Deep inferior epigastric perforator flap: An anatomic study of the perforators

Journal of military pharmaco-medicine no5-2018

DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP: AN
ANATOMICAL STUDY OF THE PERFORATORS
Nguyen Van Phung*; Tran Van Anh**; Vu Quang Vinh**
SUMMARY
Objectives: Deep inferior epigastric artery perforator flaps have become popular worldwide in
breast reconstruction to reduce done site morbidity. Isolating perforator vessels challenges most
surgeons. The purpose of study was to investigate anatomical vascular of the deep inferior
epigastric perforator flap. Subjects and methods: 40 flaps were harvested from 20 fresh adult
cadavers. The deep inferior epigastric artery and its perforators were dissected and canularized.
Barium sulfate 30% v/w diluted and mixed with blue methylen was injected. Determine details
such as perforator size, location and measurements in relation to the umbilicus. Results: 177
perforator vessels dissected from 40 flaps, average 4.4/1 flap. 106 perforators (59,9%) in a
medial row with 84 perforators (79,3%) were oblique course. 71 perforators (40,1%) in a lateral
row with 51 perforators (71,8%) were rectilinear course. 111 perforators (63,7%) located in a
distance of 10 - 40 mm from the umbilicus. The average length and diameter of the dominant
perforators was 44.3 ± 13.8 mm and 1 ± 0.1 mm. Conclusion: Understanding the morphological
characteristics of the perforator can aid the surgeon in more harvesting safety the deep inferior
epigastric artery perforator flap. Two vertical rows of perforator vessels were observed along the
anterior rectus abdominal sheath: medial row and lateral row. The perforator presents a rectilinear
course usually was in lateral row and easy to dissect than the perforator presents an oblique
course. The dominant perforators usually located in a distance of 15 - 40 mm from the umbilicus.
* Keywords: Deep inferior epigastric perforator flap; Breast reconstruction.

INTRODUCTION
The deep inferior epigastric perforator
(DIEP) flap is one of the most commonly
flaps that was used for reconstruction in
plastic surgery due to excellent quality,
adequate tissue and soft texture. Especially,

middle-aged breast cancer patients usually
have excess skin and belly fat that will be
suitable materials for breast reconstrucition.
In recent decades, the development of
DIEP flap has brought new modifications
to the conventional abdominal flaps due to
less donor-site morbidity and total muscular
preservation. The DIEP flap could decrease

abdominal bulging or muscular weakness.
In addition, the DIEP flap dissected from
the rectus abdominis, can increase in pedicle
length, which allows better freedom of design.
However, identifying the deep inferior
epigastric artery (DIEA) and vein is still
challenging the surgeons because of variable
anatomy of blood vessels in human
bodies. Our research aims to: Study on
the anatomical characteristics of the inferior
arteries that give blood supply for DIEP
flat in adult Vietnamese cadavers, that
could give useful informations for plastic
surgeons in clinical practice.

* Hochiminh University of Medicine and Pharmacy
Corresponding author: Nguyen Van Phung ()
Date received: 10/03/2018
Date accepted: 21/05/2018

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Journal of military pharmaco-medicine no5-2018
SUBJECTS AND METHODS
1. Subjects.
This research was carried out on 20
adult Vietnamese cadavers in Department
of
Anatomy, Hochiminh University from
November 2011 to Juanuary 2016.
2. Methods.
The descriptive cross-sectional study.
- A 4 cm inguinal incision was made to
explore deep epigastric artery. The catheter
was inserted to artery to inject contrast
agent (barium sulfate 30%) and blue
methylen. 24 hours later, we performed
surgery to dissect rhombus flap in abdominal
wall from umbilicus to anterior superior
iliac spine. These flaps were dissected to
superficial fascia membranous layer
(Scarpa’s fascia) to explore perforator
arteries under medical loupes (x3 - 5).
After that, we opened the anterior wall of
rectus sheath and muscle to identify DIEA.
- We determined orginin, branches,
diameter, length of deep epigastric inferior
arteries and deep epigastric perforator
arteries. We also recorded the course of
these arteries.

