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Erschienen in: European Journal of Plastic Surgery 1/2016

01.02.2016 | Original Paper

The Pfannenstiel scar and its implications in DIEP flap harvest: a clinical anatomic study

verfasst von: Vachara Niumsawatt, Keli Chow, Xiao-You Shen, Warren Matthew Rozen, David J. Hunter-Smith

Erschienen in: European Journal of Plastic Surgery | Ausgabe 1/2016

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Abstract

Background

Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption.

Methods

A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators.

Results

A total of 959 perforators were identified, with 319 perforators identified in the ‘Pfannenstiel scar’ group and 640 perforators in the ‘no abdominal scar’ group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p = 0.2819); however, perforators of the ‘Pfannenstiel scar’ group were of larger mean diameter than the ‘no abdominal scar’ group (0.96 vs 0.85 mm (p = 0.0027).

Conclusions

The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes.
Level of Evidence: Level III, risk / prognostic study.
Literatur
1.
Zurück zum Zitat Chang EI, Chang EI, Soto-Miranda MA et al (2013) Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg 132:1383–1391PubMed Chang EI, Chang EI, Soto-Miranda MA et al (2013) Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg 132:1383–1391PubMed
2.
Zurück zum Zitat Schoeller T, Wechselberger G, Roger J et al (2007) Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconst Aesth Surg 60:524–528CrossRef Schoeller T, Wechselberger G, Roger J et al (2007) Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconst Aesth Surg 60:524–528CrossRef
3.
Zurück zum Zitat Schoeller T, Huemer GM, Kolehmainen M et al (2004) Management of subcostal scars during DIEP-flap raising. Br J Plast Surg 57:511–514CrossRefPubMed Schoeller T, Huemer GM, Kolehmainen M et al (2004) Management of subcostal scars during DIEP-flap raising. Br J Plast Surg 57:511–514CrossRefPubMed
4.
Zurück zum Zitat Hsieh F, Kumiponjera D, Malata CM (2009) An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars—results from a single surgeon’s experience. J Plast Reconst Aesth Surg 62:1650–1660CrossRef Hsieh F, Kumiponjera D, Malata CM (2009) An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars—results from a single surgeon’s experience. J Plast Reconst Aesth Surg 62:1650–1660CrossRef
5.
Zurück zum Zitat Mehrara BJ, Santoro TD, Arcilla E et al (2006) Complications after microvascular breast reconstruction: Experience with 1195 flaps. Plast Reconstr Surg 118:1100–1109CrossRefPubMed Mehrara BJ, Santoro TD, Arcilla E et al (2006) Complications after microvascular breast reconstruction: Experience with 1195 flaps. Plast Reconstr Surg 118:1100–1109CrossRefPubMed
6.
Zurück zum Zitat Nichols DH (2000) Incisions. In D. H. N. a. D. L. C.-P. (Eds.) (Ed.), Gynecologic, Obstetric and Related Surgery. St. Louis, Mo: Mosby Nichols DH (2000) Incisions. In D. H. N. a. D. L. C.-P. (Eds.) (Ed.), Gynecologic, Obstetric and Related Surgery. St. Louis, Mo: Mosby
7.
Zurück zum Zitat Meeks GR (1996) Clinical anatomy of incisions. In: Mann JWJ, Stovall TG (eds) Gynecologic Surgery. Churchill Livingstone, New York Meeks GR (1996) Clinical anatomy of incisions. In: Mann JWJ, Stovall TG (eds) Gynecologic Surgery. Churchill Livingstone, New York
8.
Zurück zum Zitat Mahajan AL, Zeltzer A, Claes KE et al (2012) Are Pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions? Plast Reconstr Surg 129:797–805CrossRefPubMed Mahajan AL, Zeltzer A, Claes KE et al (2012) Are Pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions? Plast Reconstr Surg 129:797–805CrossRefPubMed
9.
