Laboratory Studies

Basic presurgical laboratory studies include blood counts and chemistries. ECGs and chest x-rays are obtained according to pre-anesthesia guidelines.

Imaging Studies

Color-flow Doppler and CT angiography have been used for imaging of blood flow patterns in various perforator flaps. They may be of use when the integrity or pattern of blood flow within the flap is in question.^{[12, 13]}However, these modalities are not typically employed in routine clinical practice.

A study by Davis et al indicated that CT angiography carried out prior to microsurgical breast reconstruction can be used to identify whether a DIEP flap will be at greater risk for postoperative venous congestion. The investigators reported that flaps found on CT angiography to have atypical venous connections between the deep and superficial systems, ie, those in which the connections were narrow, tortuous, or incomplete, had a five-fold risk of such congestion.^[14]

Treatment & Management

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Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982 Feb. 69(2):216-25. [QxMD MEDLINE Link].
Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989 Nov. 42(6):645-8. [QxMD MEDLINE Link].
Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg. 1993 Apr. 91(4):678-83. [QxMD MEDLINE Link].
Breastcancer.org. U.S. Breast Cancer Statistics. Available at https://www.breastcancer.org/symptoms/understand_bc/statistics. January 18, 2023; Accessed: May 9, 2023.
Dasari CR, Gunther S, Wisner DH, et al. Rise in microsurgical free-flap breast reconstruction in academic medical practices. Ann Plast Surg. 2015 May. 74 Suppl 1:S62-5. [QxMD MEDLINE Link].
Sacher M, Kapalschinski RN, Wallner C, et al. Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction. J Plast Reconstr Aesthet Surg. 2020 Mar. 73 (3):494-500. [QxMD MEDLINE Link].
Hakakian CS, Lockhart RA, Kulber DA, Aronowitz JA. Lateral Intercostal Artery Perforator Flap in Breast Reconstruction: A Simplified Pedicle Permits an Expanded Role. Ann Plast Surg. 2016 May. 76 Suppl 3:S184-90. [QxMD MEDLINE Link].
PAP Flap. Breastcancer.org. Available at https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/autologous-flap/pap. Updated July 27, 2022; Accessed: May 9, 2023.
Varnava C, Klietz ML, Hirsch T, Wiebringhaus P, Kueckelhaus M. Comparison of surgical and patient-reported outcomes between 85 profunda artery perforator flaps and 122 deep inferior epigastric perforator flaps as first-choice treatment for breast reconstruction. J Plast Reconstr Aesthet Surg. 2023 May. 80:168-77. [QxMD MEDLINE Link].
Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004 Apr 1. 113(4):1153-60. [QxMD MEDLINE Link].
Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008 Jan. 121(1):9-16. [QxMD MEDLINE Link].
Rozen WM, Palmer KP, Suami H, et al. The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg. 2008 Feb. 121(2):367-73. [QxMD MEDLINE Link].
Davis CR, Jones L, Tillett RL, Richards H, Wilson SM. Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging. Microsurgery. 2019 Jan. 39 (1):24-31. [QxMD MEDLINE Link]. [Full Text].
Bottero L, Lefaucheur JP, Fadhul S, Raulo Y, Collins ED, Lantieri L. Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg. 2004 Jan. 113(1):156-61. [QxMD MEDLINE Link].
Craigie JE, Allen RJ, DellaCroce FJ, Sullivan SK. Autogenous breast reconstruction with the deep inferior epigastric perforator flap. Clin Plast Surg. 2003 Jul. 30(3):359-69. [QxMD MEDLINE Link].
Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg. 1997 Jul. 50(5):322-30. [QxMD MEDLINE Link].
Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg. 2000 Oct. 53(7):578-83. [QxMD MEDLINE Link].
Knox AD, Ho AL, Leung L, et al. Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review. Plast Reconstr Surg. 2016 Jul. 138 (1):16-28. [QxMD MEDLINE Link].
Tomita K, Yano K, Hata Y, et al. DIEP Flap Breast Reconstruction Using 3-dimensional Surface Imaging and a Printed Mold. Plast Reconstr Surg Glob Open. 2015 Mar. 3(3):e316. [QxMD MEDLINE Link]. [Full Text].
Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg. 1975 Aug. 56(2):178-81. [QxMD MEDLINE Link].
Patel NG, Rozen WM, Chow WT, et al. Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping. Gland Surg. 2016 Apr. 5 (2):115-21. [QxMD MEDLINE Link]. [Full Text].
DellaCroce F, Sullivan S. Chimeric Stacked Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A New Solution to an Old Problem. J Recon Microsurg. 2007. 23:418.
DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg. 2011 Mar. 127(3):1093-9. [QxMD MEDLINE Link].
Opsomer D, Stillaert F, Blondeel P, Van Landuyt K. The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases. Plast Reconstr Surg. 2018 Jul. 142 (1):1e-8e. [QxMD MEDLINE Link].
Hamdi M, Spano A, Van Landuyt K, D'Herde K, Blondeel P, Monstrey S. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg. 2008 Feb. 121(2):389-96. [QxMD MEDLINE Link].
Chen CM, Halvorson EG, Disa JJ, et al. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg. 2007 Nov. 120(6):1477-82. [QxMD MEDLINE Link].
Sbitany H, Lentz R, Piper M. The "Dual-Plane" DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes. J Reconstr Microsurg. 2019 Jan 7. [QxMD MEDLINE Link].

Media Gallery

Presurgical markings with location of deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) signal points depicted (as determined by Doppler ultrasonography).
Superficial inferior epigastric vessels dissected out.
Presurgical superior gluteal artery perforator (SGAP) flap donor-site markings with location of SGAP signal points depicted on left (as determined by Doppler ultrasonography). Postsurgical donor site appearance clothed on right.
Perforating branches of deep inferior epigastric system dissected out.
Before and after right skin-sparing mastectomy for invasive ductal carcinoma with immediate deep inferior epigastric perforator (DIEP) flap reconstruction and left mastopexy.
Before and after bilateral prophylactic skin-sparing mastectomy with immediate deep inferior epigastric perforator (DIEP) flap reconstruction in a patient positive for the BRCA gene.
Before and after bilateral mastectomy for ductal carcinoma in situ (DCIS) with immediate deep inferior epigastric perforator (DIEP) flap reconstruction.
Before and after reconstruction of defect resulting from right lumpectomy and radiation with superior inferior epigastric artery (SIEA) flap and left mastopexy for symmetry.
Before and after delayed bilateral reconstruction with superior gluteal artery perforator (SGAP) flaps.
Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Implant reconstruction with painful capsular contracture (left) and after implant removal with superior gluteal artery perforator (SGAP) flap reconstruction bilateral (right).
Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Before and after delayed bilateral reconstruction with superior gluteal artery perforator (SGAP) flaps. Abdominal scar results from abdominoplasty performed at second stage surgery.
Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Stacked DIEP flap.
Lumbar perforator dissected out.

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Sections Perforator Flap Breast Reconstruction
Overview
Workup
Treatment
Questions & Answers
Media Gallery
References

Perforator Flap Breast Reconstruction Workup

Laboratory Studies

Imaging Studies

References

Tables

Contributor Information and Disclosures

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