Original Article WSRM Special Topic Issue—Flaps
475
Moustapha Hamdi, MD, PhD1 Barbara Craggs, MD1 Benoit Hendrickx, MD, PhD1 Assaf Zeltzer, MD1
Anne-Marie Stoel, MD1
1 Department of Plastic and Reconstructive Surgery, UZ Brussel,
Address for correspondence Moustapha Hamdi, MD, PhD, Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Laarbeeklaan 101, Brussels 1090, Belgium (e-mail: [email protected]).
Jette, Belgium J Reconstr Microsurg 2014;30:475–482.
Abstract
Keywords
► perforator flap ► superior epigastric artery perforator flap ► chest wall reconstruction
Introduction To reduce donor site morbidity in anterior chest wall reconstruction, a flap based on perforators of the superior epigastric artery (SEA) was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction. Materials and Methods We combined our anatomical and clinical experience with superior epigastric artery perforator (SEAP) flap with a PubMed search of the English language literature for articles published on “SEAP flap”. Reference lists of the articles found were then checked for other related articles of interest. Articles were compared looking at flap indication, preoperative imaging, perforator morphology, SEA integument area, surgical approach, and outcome of the flaps. Results The four best perforators were most frequently encountered in an area 2 to 6 cm from the midline and 0 to 10 cm below the xiphoid process. The territory of the SEAPs depends on the location of the perforator. Controversy exists in the current literature concerning preferable SEAP flap orientation. Although tip necrosis is the major complication, this can often be treated conservatively without affecting outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint between the xiphisternum and the umbilicus. Conclusion The SEAP flap provides a useful approach for reconstruction of defects of the anterior chest, or of the abdominal wall. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, and spares donor site morbidity.
In anterior chest wall reconstruction, the most commonly used pedicled muscle flaps are the latissimus dorsi, pectoralis major, and rectus abdominis.1–3 The omentum makes an excellent option for soft tissue reconstruction of poorly vascularized wound beds in that area but has potential intra-abdominal complications, therefore increasing the risk associated with harvesting of this flap.4 To reduce donor site morbidity in anterior chest wall reconstruction, efforts have been made to spare the rectus abdominis (RA) muscle and/or the fascia.5,6 However, it still involves sacrifice of a
segment of RA muscle. In our department, myocutaneous flaps have been progressively replaced by perforator flaps, which spare the whole muscle and fascia, for the repair of contour defects and extensive skin–fat replacement. Similarly, as deep inferior epigastric artery perforator (DIEAP) flaps that evolved from the transverse rectus abdominis myocutaneous (TRAM) flap, a flap based on perforators of the superior epigastric artery (SEA) was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction and presented in our previous publication in 2009.7
received February 24, 2014 accepted March 4, 2014 published online June 9, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1376399. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Superior Epigastric Artery Perforator Flap: Anatomy, Clinical Applications, and Review of Literature
WSRM Special Topic Issue: Flaps, Flaps, Flaps
Hamdi et al.
These perforators have been used in the past as the basis for vertical and TRAM flaps,8–11 and for thoracoepigastric fasciocutaneous flaps.12 Bohmert13 and Lejour and De Mey14 both described the use of pedicled epigastric flaps based on branches from the SEA.
of interest. Articles were compared looking at flap indication, preoperative imaging, perforator morphology, SEA integument area, surgical approach, and outcome of the flaps.