Zurück zum Zitat Rozen WM, Phillips TJ, Stella DL et al (2010) Preoperative computed tomographic angiography for deep inferior epigastric artery perforator flaps: important information for the reporting radiologist. Plast Reconstr Surg 125:70e–72eCrossRefPubMed Rozen WM, Phillips TJ, Stella DL et al (2010) Preoperative computed tomographic angiography for deep inferior epigastric artery perforator flaps: important information for the reporting radiologist. Plast Reconstr Surg 125:70e–72eCrossRefPubMed
10.
Zurück zum Zitat Phillips TJ, Stella DL, Rozen WM et al (2008) Abdominal wall CT angiography: a detailed account of a newly established preoperative imaging technique. Radiology 249:32–44CrossRefPubMed Phillips TJ, Stella DL, Rozen WM et al (2008) Abdominal wall CT angiography: a detailed account of a newly established preoperative imaging technique. Radiology 249:32–44CrossRefPubMed
11.
Zurück zum Zitat Garvey PB, Buchel EW, Pockaj BA et al (2006) DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 117:1711–1719CrossRefPubMed Garvey PB, Buchel EW, Pockaj BA et al (2006) DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 117:1711–1719CrossRefPubMed
12.
Zurück zum Zitat Rozen WM, Chubb D, Grinsell D et al (2009) The SIEA angiosome: interindividual variability predicted preoperatively. Plast Reconstr Surg 124:327–328CrossRefPubMed Rozen WM, Chubb D, Grinsell D et al (2009) The SIEA angiosome: interindividual variability predicted preoperatively. Plast Reconstr Surg 124:327–328CrossRefPubMed
13.
Zurück zum Zitat Rozen WM, Chubb D, Grinsell D et al (2010) The variability of the superficial inferior epigastric artery (SIEA) and its angiosome: a clinical anatomical study. Microsurgery 30:386–391CrossRefPubMed Rozen WM, Chubb D, Grinsell D et al (2010) The variability of the superficial inferior epigastric artery (SIEA) and its angiosome: a clinical anatomical study. Microsurgery 30:386–391CrossRefPubMed
14.
Zurück zum Zitat 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 25:289–293CrossRefPubMed 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 25:289–293CrossRefPubMed
15.
Zurück zum Zitat Chubb D, Rozen WM, Ashton MW (2010) Complete absence of the deep inferior epigastric artery: an increasingly detected anomaly detected with the use of advanced imaging technologies. J Reconstr Microsurg 26:209–210CrossRefPubMed Chubb D, Rozen WM, Ashton MW (2010) Complete absence of the deep inferior epigastric artery: an increasingly detected anomaly detected with the use of advanced imaging technologies. J Reconstr Microsurg 26:209–210CrossRefPubMed
16.
Zurück zum Zitat Rozen WM, Ashton MW, Grinsell D et al (2008) Establishing the case for CT angiography in the preoperative imaging of perforators for DIEA perforator flaps. Microsurgery 28:227–232CrossRefPubMed Rozen WM, Ashton MW, Grinsell D et al (2008) Establishing the case for CT angiography in the preoperative imaging of perforators for DIEA perforator flaps. Microsurgery 28:227–232CrossRefPubMed
17.
Zurück zum Zitat Galli A, Adami M, Berrino P et al (1992) Long-term evaluation of the abdominal wall competence after total and selective harvesting of the rectus abdominis muscle. Ann Plast Surg 28:409–413CrossRefPubMed Galli A, Adami M, Berrino P et al (1992) Long-term evaluation of the abdominal wall competence after total and selective harvesting of the rectus abdominis muscle. Ann Plast Surg 28:409–413CrossRefPubMed
18.
Zurück zum Zitat Bottero L, Lefaucheur JP, Fadhul S et al (2004) Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg 113:156–161CrossRefPubMed Bottero L, Lefaucheur JP, Fadhul S et al (2004) Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg 113:156–161CrossRefPubMed
19.
