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LETTERS

The Cutaneous Arteries of the Anterior Abdominal Wall: A Three-Dimensional Study

Rozen, Warren M. M.B.B.S.; Stella, Damien L. F.R.A.N.Z.C.R.; Ashton, Mark W. F.R.A.C.S.; Phillips, Timothy J. M.B.B.S.; Taylor, G Ian F.R.C.S., F.R.A.C.S.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 1510-1512
doi: 10.1097/01.prs.0000305364.09281.ec
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Sir:

We congratulate Tregaskiss et al. for their study utilizing computed tomography angiography in the evaluation of the abdominal wall vasculature.1 As mentioned in their article, computed tomography angiography has only recently been suggested for preoperative imaging before use of superficial inferior epigastric artery (SIEA) and deep inferior epigastric artery (DIEA) perforator flaps, but it has yet to be adequately evaluated for this purpose. Their article, “The Cutaneous Arteries of the Anterior Abdominal Wall: A Three-Dimensional Study,” certainly contributes to the literature on this topic. We would like to share our work on this topic, which we believe may shed more light on this rapidly advancing field of anatomical research, in light of their article.

We have undertaken a study of 10 cadaveric hemiabdominal walls, which is currently in the submission process for this Journal, in which we performed isolated DIEA contrast injection in each case. Our injection technique and harvesting methods were done in a fashion similar to that of Tregaskiss et al., and our specimens underwent computed tomography scanning in a similar way. Our computed tomography scanner differed in that it was a 64 multidetector row scanner, which permits a greater number of slices and greater resolution of images. Our reformatting also differed, in that we created maximum intensity projection images in addition to three-dimensional volume-rendered technique images.

In general, our findings confirm the findings of Tregaskiss et al., in that computed tomography was able to effectively demonstrate the SIEA system, the cutaneous branches of the SIEA system, the musculocutaneous perforators, and the DIEA system. Of note, we were able to identify both SIEAs in 80 percent of patients, compared with 40 percent in the study by Tregaskiss et al. These data, however, do not achieve a formal evaluation of the use of computed tomography angiography. In an attempt to achieve this, we performed post–computed tomography dissection of all the musculocutaneous perforators in each specimen (total number on computed tomography angiography = 154 perforators), which enabled us to evaluate the use of computed tomography angiography for perforator mapping, as both a tool for demonstrating cadaveric anatomy and a potential tool for preoperative imaging before use of DIEA perforator flaps.2–4

We found that the DIEA system demonstrated on computed tomography angiography, including the course of the DIEA and its branching pattern,5 was 100 percent concordant with dissection findings in all cases (Fig. 1). Similarly, the mapping of musculocutaneous perforators was highly accurate, with only eight false-positive results and six false-negative results out of 154 perforators seen on computed tomography angiography, revealing a sensitivity of 96 percent and a specificity of 95 percent for the mapping of musculocutaneous perforators of the DIEA (Fig. 2).

Fig. 1.
Fig. 1.:
(Left) Computed tomography angiogram with volume-rendered technique image of the DIEA system in a cadaveric abdominal wall. (Right) Dissection findings demonstrating concordance with computed tomography findings.
Fig. 2.
Fig. 2.:
(Left) Computed tomography angiogram with volume-rendered technique image of the musculocutaneous perforators at the level of perforating the anterior rectus sheath in a cadaveric abdominal wall. (Right) Dissection findings demonstrating concordance with computed tomography findings. In the computed tomography image, intramuscular vessels are green and cutaneous vessels are red (green arrows, perforators; pink arrow, umbilicus).

Our study demonstrates that computed tomography angiography can be used with high accuracy in anatomical studies such as that of Tregaskiss et al., and suggests that this may be an ongoing modality for imaging vasculature in both anatomical studies and preoperative imaging. This type of anatomic cadaveric study does not necessarily reflect the accuracy of computed tomography angiography in the clinical setting, where it is used preoperatively to localize DIEA perforators before DIEA perforator flap surgery. Further work in this area is required to establish the role and accuracy of computed tomography angiography in DIEA perforator flap planning.

Warren M. Rozen, M.B.B.S.

Jack Brockhoff Reconstructive Plastic Surgery Research Unit

University of Melbourne

Damien L. Stella, F.R.A.N.Z.C.R.

Department of Radiology

Royal Melbourne Hospital

Mark W. Ashton, F.R.A.C.S.

Jack Brockhoff Reconstructive Plastic Surgery Research Unit

University of Melbourne

Timothy J. Phillips, M.B.B.S.

Department of Radiology

Royal Melbourne Hospital

G. Ian Taylor, F.R.C.S., F.R.A.C.S.

Jack Brockhoff Reconstructive Plastic Surgery Research Unit

University of Melbourne

Parkville, Victoria, Australia

DISCLOSURE

The authors declare that there is no source of financial or other support or any financial or professional relationships that may pose a competing interest.

REFERENCES

1. Tregaskiss, A. P., Goodwin, A. N., and Acland, R. D. The cutaneous arteries of the anterior abdominal wall: A three-dimensional study. Plast. Reconstr. Surg. 120: 442, 2007.
2. Rozen, W. M., Palmer, K. P., Suami, H., et al. The DIEA branching pattern and its relationship to perforators: The importance of preoperative computed tomography angiography for DIEA perforator flaps. Plast. Reconstr. Surg. (in press).
3. Rozen, W. M., Phillips, T. J., Ashton, M. W., et al. Preoperative imaging for DIEA perforator flaps: A comparison of computed tomography angiography and Doppler ultrasound. Plast. Reconstr. Surg. (in press).
4. Rozen, W. M., Phillips, T. J., Ashton, M. W., et al. A new imaging modality for free flaps in breast reconstruction: Computed tomography angiography. Plast. Reconstr. Surg. (in press).
5. Moon, H. K., and Taylor, G. I. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast. Reconstr. Surg. 82: 815, 1988.

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