Management of abnormal deep inferior epigastric vessels in microsurgical breast reconstruction: a report of 3 complex cases

  • Georgios OrfaniotisEmail author
  • Toby Ivor Vinycomb
  • Simon Overstall
  • Eldon Mah
  • Vachara Niumsawatt
  • Dean Trotter
Case Report


The deep inferior epigastric artery perforator flap is the gold standard in microsurgical breast reconstruction. It is now increasingly offered in patients with previous abdominal scars and in such cases, computed tomography angiography (CTA) is routinely implemented. However, previous injury of the deep inferior epigastric vessels may be difficult to detect with CTA. We report three cases of successful bilateral breast reconstruction, in which a unilateral DIEA was found to be abnormal. In the first two cases, the unilateral DIE vessels were found to be damaged and the flaps salvaged based on the deep superior epigastric artery. In the third patient, previous DIEA injury resulted in vessel recanalization, which was only evident following initial anastomotic failure. In this case, the damaged DIEA segment was subsequently removed and the flap successfully revascularized. All three patients had an uneventful post-operative recovery and all flaps survived with no complications. Based on our experience, we believe that awareness of the potential pitfalls and careful planning for lifeboats are essential to avoid flap loss in such circumstances.

Level of Evidence: Level V, therapeutic study.


Microsurgery DIEP flaps Computed tomography angiography Epigastric vessels Abdominal scars 


Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Patient consent

Informed written consent was obtained from all participants whose potentially identifying photographs have been used in this manuscript.

Conflict of interest

Georgios Orfaniotis, Toby Vinycomb, Simon Overstall, Eldon Mah, Vachara Niumsawatt, and Dean Trotter declare that they have no conflict of interest.


  1. 1.
    Rozen WM, Ashton MW (2009) Modifying techniques in deep inferior epigastric artery perforator flap harvest with the use of preoperative imaging. ANZ J Surg 79(9):598–603CrossRefGoogle Scholar
  2. 2.
    Rozen WM, Ashton MW, Grinsell D, Stella DL, Phillips TJ, Taylor GI (2008) Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators. Microsurgery 28(5):306–313CrossRefGoogle Scholar
  3. 3.
    Rozen WM, Houseman ND, Ashton MW (2009) The absent inferior epigastric artery: a unique anomaly and implications for deep inferior epigastric artery perforator flaps. J Reconstr Microsurg 25(5):289–293CrossRefGoogle Scholar
  4. 4.
    Parrett BM, Caterson SA, Tobias AM, Lee BT (2008) DIEP flaps in women with abdominal scars: are complication rates affected? Plast Reconstr Surg 121(5):1527–1531CrossRefGoogle Scholar
  5. 5.
    Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Corlett RJ, Taylor GI, Ashton MW (2009) The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: a cadaveric and clinical study with clinical implications. Clin Anat 22(7):815–822CrossRefGoogle Scholar
  6. 6.
    Kim SY, Lee K-T, Mun G-H (2017) The influence of Pfannenstiel scar on venous anatomy of the lower abdominal wall and implications for deep inferior epigastric artery perforator flap breast reconstruction. Plast Reconstr Surg 193:540–548CrossRefGoogle Scholar
  7. 7.
    Hansen KS, Gutwein LG, Hartman BC, Sood R, Socas J (2016) Immediate bilateral breast reconstruction with unilateral deep superior epigastric artery and superficial circumflex iliac artery flaps. Arch Plast Surg 43(5):457–460CrossRefGoogle Scholar
  8. 8.
    Atisha D, Alderman AK, Janiga T, Singal B, Wilkins EG (2009) The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg 63(4):383–388CrossRefGoogle Scholar
  9. 9.
    Schwitzer JA, Miller HC, Pusic AL, Matros E, Mehrara BJ, McCarthy CM, Lennox PA, Van Laeken N, Disa JJ (2015) Satisfaction following unilateral breast reconstruction: a comparison of pedicled TRAM and free abdominal flaps. Plast Reconstr Surg Glob Open 3(8):e482CrossRefGoogle Scholar
  10. 10.
    Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury R, Cromwell DA (2015) Donor-site hernia repair in abdominal flap breast reconstruction: a population-based cohort study of 7929 patients. Plast Reconstr Surg 136(1):1–9CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Georgios Orfaniotis
    • 1
    Email author
  • Toby Ivor Vinycomb
    • 1
  • Simon Overstall
    • 1
  • Eldon Mah
    • 1
  • Vachara Niumsawatt
    • 1
  • Dean Trotter
    • 1
  1. 1.Department of Plastic and Reconstructive SurgeryRoyal Melbourne HospitalParkvilleAustralia

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