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Avoiding denervation of rectus abdominis in DIEP flap harvest: the importance of medial row perforators
Warren M Rozen1, Mark W Ashton, Alice C A Murray
1Parkville, Victoria, Australia From the Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne.
Background:
The deep inferior epigastric artery (DIEA) perforator flap for breast reconstruction spares rectus abdominis muscle and has low donor-site morbidity. However, abdominal wall weakness and bulge remain significant complications, with damage to the motor innervation of the rectus abdominis postulated as a cause. This study describes the relationship between the nerves supplying rectus abdominis and perforators, based on a thorough cadaveric study and review of the literature.
Methods:
Twenty hemiabdominal walls from fresh and embalmed cadavers were dissected, mapping the course of the nerve and vascular supply of rectus abdominis.
Results:
The infraumbilical segment of rectus abdominis was innervated by T9-L1, with four to seven nerve branches entering rectus abdominis from its lateral border (12 cases) or posterior surface (93 cases). Each nerve entered a nerve plexus running with the most lateral branch of the DIEA, before running with arterial perforators into rectus abdominis. Nerves entered rectus muscle more medial than the lateral row perforators (83 percent of cases), with the medial branches of the DIEA devoid of these nerve branches.
Conclusions:
The nerves innervating rectus abdominis are at risk during the raising of a DIEA perforator flap. These nerves enter the posterior surface of rectus abdominis and run with the most lateral branch of the DIEA and its perforators. Damage to these nerves may denervate rectus abdominis muscle and contribute to donor-site morbidity. As medial row perforators were not related to these motor nerves, these perforators are ideal for inclusion in DIEA perforator and transverse rectus abdominis myocutaneous flaps.
Insights
Damage to nerves supplying the rectus abdominis muscle during deep inferior epigastric artery (DIEA) perforator flap surgery can cause abdominal weakness. Medial row perforators are safer for DIEA flaps as they avoid these motor nerves.
Area of Science:
- Anatomy
- Microsurgery
- Plastic Surgery
Background:
- Deep inferior epigastric artery (DIEA) perforator flaps offer breast reconstruction with reduced donor-site morbidity.
- Abdominal wall weakness and bulge are significant complications, potentially linked to nerve damage in the rectus abdominis muscle.
Purpose of the Study:
- To investigate the anatomical relationship between nerves supplying the rectus abdominis muscle and DIEA perforators.
- To identify strategies for minimizing nerve damage during DIEA perforator flap harvest.
Main Methods:
- Dissection of twenty fresh and embalmed cadaver hemiabdominal walls.
- Mapping of the nerve and vascular supply to the rectus abdominis muscle.
Main Results:
- Nerves innervating the infraumbilical rectus abdominis originate from T9-L1.
- Nerve branches form a plexus with the lateral DIEA branches and enter the muscle medial to lateral row perforators.
- Medial DIEA branches lack associated motor nerves.
Conclusions:
- Motor nerves to the rectus abdominis are at risk with lateral DIEA perforator harvest.
- Damage to these nerves can lead to denervation and donor-site morbidity.
- Medial row perforators are recommended for DIEA and transverse rectus abdominis myocutaneous flaps to preserve nerve supply.
