Download PDF
J Reconstr Microsurg 2021; 37(03): 256-262
DOI: 10.1055/s-0040-1717153
Original Article

Prevalence and Utilization of Obturator Artery Anatomic Variant in Autologous Breast Reconstruction

Katherine D. Reuter Muñoz
1   Virginia Commonwealth University School of Medicine, Richmond, Virginia
,
Jeremy M. Powers 
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Virginia Commonwealth University Health, Richmond, Virginia
,
Shuhao Zhang
3   Department of Plastic Surgery, Mercy Medical Group, Sacramento, California
,
Santosh S. Kale
4   Midwest Breast & Aesthetic Surgery, Columbus, Ohio
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Background The objective of this study is to quantify the prevalence and describe the utilization of an anatomic vascular variant in which the obturator artery (OA) arises from the trunk of the deep inferior epigastric artery (DIEA) in stacked/dual-pedicled autologous breast reconstruction. When this variant is identified preoperatively on computed tomography angiography (CTA), it may be utilized in a “flow-through” fashion to direct antegrade internal mammary artery (IMA) flow into a second free flap to facilitate anastomotic arrangement and optimize perfusion.

Methods Preoperatively obtained abdomen/pelvis CTA imaging of 121 autologous breast reconstruction patients were retrospectively reviewed for the unilateral or bilateral presence of the OA branch arising from the DIEA (OA variant). The results were analyzed using descriptive statistics.

Results Our analysis revealed the presence of the OA variant in 60 of the 121 (49.6%) breast reconstruction candidates, either unilaterally or bilaterally. Out of these patients, the variant was present unilaterally in 33 (55%) and bilaterally in 27 (45%) patients. Of the unilateral variants, 12 (36.4%) patients demonstrated right-sided laterality, while 21 (63.6%) patients demonstrated left-sided laterality. Clinically, this anatomic variant has been utilized in several cases of autologous breast reconstruction with flap survival in all cases.

Conclusion Utilization of this anatomic variant in stacked or dual-pedicled autologous breast reconstruction results in antegrade IMA perfusion of both primary and secondary flaps, as well as improved size match compared with other anastomotic options. Knowledge of the vascular anatomy and variations in the inferior epigastric system is crucial to both preventing complications and optimizing flap planning and outcome.