Zurück zum Zitat Bajaj AK, Chevray PM, Chang DW (2006) Comparison of donor site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 117:737–746CrossRefPubMed Bajaj AK, Chevray PM, Chang DW (2006) Comparison of donor site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 117:737–746CrossRefPubMed
20.
Zurück zum Zitat Takeishi M, Shaw WW, Ahn CY et al (1997) TRAM flaps in patients with abdominal scars. Plast Reconstr Surg 99:713–722 Takeishi M, Shaw WW, Ahn CY et al (1997) TRAM flaps in patients with abdominal scars. Plast Reconstr Surg 99:713–722
21.
Zurück zum Zitat Losken A, Carlson GW, Jones GE et al (2002) Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction. Ann Plast Surg 49:115–119CrossRefPubMed Losken A, Carlson GW, Jones GE et al (2002) Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction. Ann Plast Surg 49:115–119CrossRefPubMed
22.
Zurück zum Zitat Rozen WM, Garcia-Tutor E, Alonso-Burgos A et al (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 22:815–822CrossRefPubMed Rozen WM, Garcia-Tutor E, Alonso-Burgos A et al (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 22:815–822CrossRefPubMed
23.
Zurück zum Zitat Rozen WM, Whitaker IS, Ashton MW et al (2012) Changes in vascular anatomy following reconstructive surgery: an in vivo angiographic demonstration of the delay phenomenon and venous recanalization. J Reconstr Microsurg 28:363–365PubMed Rozen WM, Whitaker IS, Ashton MW et al (2012) Changes in vascular anatomy following reconstructive surgery: an in vivo angiographic demonstration of the delay phenomenon and venous recanalization. J Reconstr Microsurg 28:363–365PubMed
24.
Zurück zum Zitat Rozen WM, Ashton MW, Le Roux CM et al (2010) The perforator angiosome: A new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 30:1–7CrossRefPubMed Rozen WM, Ashton MW, Le Roux CM et al (2010) The perforator angiosome: A new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 30:1–7CrossRefPubMed
25.
Zurück zum Zitat Callegari PR, Taylor GI, Caddy CM et al (1992) An anatomic review of the delay phenomenon: I. Experimental studies. Plast Reconstr Surg 89:397–407CrossRefPubMed Callegari PR, Taylor GI, Caddy CM et al (1992) An anatomic review of the delay phenomenon: I. Experimental studies. Plast Reconstr Surg 89:397–407CrossRefPubMed
26.
Zurück zum Zitat Taylor GI, Corlett RJ, Caddy CM et al (1992) An anatomic review of the delay phenomenon: II. Clinical applications. Plast Reconst Surg 89:408–416CrossRefPubMed Taylor GI, Corlett RJ, Caddy CM et al (1992) An anatomic review of the delay phenomenon: II. Clinical applications. Plast Reconst Surg 89:408–416CrossRefPubMed
27.
Zurück zum Zitat Dhar SC, Taylor GI (1999) The delay phenomenon: the story unfolds. Plast Reconstr Surg 104:2079–2091CrossRefPubMed Dhar SC, Taylor GI (1999) The delay phenomenon: the story unfolds. Plast Reconstr Surg 104:2079–2091CrossRefPubMed
28.
Zurück zum Zitat Reinisch JF (1974) The pathophysiology of skin flap circulation. The delay phenomenon. Plast Reconstr Surg 54:585–598CrossRefPubMed Reinisch JF (1974) The pathophysiology of skin flap circulation. The delay phenomenon. Plast Reconstr Surg 54:585–598CrossRefPubMed
29.
Zurück zum Zitat Dayhim F, Wilkins EG (2004) The impact of Pfannenstiel scars on TRAM flap complications. Ann Plast Surg 53:432–435CrossRefPubMed Dayhim F, Wilkins EG (2004) The impact of Pfannenstiel scars on TRAM flap complications. Ann Plast Surg 53:432–435CrossRefPubMed
30.
Zurück zum Zitat Parrett BM, Caterson SA, Tobias AM, Lee BT (2008) DIEP flaps in women with abdominal scars: are complication rates affected? Plast Reconstr Surg 121:1527–1531CrossRefPubMed Parrett BM, Caterson SA, Tobias AM, Lee BT (2008) DIEP flaps in women with abdominal scars: are complication rates affected? Plast Reconstr Surg 121:1527–1531CrossRefPubMed
