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Perforasomes of the DIEP Flap: Vascular Anatomy of the Lateral versus Medial Row Perforators and Clinical Implications

Wong, Corrine M.R.C.S.; Saint-Cyr, Michel M.D.; Mojallal, Ali M.D.; Schaub, Tim M.D.; Bailey, Steven H. M.D.; Myers, Simon Ph.D., F.R.C.S.; Brown, Spencer Ph.D.; Rohrich, Rod J. M.D.

Plastic and Reconstructive Surgery: March 2010 - Volume 125 - Issue 3 - p 772-782
doi: 10.1097/PRS.0b013e3181cb63e0
Breast: Original Articles

Background: Regarding the perfusion of a deep inferior epigastric perforator (DIEP) flap, the classic Hartrampf zones II and III were demonstrated by Holm et al. to be reversed using fluorescent perfusion techniques, implying that blood flow from the pedicle travels to the ipsilateral side before crossing the midline. The authors' hypothesis is that the zones of perfusion and the vascular anatomy differ greatly between lateral row and medial row perforators.

Methods: Three-dimensional and four-dimensional computed tomographic angiography was utilized to reappraise the zones of vascularity. Thirty-six DIEP flaps were simulated for this study (14 lateral row perforators versus 22 medial row perforators). Individual perforators were injected with contrast and each flap was subjected to dynamic computed tomography scanning. Images were viewed using TeraRecon software, allowing analysis of branching patterns and perfusion flow.

Results: The mean vascular territory for a medial perforator DIEP flap injected with contrast was 296 cm2, compared with 196 cm2 for a lateral perforator DIEP flap. Zone II perfusion was greater in a medial perforator compared with a lateral perforator. Zone III had greater perfusion in a lateral perforator compared with a medial perforator. The authors found that medial perforators conform to the Hartrampf zones of perfusion and lateral perforators follow the Holm theory of perfusion (zones II and III should be reversed for lateral perforator DIEP flaps). Injection of a lateral row–based perforator flap gave a vascular territory that rarely crossed the midline.

Conclusion: Medial and lateral row perforators offer distinct and stereotypical zones of perfusion that have a significant effect on flap design and harvesting.


Dallas, Texas

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.

Received for publication July 5, 2009; accepted September 21, 2009.

Presented at the Plastic Surgery Research Council 54th Annual Meeting, in Pittsburgh, Pennsylvania, May 28 through 30, 2009, and given the Shenaq International Research Award. Presented as an Outstanding Paper at the American Society for Reconstructive Microsurgery Annual Scientific Meeting in Boca Raton, Florida, January 9 through 12, 2010.

Disclosure: The authors have no financial interests in this research project or in any of the techniques or equipment used in this study.

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Michel Saint-Cyr, M.D., Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas 75290-9132,

©2010American Society of Plastic Surgeons