Results Anatomical Studies
Materials and Methods We combined our anatomical and clinical experience with SEAP flap with a PubMed search of the English language literature for articles published on “SEAP flap” (superior epigastric artery perforator flap). Reference lists of the articles found were then checked for other related articles
According to previous anatomical studies,8,9,15 the SEA continues inferiorly along the same line as the internal thoracic artery and may send a large superficial branch (diameter 1.0 mm) through the origin of the RA muscle to supply the overlying skin. Manchot16 originally described this branch as the superficial SEA. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
476
Fig. 1 A 76-year-old male patient who developed an infected sternal wound postoperatively after coronary artery bypass graft surgery. Despite multiple debridements, the patient developed a chronic fistula. A pedicled superior epigastric artery perforator (SEAP) was planned using a multidetector computed tomography. (A) The wound after debridement and the SEAP flap design based on the computed tomographic findings. A dominant SEAP was found at the right side. The flap (20 8 cm 2 ) was designed parallel to the subcostal area. (B) An anterior incision was used to explore the perforator. (C) The rectus abdominis fascia was incised and the perforator was freed up to the main pedicle (SEAP). (D–F) the flap was rotated in propeller way to reach the defect. (G) Complete wound closure was done with primary closure of the donor site. Journal of Reconstructive Microsurgery
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10, 10–15, and 5–20 cm) on the Y-axis. Their findings were recently confirmed in a cadaver study by Schmidt et al17: emerging perforators with a calibre of > 0.5 mm were most frequently encountered in an area 2 to 6 cm from the midline and 0 to 10 cm below the xiphoid process. The reference point
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
The total number, calibre, and localization and branching of the perforators were evaluated by Hamdi et al.7 The distribution of the four best perforators—the dominant perforators— in each patient was then evaluated within four zones (0–5, 5–
Hamdi et al.
Fig. 2 A 71-year-old female patient presented with major fat necrosis after a pedicled latissimus dorsi flap was used for partial breast reconstruction. A pedicled superior epigastric artery perforator (SEAP) flap was planned based on the multidetector computed tomography (MDCT) exam. (A, B) Preoperative views. (C, D) The MCDT images show two large SEAP originating from the right pedicle. (E) A SEAP flap was vertically designed (27 7 cm2 ). (F) The debridement of the fat necrosis within the right breast. (G) The more distal SEAP was dissected. (H) The flap was transferred to the defect with primary closure of the donor site. (I) The result at 1 year postoperatively with complete wound healing. Journal of Reconstructive Microsurgery
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Hamdi et al.
used by Hamdi et al7 was more cranial: namely, at the junction between sternal body and the xyphoid bone. The mean external diameter of the perforators in the Schmidt et al study17 were somewhat smaller in diameter compared with what Hamdi et al7 and Mah et al18 who found both studied SEAP anatomy by using multidetector row computed tomographic scans (MDCT). In CT scans, however, vessel diameter is very often overestimated because of the partial volume effect. Every dissected perforator was accompanied by a minimum of one single vein. Two accompanying veins were present in 11% of perforators.
Superior Epigastric Artery Integument Area SEA integument area measured 150 40 cm2 according to Offman et al19 and 65 31.4 cm2 according to Schmidt et al17 although in vivo dynamic perforasomes might be even larger (21 12 cm2) as demonstrated by Ziegler et al.20 The area seemed to stop two fingers above the umbilicus with an oblique extension toward the breast axis.7 Necrosis can occur at the distal end of the flap caudal to the umbilicus due to venous congestion, possibly because of imbalanced choke vessel communication with the DIEA system around the umbilicus, or with that of the intercostal arteries.7,21 The territory of the SEAP depends on the location of the perforator; for example, a SEAP flap that is based on a perforator located 2 to 3 cm superior to the umbilicus can be extended caudally beyond the umbilicus. On the contrary, a flap that is based on SEAP that is located higher up may not be able to carry a flap extending beyond the umbilicus. Mah et al18 has shown that the linea semilunaris is the lateral limit for supply by deep SEAPs, however, this may be extended using delay.12 Lateral to this, posterior intercostal arteries provide the principal blood supply, and this is the zone (particularly lateral to the anterior axillary line) that has contributed to flap tip necrosis in our series.7 Similarly, the zone below the midpoint between the xiphoid process and the umbilicus is supplied primarily by DIEAP, which has contributed to tip necrosis in the vertical deep SEAP flap.7,21 Controversy exists in the current literature concerning preferable SEAP flap orientation. Distal flap necrosis has been reported specifically in vertically designed SEAP flaps.7,21,22The Schmidt et al study17 corroborates that a mediolateral orientation of subcostal SEAP angiosomes yields
better outcomes than a craniocaudal direction. This is in agreement with Boyd et al8 who studied the vascular territory of the SEA and DIEA in detail in 1983. The SEA connects to the DIEA in a watershed area midway between the xyphoid process and the umbilicus. A vertically oriented SEAP flap design reaching supraumbilical skin will include neighboring DIEAP angiosomes supplied by at least two choke anastomoses, thus predisposing for distal flap vascular compromise. Consequently, a vertical SEAP flap design extending into the periumbilical region with the nourishing perforator located far proximally in the substernal region might lead to distal flap necrosis. Thus, a vertical flap design might be safer for more caudally located perforators or reduced vertical flap length. A similar situation is found with the skin paddle of the musculocutaneous gracilis flap. Whereas in the initial description of this flap the vertically oriented skin island was prone to tip necrosis, the change to a transverse orientation resulted in safer and wider field of application.23 Thus, a transversely oriented SEAP flap based on infraxyphoidal/subcostally emerging perforators seems to be of special clinical interest.
