Three-dimensional CT angiography assessment of the impact of the dermis and the subdermal plexus in DIEP flap perfusion

Alexis T. Laungani, Nick Van Alphen, Jodie A. Christner, Nirusha Lachman, Wojciech Pawlina, Karla V. Ballman, Michel Saint-Cyr

Research output: Contribution to journalArticle

10 Citations (Scopus)

Abstract

Background Single-stage breast reconstruction following skin-sparing or nipple-sparing mastectomy with free deep inferior epigastric perforator (DIEP) flap usually does not require a large skin paddle. Most of the flap skin paddle is removed, and the flap is placed under native, conserved skin to provide adequate volume to the reconstructed breast mound. We hypothesized that conservation of intact dermis and its subdermal plexus has a critical role in overall flap perfusion through recruitment of indirect linking vessels. The study goal was to investigate and compare the vascularity of DIEP flaps with intact dermis versus DIEP flaps with the dermis removed. Methods Twelve hemi-DIEP flaps were harvested from fresh cadavers. The largest dominant perforator was cannulated using a 24-gauge butterfly catheter. Flaps were imaged with computed tomography (CT) after injection of a contrast agent. After scanning, the contrast agent was flushed out of the flap. The flap skin was removed with cautery at the subdermal dissection plane. The flaps were reimaged with CT after injection of the contrast agent. Three-dimensional (3-D) CT angiographic reconstructions were obtained for each protocol stage, and the percentage of flap perfusion was calculated. Flap vascularity with and without dermis was compared. Results A mean difference of 25.9% in flap perfusion occurred when the dermis was removed (P < 0.001). The 3-D CT angiographic images showed that the impact of dermis excision was caused by interrupting the recurrent flow through the dermis and subdermal plexus via indirect linking vessels. Conclusion The dermis has a significant role in enhancing overall DIEP flap perfusion through preservation of indirect linking vessels organized in the subdermal plexus. Despite being time consuming, a cautious de-epithelialization of the DIEP flap should be performed to retain dermis integrity. Enhancement of flap vascularity ultimately leads to a decrease in such complications as partial or total flap necrosis, as well as fat necrosis.

Original languageEnglish (US)
Pages (from-to)525-530
Number of pages6
JournalJournal of Plastic, Reconstructive and Aesthetic Surgery
Volume68
Issue number4
DOIs
StatePublished - Apr 1 2015

Fingerprint

Perforator Flap
Dermis
Perfusion
Skin
Tomography
Contrast Media
Fat Necrosis
Computed Tomography Angiography
Cautery
Butterflies
Injections
Nipples
Mammaplasty
Mastectomy
Cadaver
Dissection
Breast
Necrosis
Catheters

Keywords

  • Angiography
  • Assessment
  • Dermis
  • Flap
  • Perfusion

ASJC Scopus subject areas

  • Surgery

Cite this

Three-dimensional CT angiography assessment of the impact of the dermis and the subdermal plexus in DIEP flap perfusion. / Laungani, Alexis T.; Van Alphen, Nick; Christner, Jodie A.; Lachman, Nirusha; Pawlina, Wojciech; Ballman, Karla V.; Saint-Cyr, Michel.

In: Journal of Plastic, Reconstructive and Aesthetic Surgery, Vol. 68, No. 4, 01.04.2015, p. 525-530.

Research output: Contribution to journalArticle

Laungani, Alexis T. ; Van Alphen, Nick ; Christner, Jodie A. ; Lachman, Nirusha ; Pawlina, Wojciech ; Ballman, Karla V. ; Saint-Cyr, Michel. / Three-dimensional CT angiography assessment of the impact of the dermis and the subdermal plexus in DIEP flap perfusion. In: Journal of Plastic, Reconstructive and Aesthetic Surgery. 2015 ; Vol. 68, No. 4. pp. 525-530.
@article{47714b8321cc4e94998a9dc80d43ca8a,
title = "Three-dimensional CT angiography assessment of the impact of the dermis and the subdermal plexus in DIEP flap perfusion",
abstract = "Background Single-stage breast reconstruction following skin-sparing or nipple-sparing mastectomy with free deep inferior epigastric perforator (DIEP) flap usually does not require a large skin paddle. Most of the flap skin paddle is removed, and the flap is placed under native, conserved skin to provide adequate volume to the reconstructed breast mound. We hypothesized that conservation of intact dermis and its subdermal plexus has a critical role in overall flap perfusion through recruitment of indirect linking vessels. The study goal was to investigate and compare the vascularity of DIEP flaps with intact dermis versus DIEP flaps with the dermis removed. Methods Twelve hemi-DIEP flaps were harvested from fresh cadavers. The largest dominant perforator was cannulated using a 24-gauge butterfly catheter. Flaps were imaged with computed tomography (CT) after injection of a contrast agent. After scanning, the contrast agent was flushed out of the flap. The flap skin was removed with cautery at the subdermal dissection plane. The flaps were reimaged with CT after injection of the contrast agent. Three-dimensional (3-D) CT angiographic reconstructions were obtained for each protocol stage, and the percentage of flap perfusion was calculated. Flap vascularity with and without dermis was compared. Results A mean difference of 25.9{\%} in flap perfusion occurred when the dermis was removed (P < 0.001). The 3-D CT angiographic images showed that the impact of dermis excision was caused by interrupting the recurrent flow through the dermis and subdermal plexus via indirect linking vessels. Conclusion The dermis has a significant role in enhancing overall DIEP flap perfusion through preservation of indirect linking vessels organized in the subdermal plexus. Despite being time consuming, a cautious de-epithelialization of the DIEP flap should be performed to retain dermis integrity. Enhancement of flap vascularity ultimately leads to a decrease in such complications as partial or total flap necrosis, as well as fat necrosis.",
keywords = "Angiography, Assessment, Dermis, Flap, Perfusion",
author = "Laungani, {Alexis T.} and {Van Alphen}, Nick and Christner, {Jodie A.} and Nirusha Lachman and Wojciech Pawlina and Ballman, {Karla V.} and Michel Saint-Cyr",
year = "2015",
month = "4",
day = "1",
doi = "10.1016/j.bjps.2014.12.004",
language = "English (US)",
volume = "68",
pages = "525--530",
journal = "Journal of Plastic, Reconstructive and Aesthetic Surgery",
issn = "1748-6815",
publisher = "Churchill Livingstone",
number = "4",

