From the Guidelines
The vessels most at risk of injury during rectus muscle flap reconstruction post mastectomy are the deep inferior epigastric vessels, specifically the deep inferior epigastric artery (DIEA) and its perforators, as they are the primary blood supply to the rectus abdominis muscle flap. According to the most recent study 1, the DIEP flap is a muscle-sparing perforator free flap breast reconstruction technique that uses the DIEA perforators to create a vascular pedicle. The anatomy of the perforators used in DIEP flap is variable, and lack of preoperative imaging can lead to increased operative times given the time-consuming nature of identifying the variable vascular anatomy.
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. The superficial inferior epigastric vessels may also be compromised during dissection. Additionally, the superior epigastric vessels at the superior aspect of the rectus muscle can be injured, particularly when mobilizing the upper portion of the flap.
Some key points to consider during the procedure include:
- The location, size, and intramuscular course of the perforator branch are critical to the surgical team 1
- Multiple perforators are identified by imaging, which are typically ranked based on size, location, and intramuscular course 1
- The efficiency of the vascular pedicle selection process can be significantly improved with preoperative imaging 1
- Careful identification and preservation of these vascular structures is essential to ensure flap viability and reduce complications such as flap necrosis, hematoma formation, or compromised reconstruction outcomes.
Overall, careful planning and identification of the vascular anatomy are crucial to minimize the risk of injury to the vessels during rectus muscle flap reconstruction post mastectomy.
From the Research
Vessels at Risk of Injury during Rectus Muscle Flap Reconstruction
The vessels at risk of injury during rectus muscle flap reconstruction post mastectomy include:
- Inferior Epigastric Artery: This artery is commonly used in breast reconstruction procedures, including the deep inferior epigastric perforator (DIEP) flap and the superficial inferior epigastric artery (SIEA) flap 2, 3, 4.
- Superior Epigastric Artery: Although not as commonly used as the inferior epigastric artery, the superior epigastric artery may also be at risk of injury during rectus muscle flap reconstruction 5.
Anatomical Considerations
The internal mammary vessels, including the inferior epigastric artery, are often used as recipient vessels in free-flap autologous breast reconstruction 5. The use of a rib-sparing technique can help minimize chest wall morbidity and reduce the risk of complications associated with rib cartilage removal 5.
Surgical Techniques and Considerations
The choice of surgical technique and flap type can affect the risk of vessel injury and other complications. For example, the SIEA flap has a lower risk of abdominal wall morbidity but a higher risk of thrombotic events compared to other abdominally based autologous breast reconstruction techniques 6. Preoperative imaging and mapping of the perforators can help reduce operating times and improve outcomes 3.