Surgical Technique Flap Planning Flap planning based on hand-held doppler examination is possible,20 although exact delineation of the perforator by CT helps in more rapid dissection of the flap. Multidetector computed tomography (MDCT)–based imaging has provided detailed information on the quality, course, and localization in three-dimensional images of the perforators. The high sensitivity and specificity make it possible to select the preferred perforator preoperatively, effectively improving surgical strategy and reducing operating time and postoperative complications.24 Hamdi et al7 recommend using the MDCT for salvage cases (e.g., ►Figs. 1 and 2) where perforators could be injured after harvesting a DIEAP flap with abdominal skin undermining. A transversely oriented skin island based on the SEAPs can be designed to cross the midline. The flap’s arc of rotation easily reaches the lower half of the anterior chest wall and the upper half of the abdominal wall. Controversy exists in the current literature concerning preferable SEAP flap
Table 1 Indications for SEAP flaps in published clinical studies Author
Patient n
Uemura 200721
3
Mah et al 200918
3
Hamdi et al 20097
7
3
Woo et al 201025
1
1
1
1
1
1
Ziegler et al 2011 Oni et al 2011
26
20
Trauma
Tumor (primary or recurrence)
Infection sternum
1
2 3 (after CABG) 1 recurrent presternal keloid with chronic fistula
Abbreviations: CABG, coronary artery bypass graft; IMA, internal mammary artery. Journal of Reconstructive Microsurgery
(Radio) necrosis sternum
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3
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0/1
479
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Abbreviation: MDCT, multidetector computed tomography. No. 7/2014
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0/1 Not specified 1 Partial used of FTG 12 20 cm2 Handheld doppler Ziegler et al 201120
1
0/1 0/1 Not specified Not specified Primary 38 15 cm2 Handheld doppler Oni et al 201126
1 (2 flaps)
0/1 0/1 Not specified 1 Primary 20 10 cm2 Handheld doppler þ MDCT Woo et al 201025
1
0/7 2/7 110 (range, 55– 120) 1 Primary 21.7 6.7 cm 2 Handheld doppler þ MDCT Hamdi et al 20097
7
0/3 2/3 Operation time: 80 Not specified Primary Not specified Handheld doppler þ MDCT
3
Hamdi et al.