- Gross photo and X-ray were taken in
all cases.
- We analyzed data by statistical software.
RESULTS
1. Deep inferior epigastric artery
perforator.
The DIEA was recognized on both
sides of 20 human cadavers and the orgin
was a single branch from the external iliac
artery. It curved forward in the subperitoneal
144

tissue, and then ascended obliquely along
the medial margin of the abdominal
inguinal ring; continuing its course upward,
it pierced the transversalis fascia and
passed in front of the linea semicircularis,
ascended between the rectus abdominis
and the posterior lamella of its sheath
(31/40). The other ateries entered in rectus
abdominis muscle (9/40). We found the
DIEA divided into 2 main branches in 17
cases, 3 main branches in 2 cases. The
other cases had only 1 main branch.
The average diameter of DIEA at the
orgin was 2.2 ± 0.2 mm and at the lateral
boder of the rectus abdominis was 1.9 ±
0.2 mm.
The average length of DIEA from the
orgin and the lateral boder of the rectus

abdominis to the perforator arteries was
14.9 ± 3.5 cm and 10.9 ± 1.1 cm, respectively.
39 cases had 2 veins that went along
with DIEA and 1 case had 1 vein. All these
veins drained to the external iliac vein.
2. The perforators.
In this research, we studied the perforator
that ≥ 0.5 mm of diameter in rhombus flap.
* Number:
There were 177 perforators which divived
from 40 orversed DIEA (4.4 perforators per
DIEA). The average number of perforators
of DIEA that had 1 main branch and
2 main branches were 4.33 and 4.18,
respectively. In the DIEA that had 2 main
branches, the average number of perforators
of lateral branch and medial branch were
2.0 and 2.12, respectively. In 2 cases of
the DIEA that had 3 main branches, they
had 3 and 4 perforators.


Journal of military pharmaco-medicine no5-2018
* Location and distribution:
In front of retus sheath, the perforators
were distributed in 2 lines: the lateral line
in lateral one-third of restus abdominis
muscle and the medial line in the medial
one-third of restus abdominis muscle.
There were 106 perforators (59.9%) in the

medial line and 71 perforators (40.1%) in
the lateral line, of which the number of
dominant perforators in each line were 24
(60%) and 16 (40%).

If the umbilicus was the O-axis of the
XY axis, the average distance from the
perforators to the X-axis was 23.8 ± 15.8
mm, the Y axis was 22.5 ± 12 mm. The
average distance from the most dominant
perforator to the X axis was 16.2 ± 7.1 mm,
while the Y axis was 23.4 ± 13.1 mm.
Within the circle of the center of the
umbilicus, the distribution of the perforators
and dominant perforators as shown in
table 1:

Table 1: Distribution of perforators in scope the bottom half of circle, of which the
center was umbilicus.
0 - 2 cm

< 2 - 4 cm

< 4 - 6 cm

< 6 - 8 cm

Number of perforators (n = 177)

55 (31.1)

56 (31.6%)

52 (29.4%)

14 (7.9%)

Number of dominant perforators (n = 40)

16 (40%)

13 (32.5%)

11 (27.5%)

0 (0%)

The average distance from perforators to umbilicus was 34.4 ± 17.2. Most of the
perforators were within 10 - 40 mm from the umbilicus.

Figure 1: The perforators of DIEA - cadaver number 476.
* Length and diameter:
In the study, we measured the diameters of the perforators at the origin and the length
of the perforators from the point of origin to the point of entry into the superficial fascia.
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Journal of military pharmaco-medicine no5-2018
Table 2: The size of the perforators.

Average diameter
Average length

Perforators
with diameters
≥ 0.5 mm
(n = 177)

Dominant
perforators
(n = 40)

0.7 ± 0.2

1 ± 0.1

45.8 ± 11.8

44.3 ± 13.8

Most perforators had relatively short
length, including the dominant perforators.
The diameter of the perforators was quite
small, with most of the perforators less
than 1 mm in diameter. Therefore, it was
difficult to directly use these perforators
for
the
flap’s
blood

supply
in
supermicrosurgery. It could be required to
use DIEA together.

was rectilinear course and
(42.5%) was oblique course.

with 17

* The characteristics of perforator in Xray:
The skin flaps were X-rayed and the
results showed that the blood supply to
the flap was plentiful, with connections
between the perforators. The blood
supply area of each perforator was
dependent on its diameter at the enter
point of muscle fascia.