Keywords

autologous breast reconstruction - obturator artery - stacked flap anastomosis


Publication History

Received: 01 June 2020

Accepted: 25 August 2020

Article published online:
08 October 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
    CrossrefPubMedGoogle Scholar
  • 2 Hamdi M, Rebecca A. The deep inferior epigastric artery perforator flap (DIEAP) in breast reconstruction. Semin Plast Surg 2006; 20 (02) 95-102
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Chang DW. Breast reconstruction with microvascular MS-TRAM and DIEP flaps. Arch Plast Surg 2012; 39 (01) 3-10
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Munder B, Andree C, Witzel C. et al. The DIEP flap as well-established method of choice for autologous breast reconstruction with a low complication rate - retrospective single-centre 10-year experience. Geburtshilfe Frauenheilkd 2020; 80 (06) 628-638
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Tan MG, Isaranuwatchai W, DeLyzer T. et al. A cost-effectiveness analysis of DIEP vs free MS-TRAM flap for microsurgical breast reconstruction. J Surg Oncol 2019; 119 (03) 388-396
    CrossrefPubMedGoogle Scholar
  • 6 Beahm EK, Walton RL. The efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction. Plast Reconstr Surg 2007; 120 (01) 41-54
    CrossrefPubMedGoogle Scholar
  • 7 Agarwal JP, Gottlieb LJ. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction. Ann Plast Surg 2007; 58 (04) 359-363
    CrossrefPubMedGoogle Scholar
  • 8 Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007; 60 (08) 904-912 , discussion 913–914
    CrossrefPubMedGoogle Scholar
  • 9 Murray A, Wasiak J, Rozen WM, Ferris S, Grinsell D. Stacked abdominal flap for unilateral breast reconstruction. J Reconstr Microsurg 2015; 31 (03) 179-186
    PubMedGoogle Scholar
  • 10 Malata CM, Rabey NG. Decision making in double-pedicled DIEP and SIEA abdominal free flap breast reconstructions: an algorithmic approach and comprehensive classification. Front Surg 2015; 2: 49
    CrossrefPubMedGoogle Scholar
  • 11 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; 35 (06) 411-416
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Gassman AA, Pan J, Acevedo Jr E, Haddock N, Teotia S. The superficial and deep inferior epigastric artery composite perforator flap for breast reconstruction: a case report. Microsurgery 2018; 38 (07) 799-803
    CrossrefPubMedGoogle Scholar
  • 13 Cohen AJ, Ameika JA, Briggs RA, Grishkin BA, Helsel RA. Retrograde flow in the internal mammary artery. Ann Thorac Surg 1988; 45 (01) 48-49
    CrossrefPubMedGoogle Scholar
  • 14 González-Santos JM, Bastida E, Riesgo M. et al. Flow capacity of the human retrograde internal mammary artery: surgical considerations. Ann Thorac Surg 1990; 50 (03) 360-366
    CrossrefPubMedGoogle Scholar
  • 15 Li S, Mu L, Li Y. et al. Breast reconstruction with the free bipedicled inferior TRAM flap by anastomosis to the proximal and distal ends of the internal mammary vessels. J Reconstr Microsurg 2002; 18 (03) 161-168
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Stalder MW, Lam J, Allen RJ, Sadeghi A. Using the retrograde internal mammary system for stacked perforator flap breast reconstruction: 71 breast reconstructions in 53 consecutive patients. Plast Reconstr Surg 2016; 137 (02) 265e-277e
    CrossrefPubMedGoogle Scholar
  • 17 Salgarello M, Visconti G, Barone-Adesi L, Cina A. The retrograde limb of internal mammary vessels as reliable recipient vessels in DIEP flap breast reconstruction: a clinical and radiological study. Ann Plast Surg 2015; 74 (04) 447-453
    CrossrefPubMedGoogle Scholar
  • 18 Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators. Br J Plast Surg 2004; 57 (03) 258-265
    CrossrefPubMedGoogle Scholar
  • 19 Pai MM, Krishnamurthy A, Prabhu LV, Pai MV, Kumar SA, Hadimani GA. Variability in the origin of the obturator artery. Clinics (São Paulo) 2009; 64 (09) 897-901
    CrossrefPubMedGoogle Scholar
  • 20 Gilroy AM, Hermey DC, DiBenedetto LM, Marks Jr SCJ, Page DW, Lei QF. Variability of the obturator vessels. Clin Anat 1997; 10 (05) 328-332
    CrossrefPubMedGoogle Scholar
  • 21 Ates M, Kinaci E, Kose E. et al. Corona mortis: in vivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia repair. Hernia 2016; 20 (05) 659-665
    CrossrefPubMedGoogle Scholar
  • 22 Sanna B, Henry BM, Vikse J. et al. The prevalence and morphology of the corona mortis (Crown of death): a meta-analysis with implications in abdominal wall and pelvic surgery. Injury 2018; 49 (02) 302-308
    CrossrefPubMedGoogle Scholar
  • 23 Requarth JA, Miller PR. Aberrant obturator artery is a common arterial variant that may be a source of unidentified hemorrhage in pelvic fracture patients. J Trauma 2011; 70 (02) 366-372
    CrossrefPubMedGoogle Scholar
  • 24 Smith JC, Gregorius JC, Breazeale BH, Watkins GE. The corona mortis, a frequent vascular variant susceptible to blunt pelvic trauma: identification at routine multidetector CT. J Vasc Interv Radiol 2009; 20 (04) 455-460