}

TY - JOUR

T1 - Three-dimensional CT angiography assessment of the impact of the dermis and the subdermal plexus in DIEP flap perfusion

AU - Laungani, Alexis T.

AU - Van Alphen, Nick

AU - Christner, Jodie A.

AU - Lachman, Nirusha

AU - Pawlina, Wojciech

AU - Ballman, Karla V.

AU - Saint-Cyr, Michel

PY - 2015/4/1

Y1 - 2015/4/1

N2 - Background Single-stage breast reconstruction following skin-sparing or nipple-sparing mastectomy with free deep inferior epigastric perforator (DIEP) flap usually does not require a large skin paddle. Most of the flap skin paddle is removed, and the flap is placed under native, conserved skin to provide adequate volume to the reconstructed breast mound. We hypothesized that conservation of intact dermis and its subdermal plexus has a critical role in overall flap perfusion through recruitment of indirect linking vessels. The study goal was to investigate and compare the vascularity of DIEP flaps with intact dermis versus DIEP flaps with the dermis removed. Methods Twelve hemi-DIEP flaps were harvested from fresh cadavers. The largest dominant perforator was cannulated using a 24-gauge butterfly catheter. Flaps were imaged with computed tomography (CT) after injection of a contrast agent. After scanning, the contrast agent was flushed out of the flap. The flap skin was removed with cautery at the subdermal dissection plane. The flaps were reimaged with CT after injection of the contrast agent. Three-dimensional (3-D) CT angiographic reconstructions were obtained for each protocol stage, and the percentage of flap perfusion was calculated. Flap vascularity with and without dermis was compared. Results A mean difference of 25.9% in flap perfusion occurred when the dermis was removed (P < 0.001). The 3-D CT angiographic images showed that the impact of dermis excision was caused by interrupting the recurrent flow through the dermis and subdermal plexus via indirect linking vessels. Conclusion The dermis has a significant role in enhancing overall DIEP flap perfusion through preservation of indirect linking vessels organized in the subdermal plexus. Despite being time consuming, a cautious de-epithelialization of the DIEP flap should be performed to retain dermis integrity. Enhancement of flap vascularity ultimately leads to a decrease in such complications as partial or total flap necrosis, as well as fat necrosis.

AB - Background Single-stage breast reconstruction following skin-sparing or nipple-sparing mastectomy with free deep inferior epigastric perforator (DIEP) flap usually does not require a large skin paddle. Most of the flap skin paddle is removed, and the flap is placed under native, conserved skin to provide adequate volume to the reconstructed breast mound. We hypothesized that conservation of intact dermis and its subdermal plexus has a critical role in overall flap perfusion through recruitment of indirect linking vessels. The study goal was to investigate and compare the vascularity of DIEP flaps with intact dermis versus DIEP flaps with the dermis removed. Methods Twelve hemi-DIEP flaps were harvested from fresh cadavers. The largest dominant perforator was cannulated using a 24-gauge butterfly catheter. Flaps were imaged with computed tomography (CT) after injection of a contrast agent. After scanning, the contrast agent was flushed out of the flap. The flap skin was removed with cautery at the subdermal dissection plane. The flaps were reimaged with CT after injection of the contrast agent. Three-dimensional (3-D) CT angiographic reconstructions were obtained for each protocol stage, and the percentage of flap perfusion was calculated. Flap vascularity with and without dermis was compared. Results A mean difference of 25.9% in flap perfusion occurred when the dermis was removed (P < 0.001). The 3-D CT angiographic images showed that the impact of dermis excision was caused by interrupting the recurrent flow through the dermis and subdermal plexus via indirect linking vessels. Conclusion The dermis has a significant role in enhancing overall DIEP flap perfusion through preservation of indirect linking vessels organized in the subdermal plexus. Despite being time consuming, a cautious de-epithelialization of the DIEP flap should be performed to retain dermis integrity. Enhancement of flap vascularity ultimately leads to a decrease in such complications as partial or total flap necrosis, as well as fat necrosis.

KW - Angiography

KW - Assessment

KW - Dermis

KW - Flap

KW - Perfusion

UR - http://www.scopus.com/inward/record.url?scp=84926245020&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84926245020&partnerID=8YFLogxK

U2 - 10.1016/j.bjps.2014.12.004

DO - 10.1016/j.bjps.2014.12.004

M3 - Article

C2 - 25665491

AN - SCOPUS:84926245020

VL - 68

SP - 525

EP - 530

JO - Journal of Plastic, Reconstructive and Aesthetic Surgery

JF - Journal of Plastic, Reconstructive and Aesthetic Surgery

SN - 1748-6815

IS - 4

ER -