Mah et al 200918
1/3 Not specified 2 Primary Handheld doppler Uemura 200721
Patient number
The first anatomic studies of the superior epigastric vascular system were performed by Boyd et al8 in 1984, Taylor and Palmer9 in 1987, Taylor15 in 2003, and Miller et al10 in 1988. Hallock22 was the first to describe a perforator flap based on the SEA. The vascular bases of the SEAP flap and its clinical applications have been evaluated by means of CT angiography scans by Hamdi et al.7 According to these findings7 and supported by Morris et al,27 the superficial branch pierces the rectus fascia directly under the xiphoid toward the skin. Flaps based on the superficial branch have therefore a reasonably short pedicle length but are still very useful for coverage of presternal defects. The main trunk of the SEA (or the so-calledDSEA) enters the RA muscle on its deep surface, approximately 7 cm below the costal margin. Several perforators arise from the branches of the SEA, usually just below the costal margin up to the second tendineous intersection that is situated midway between the costal margin and the umbilicus. The perforators pierce the rectus muscle or sometimes pierce the sheath beside the lateral border of the muscle. Similar findings were reported by Morris et al.27 The artery subdivides into several branches that arborize further to anastomose inferiorly with the DIEA, and laterally with terminal branches of the intercostal arteries. The MDCT can easily
Preop imaging
Discussion
Table 2 SEAP flap planning, surgery and outcome in published clinical studies
The indications for SEAP flaps in the six clinical studies are given in ►Table 1. Abbreviations used are: coronary artery bypass graft and internal mammary artery (IMA). The average flap dimension, number of perforators used, and mean harvesting time in these studies are outlined in ►Table 2.
Author
Flap Outcome
Average flap dimension
Donor site closure
N perforators per flap
Mean harvesting time (min)
We prefer to approach the perforator from the ipsilateral side suprafascially until the perforator is encountered.7 Mah et al18 raised the transverse flap from lateral to medial, at the level of the anterior rectus sheath. He incises the anterior rectus sheath to provide adequate release for reaching the defect. The SEAP usually have a suprafascial course above the deep fascia for 1 to 3 cm. We therefore recommend to open the deep fascia only where the perforator pierces it. RA muscle fibers are then split and the perforator dissection is performed in standard way by clipping or coagulating the side branches until the main pedicle is reached. Dissection of the superior epigastric vessels is performed up to their exit under the rib edge. The flap is transferred into the defect as a V–Y transposition or as a rotation flap. The deep fascia is closed primarily with a braided nonabsorbable running matrass suture and the donor site is closed primarily in layers after limited skin edge undermining, under closed suction drainage.7,18
22.2 6 cm2
Flap Harvesting
3
Distal tip necrosis
Flap failure
orientation, since distal flap necrosis has been reported, especially in vertically designed SEAP flaps.20–22 This design can be used for more caudally located perforators or if moderate flap length is needed. Depending on the skin laxity and indication, the flaps are designed vertically on the paramedian region, or transversely under the inframammary fold or from the midline at the lower edge of the defect.18
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distinguish between perforators arising from the DSEA and those arising from the intercostal or even those from the costomarginal artery, which branches out of the lateral division of the DSEA and its anastomosis with the eighth posterior intercostal artery. Thus, several perforator-based flaps can be raised for trunk reconstruction. Although a diameter of 1 mm is considered to be sufficient, one should be cautious because this diameter is very often slightly overestimated because of the partial volume effect. The veins cannot be seen distally. Up to date, only a handful of cadaver, anatomical, and clinical application studies have been performed. The results of these studies however corroborate, and have contributed to our knowledge of the vascular anatomy of the deep SEA, and may make it as useful as its neighbor the DIEA. More specifically, it can be used for reconstruction of breast, sternal, and abdominal wall defects without disrupting the muscular continuity of the abdominal wall. Deep SEA–based adipocutaneous flaps offer an attractive alternative in sternal wound coverage. In patients with an intact internal mammary artery–deep SEA vascular axis, the use of this flap maintains future use of RA or pectoralis major myocutaneous flaps. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, with reduced donor site morbidity related to muscle harvest or laparotomy. From our experience with the DIEAP flap, we know that a safe length of a perforator flap depends on many factors such as perforator diameter, location, and orientation in the soft tissue. Although tip necrosis is the major complication,7,18 this can often be treated conservatively without affecting outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint between the xiphisternum and the umbilicus.
Conclusion
2 Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of
500 consecutive patients. Plast Reconstr Surg 1996;98(5):804–810 3 Shibata T, Hattori K, Hirai H, Fujii H, Aoyama T, Seuhiro S. Rectus
4
5
6
7
8
9
10
11
12
13
14
Our clinical experience indicates that the SEAP flap provides a useful approach for reconstruction of defects of the anterior chest wall or breast reconstruction, or for abdominal wall reconstructive purposes. CT-based imaging allows for assessment of the perforators of the SEA. Moreover, MDCT scan improves preoperative planning in salvage cases. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, and spares donor site morbidity related to muscle harvest or laparotomy. Although tip necrosis is quite often seen, this can often be treated conservatively or even be avoided by either limiting flap length, or by transverse orientation of the flap.
