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. The DIEA arises from the external iliac artery and its perforators have a variable anatomy, making preoperative imaging crucial for identifying the most suitable vessel to serve as the vascular pedicle 1. The superficial epigastric vessels may also be compromised during dissection, and the superior epigastric vessels at the superior portion 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 ideal perforator should have the largest caliber available and be 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 to minimize donor site morbidity 1.
- Preoperative imaging, such as CT angiography, can help map the vessels before surgery and reduce operative time, abdominal morbidity, and increase flap reliability 1.
- Careful identification and preservation of the vascular structures is essential to maintain flap viability and reduce complications such as partial or complete flap necrosis.
In terms of specific vessels, the deep inferior epigastric artery (DIEA) is the primary vessel at risk, and its perforators are critical for the success of the procedure. The superior epigastric artery, which is the other option, is not the primary vessel at risk, but it can still be injured during the procedure, particularly when mobilizing the upper portion of the flap. Therefore, the correct answer is A. Inferior Epigastric Artery, as it is the primary vessel at risk of injury 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 involved in the blood supply to the rectus abdominis muscle and is at risk of injury during the harvest of the rectus muscle flap for breast reconstruction 2, 3.
- Superior Epigastric artery: Although not directly mentioned as being at risk in the provided studies, the superior epigastric artery is also a part of the blood supply to the rectus abdominis muscle and could potentially be affected during rectus muscle flap reconstruction.
- Deep Inferior Epigastric Artery: This artery is specifically mentioned in the context of the deep inferior epigastric perforator (DIEP) flap, which is a type of flap used in breast reconstruction 2, 3.
- Superficial Inferior Epigastric Artery: This artery is also involved in breast reconstruction, particularly with the superficial inferior epigastric artery (SIEA) free flap 2, 4.
Flap Types and Vessel Injury
Different flap types used in breast reconstruction may have varying risks of vessel injury:
- TRAM (Transverse Rectus Abdominis Musculocutaneous) flap: This flap type may pose a greater risk of harm to the area of flap harvest, including abdominal bulge/hernia and need for surgical repair 3.
- DIEP (Deep Inferior Epigastric Perforator) flap: This flap type may have a lower risk of abdominal wall morbidity compared to the TRAM flap, but may have a higher risk of thrombotic events 3, 4.
- SIEA (Superficial Inferior Epigastric Artery) flap: This flap type may have a higher risk of thrombotic events and flap loss compared to other abdominally based autologous breast reconstruction techniques 4.