery and employ meticulous dissection techniques to minimize vascular injury during the procedure 1
From the Research
Vessels at Risk of Injury during Mastectomy Reconstruction
The vessels at risk of injury during a mastectomy reconstruction using the rectus abdominis muscle are:
- Inferior epigastric artery
- Superior epigastric artery
Rationale
The deep inferior epigastric artery and the superior epigastric artery are the primary blood supply to the rectus abdominis muscle 2, 3, 4. During a TRAM flap reconstruction, these arteries are at risk of injury, particularly the deep inferior epigastric artery, which is responsible for perfusion of the subcutaneous fat and skin of the flap 2. The superior epigastric artery also plays a crucial role in supplying the skin of the anterior abdominal wall 3, 4.
Additional Considerations
The internal mammary artery and external iliac artery are not directly involved in the blood supply to the rectus abdominis muscle and are therefore less likely to be injured during a TRAM flap reconstruction 3, 4. However, it is essential to note that individual anatomical variations may exist, and preoperative imaging can help identify these variations and plan the surgical approach accordingly 2, 5, 6.