    CrossrefPubMedGoogle Scholar
  • 25 Tajra JBM, Lima CF, Pires FR, Sales L, Junqueira D, Mauro E. Variability of the obturator artery with its surgical implications. J Morphol Sci 2016; 33 (02) 96-98
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Perandini S, Perandini A, Puntel G, Puppini G, Montemezzi S. Corona mortis variant of the obturator artery: a systematic study of 300 hemipelvises by means of computed tomography angiography. Pol J Radiol 2018; 83: e519-e523
    CrossrefPubMedGoogle Scholar
  • 27 Noussios G, Galanis N, Chatzis I. et al. The anatomical characteristics of corona mortis: a systematic review of the literature and its clinical importance in hernia repair. J Clin Med Res 2020; 12 (02) 108-114
    CrossrefPubMedGoogle Scholar
  • 28 Steinberg EL, Ben-Tov T, Aviram G, Steinberg Y, Rath E, Rosen G. Corona mortis anastomosis: a three-dimensional computerized tomographic angiographic study. Emerg Radiol 2017; 24 (05) 519-523
    CrossrefPubMedGoogle Scholar
  • 29 Teunis T, Heerma van Voss MR, Kon M, van Maurik JFMM. CT-angiography prior to DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery 2013; 33 (06) 496-502
    CrossrefPubMedGoogle Scholar
  • 30 Mohan AT, Saint-Cyr M. Advances in imaging technologies for planning breast reconstruction. Gland Surg 2016; 5 (02) 242-254
    PubMedGoogle Scholar
  • 31 Cho M-J, Haddock NT, Teotia SS. Clinical decision making using CTA in conjoined, bipedicled DIEP and SIEA for unilateral breast reconstruction. J Reconstr Microsurg 2020; 36 (04) 241-246
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Uppal RS, Casaer B, Van Landuyt K, Blondeel P. The efficacy of preoperative mapping of perforators in reducing operative times and complications in perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg 2009; 62 (07) 859-864
    CrossrefPubMedGoogle Scholar
  • 33 Malhotra A, Chhaya N, Nsiah-Sarbeng P, Mosahebi A. CT-guided deep inferior epigastric perforator (DIEP) flap localization -- better for the patient, the surgeon, and the hospital. Clin Radiol 2013; 68 (02) 131-138
    CrossrefPubMedGoogle Scholar
  • 34 Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction. Gland Surg 2015; 4 (02) 164-178
    PubMedGoogle Scholar
  • 35 Rodkin B, Hunter-Smith DJ, Rozen WM. A review of visualized preoperative imaging with a focus on surgical procedures of the breast. Gland Surg 2019; 8 (Suppl. 04) S301-S309
    CrossrefPubMedGoogle Scholar
  • 36 Ali RS, Garrido A, Ramakrishnan V. Stacked free hemi-DIEP flaps: a method of autologous breast reconstruction in a patient with midline abdominal scarring. Br J Plast Surg 2002; 55 (04) 351-353
    CrossrefPubMedGoogle Scholar
  • 37 Seth AK, Koolen PGL, Sultan SM, Lee BT, Erhard HA, Greenspun DT. Unilateral autologous breast reconstruction with bi-pedicled, conjoined deep inferior epigastric perforator flaps. J Reconstr Microsurg 2019; 35 (02) 145-155
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Sultan SM, Seth AK, Lamelas AM, Greenspun DT, Erhard HA. Bipedicle-conjoined deep inferior epigastric perforator flaps for unilateral breast reconstruction in overweight and obese patients: do the benefits outweigh the risks?. J Reconstr Microsurg 2020; 36 (05) 346-352
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Seth AK, Allen Jr RJ. Modern techniques and alternative flaps in microsurgical breast reconstruction. J Surg Oncol 2018; 118 (05) 768-779
    CrossrefPubMedGoogle Scholar
  • 40 Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW. Changing trends in recipient vessel selection for microvascular autologous breast reconstruction: an analysis of 1483 consecutive cases. Plast Reconstr Surg 2007; 119 (07) 1993-2000
    CrossrefPubMedGoogle Scholar
  • 41 Tansatit T, Chokrungvaranont P, Sanguansit P, Wanidchaphloi S. Neurovascular anatomy of the deep inferior epigastric perforator flap for breast reconstruction. J Med Assoc Thai 2006; 89 (10) 1630-1640
    PubMedGoogle Scholar
  • 42 Colohan S, Maia M, Langevin CJ. et al. The short- and ultrashort-pedicle deep inferior epigastric artery perforator flap in breast reconstruction. Plast Reconstr Surg 2012; 129 (02) 331-340
    CrossrefPubMedGoogle Scholar
  • 43 Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat 2007; 20 (04) 433-439
    CrossrefPubMedGoogle Scholar
  • 44 Rockwell WB, Hurst CA, Morton DA, Kwok A, Foreman KB. The deep inferior epigastric artery: anatomy and applicability as a source of microvascular arterial grafts. Plast Reconstr Surg 2007; 120 (01) 209-214
    CrossrefPubMedGoogle Scholar
  • 45 Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review. Plast Reconstr Surg 2014; 134 (05) 810e-821e
    CrossrefPubMedGoogle Scholar
  • 46 Teotia SS, Dumestre DO, Jayaraman AP, Sanniec KJ, Haddock NT. Revisiting anastomosis to the retrograde internal mammary system in stacked free flap breast reconstruction: an algorithmic approach to recipient-site selection. Plast Reconstr Surg 2020; 145 (04) 880-887
    CrossrefPubMedGoogle Scholar