* The course of perforators:
The course of perforators before
entering the superficial fascia was recored
in two different forms. The first form, a
direction of perforator was perpendicular
to the distance from the origin to skin flap.
For this form, when dissecting to isolate
the perforator, we only need to seperate
along them without removing muscle, and
distance from the flap to DIEA is shorter.
The second form, from the origin of

perforators with cross direction through
muscle to skin flap, it could be outward,
inward, downward, or upward. Muscle
could be removed when dissecting the
cross croner perforator because the
distance is longer. The perforators in a
medial line with 21 (19.8%) was rectilinear
course and with 84 (79.3%) was oblique
course. The perforators in a lateral line
with 51 (71.8%) was rectilinear course
and with 20 (28.2%) was oblique course.
The dominant perforators with 23 (57.5%)
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Figure 2: The perforators on X-ray Cadaver 482.
DISCUSSION
Breast reconstruction following breast
cancer surgery is a necessity for patients
to improve the quality of life. The suitable
breast reconstruction material is always a
challenge in clinical study that requires to
find a material that adequately meets the
regenerative volume, closely relates to
the opposite breast and the least affects
tissue supply. The DIEP flap is the skin
flap that fully filled the above criteria. It
was applied clinically by Koshima and
Seoda in 1989 firstly. After that, Allen
used this flap for breast reconstruction in
1994. Nowadays, DIEP has been used

more and more commonly in breast
reconstruction [1, 2, 7]..


Journal of military pharmaco-medicine no5-2018
Despite of many advantages of breast
reconstruction, the application of DIEP
flap in clinical remains difficult for surgeons
due to abnormalities and differences in
anatomy such as the course of the DIEA
and its perforators, causes obstacles to lift
safely. Thus, studying the DIEA and its
perforators has always been interesting [5,
8, 9]. There were many studies on this
issue, but the results were not consistent.
According to Itoh, Boyd, Tansatit, ElMrakby... the DIEA was divided into 2
branches in most of cases [3, 4, 6, 11].
Meanwhile, according to Nguyen Tran
Quynh, the DIEA was not divided into 2
branches but ran straight up in the form of
a main body in most of cases. In our
study, 52.5% of the cases of DIEA were
main body type, which ran up, 47.5% of
the cases of DIEA divided into 2 - 3
branches.
The number of perforators per DIEA
was also reported differently by many
authors, depending on how large or short
perforators were determined by the
diameter of the perforators included in the

study, the number of perforators of DIEA
for abdominal intervals from 0.8 to 6.8. In
our study, examined perforators with
diameter of ≥ 0.5 mm were found with an
average of 4.4 peforator per DIEA. Itoh
and Boyd also examined perforators with
diameter of ≥ 0.5 mm but within the
umbilicus region with an average of 6.5
and 6.8 perforators per DIEA. In
agreement with the other authors, we
found that the perforators were distributed
in two lines at the entry point of the rectus
abdominis: medial and lateral, with 106

(59.9%) and 71 (40.1%), respectively.
When osbserving the direction of
perforators, we found that perforators in
the medial rows were often oblique
course in the muscle (79.3%), while in the
lateral rows were often rectilinear course
(71.8 %), which was consistent with other
authors' reports. This was a feature that
should be noted for the selection of
perforators when lifting the flaps. For the
perpendicular perforator, we only need to
seperate along them without removing
muscle. Muscle could be removed when
dissecting the cross croner peforator
because the distance was longer.
When studying the distance betwwen

the entry point of the perforators at the
superficial fascia and the umbilicus, we
found that the most perforators (62.7%)
were located within a radius of 0 - 40 mm
with the center of umbilicus, which was
consistent with the other authors. The
dominant perforator was also concentrated
in a radius of 0 - 40 mm with the center of
umbilicus (72.5%). The most dominant
perforator in our study had an average
diameter of 1 ± 0.1 mm (0.8 - 1.2 mm),
with an average length of 44.3 ± 13.8 mm.
The length from the starting position of the
most dominant perforator to the DIEA at
the lateral rectus abdominis was 10.9 ± 1.1.
CONCLUSION
The perforators were in 2 lines along
the anterior rectus abdominal sheath: medial
and lateral. The perforator presents a
rectilinear course usually was in lateral
row and easy to dissect than the perforator
presents an oblique course. The dominant
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Journal of military pharmaco-medicine no5-2018
perforators usually located in 0 - 40 mm
from the umbilicus. Understanding the
morphological characteristics of the
perforator can help the surgeon in more

harvesting safety the deep inferior epigastric
artery perforator flap.
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