Abstract
The vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap
has been well studied in the planning for autologous breast reconstruction. Preoperative
imaging with computed tomography angiography (CTA) provides accurate assessment of
this vascular anatomy, which varies widely across patients. Several papers to date
have described their encounter with an anomalous “epiperitoneal” or “peritoneo-cutaneous”
perforator during flap harvest, a perforator that pierces the posterior rectus sheath
from a peritoneal origin, to traverse rectus abdominis and supply the DIEP flap integument.
In the course of over 3,000 CTA assessments of the vascular anatomy of the abdominal
wall, we have encountered dominant peritoneo-cutaneous perforators in 1% of cases,
and smaller perforators seen in many more cases, approaching 5% of cases. With increasing
sensitivity of imaging, we also describe a unique case of multiple large bilateral
peritoneo-cutaneous perforators, and present these findings in the context of DIEP
flap harvest. It is critical to recognize these peritoneo-cutaneous perforators preoperatively
to avoid mistaking them for a DIEP during the raising of a DIEP flap. The routine
use of preoperative CTA enables the safe identification of individual vascular anatomy,
including significant peritoneo-cutaneous perforators.
Keywords
microsurgery - breast reconstruction - anatomy