31.
Zurück zum Zitat Bar-Meir ED, Reish RG, Yueh JH et al (2009) The Maylard incision: a low transverse incision variant seen in DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 62:e447–e452CrossRefPubMed Bar-Meir ED, Reish RG, Yueh JH et al (2009) The Maylard incision: a low transverse incision variant seen in DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 62:e447–e452CrossRefPubMed
32.
Zurück zum Zitat Rozen WM, Ashton MW, Stella DL et al (2008) The accuracy of CT angiography for mapping the perforators of the DIEA: a blinded, prospective cohort study. Plast Reconstr Surg 122:1003–1009CrossRefPubMed Rozen WM, Ashton MW, Stella DL et al (2008) The accuracy of CT angiography for mapping the perforators of the DIEA: a blinded, prospective cohort study. Plast Reconstr Surg 122:1003–1009CrossRefPubMed
33.
Zurück zum Zitat Rozen WM, Ashton MW, Stella DL et al (2008) The accuracy of CT angiography for mapping the perforators of the DIEA: a cadaveric study. Plast Reconstr Surg 122:363–369CrossRefPubMed Rozen WM, Ashton MW, Stella DL et al (2008) The accuracy of CT angiography for mapping the perforators of the DIEA: a cadaveric study. Plast Reconstr Surg 122:363–369CrossRefPubMed
34.
Zurück zum Zitat Fischer MJ, Uchida S, Messlinger K (2010) Measurement of meningeal blood vessel diameter in vivo with a plug-in for ImageJ. Microvasc Res 80:258–266CrossRefPubMed Fischer MJ, Uchida S, Messlinger K (2010) Measurement of meningeal blood vessel diameter in vivo with a plug-in for ImageJ. Microvasc Res 80:258–266CrossRefPubMed
35.
Zurück zum Zitat Ozerdem U, Wojcik EM, Duan X et al (2013) Prognostic utility of quantitative image analysis of microvascular density in prostate cancer. Pathol Int 63:277–282CrossRefPubMed Ozerdem U, Wojcik EM, Duan X et al (2013) Prognostic utility of quantitative image analysis of microvascular density in prostate cancer. Pathol Int 63:277–282CrossRefPubMed
37.
Zurück zum Zitat Laporta R, Longo B, Sorotos M, SantanellidiPompeo F (2015) Tips and tricks for DIEP flap breast reconstruction in patients with previous abdominal scar. Microsurgery. doi:10.1002/micr.22457 Laporta R, Longo B, Sorotos M, SantanellidiPompeo F (2015) Tips and tricks for DIEP flap breast reconstruction in patients with previous abdominal scar. Microsurgery. doi:10.​1002/​micr.​22457
38.
Zurück zum Zitat Santanelli F, Longo B, Cagli B, Pugliese P, Sorotos M, Paolini G (2015) Predictive and protective factors for partial necrosis in DIEP flap breast reconstruction: does nulliparity bias flap viability? Ann Plast Surg 74:47–51CrossRefPubMed Santanelli F, Longo B, Cagli B, Pugliese P, Sorotos M, Paolini G (2015) Predictive and protective factors for partial necrosis in DIEP flap breast reconstruction: does nulliparity bias flap viability? Ann Plast Surg 74:47–51CrossRefPubMed
39.
Zurück zum Zitat Rubino C, Ramakrishnan V, Figus A, Bulla A, Coscia V, Cavazzuti MA (2009) Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage. J Plast Reconstr Aesthet Surg 62:1666–1670CrossRefPubMed Rubino C, Ramakrishnan V, Figus A, Bulla A, Coscia V, Cavazzuti MA (2009) Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage. J Plast Reconstr Aesthet Surg 62:1666–1670CrossRefPubMed
Metadaten
Titel
The Pfannenstiel scar and its implications in DIEP flap harvest: a clinical anatomic study
verfasst von
Vachara Niumsawatt
Keli Chow
Xiao-You Shen
Warren Matthew Rozen
David J. Hunter-Smith
Publikationsdatum
01.02.2016
Verlag
Springer Berlin Heidelberg
Erschienen in
European Journal of Plastic Surgery / Ausgabe 1/2016
Print ISSN: 0930-343X
Elektronische ISSN: 1435-0130
DOI
https://doi.org/10.1007/s00238-015-1176-0

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