15 16 17
18
19
20
Disclosure The authors have no financial interest in any medical device or product mentioned in this article.
21 22
References
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1 Chang RR, Mehrara BJ, Hu QY, Disa JJ, Cordeiro PG. Reconstruction
of complex oncologic chest wall defects: a 10-year experience. Ann Plast Surg 2004;52(5):471–479, discussion 479 Journal of Reconstructive Microsurgery
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abdominis myocutaneous flap after unsuccessful delayed sternal closure. Ann Thorac Surg 2003;76(3):956–958 Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results. Ann Plast Surg 2001;46(3):242–249 Erni D, Harder YD. The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath. Br J Plast Surg 2003;56(4):395–400 Clugston PA, Gingrass MK, Azurin D, Fisher J, Maxwell GP. Ipsilateral pedicled TRAM flaps: the safer alternative? Plast Reconstr Surg 2000;105(1):77–82 Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62(9):1127–1134 Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73(1):1–16 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40(2):113–141 Miller LB, Bostwick J III, Hartrampf CR Jr, Hester TR Jr, Nahai F. The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study. Plast Reconstr Surg 1988;81(5):713–724 Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82(5):815–832 Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for recurrent breast cancer. Plast Reconstr Surg 1974;53(1):52–54 Bohmert H. Experience in breast reconstruction with thoracoepigastric and advancement flaps. Acta Chir Belg 1980;79(2): 105–110 Lejour M, De Mey A. Experience with 33 epigastric rectus flaps in breast reconstruction. Handchir Mikrochir Plast Chir 1983;15(4): 257–260 Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30(3):331–342, v Manchot K. Die Hautarterien des Meslichen Korpers. Leipzig: FCW Vogel; 1889 Schmidt M, Tinhofer I, Duscher D, Huemer GM. Perforasomes of the upper abdomen: an anatomical study. J Plast Reconstr Aesthet Surg 2014;67(1):42–47 Mah E, Rozen WM, Ashton MW, Flood S. Deep superior epigastric artery perforators: anatomical study and clinical application in sternal reconstruction. Plast Reconstr Surg 2009;123(6): 1719–1723 Offman SL, Geddes CR, Tang M, Morris SF. The vascular basis of perforator flaps based on the source arteries of the lateral lumbar region. Plast Reconstr Surg 2005;115(6):1651–1659 Ziegler K, Schmidt M, Huemer GM. A pedicled superior epigastric artery perforator (SEAP-) propeller flap for 2-cavity reconstruction after oncologic rib resection. Microsurgery 2011;31(4): 335–336 Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120(1):1e–5e Hallock GG. The superior epigastric (RECTUS ABDOMINIS) muscle perforator flap. Ann Plast Surg 2005;55(4):430– 432 Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008;122(1): 29–38
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26 Oni G, Sharma R, Rao R, Unger J, Saint-Cyr M. Bilateral superior
detector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006;59(6):594–599 25 Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ’propeller’ flap for abdominal wall reconstruction: A case report. J Plast Reconstr Aesthet Surg 2010; 63(7):1223–1226
epigastric pedicle perforator flaps for total chest wall coverage. J Plast Reconstr Aesthet Surg 2011;64(8):1104–1107 27 Geddes CR, Tang M, Yang D, et al. Anatomy of the integument of the trunk. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, ed. Perforator flaps, anatomy, technique & clinical application. St. Louis, MO: Quality Medical Publishing; 2013;443:e68
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
24 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multi-
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475
Moustapha Hamdi, MD, PhD1 Barbara Craggs, MD1 Benoit Hendrickx, MD, PhD1 Assaf Zeltzer, MD1
Anne-Marie Stoel, MD1
1 Department of Plastic and Reconstructive Surgery, UZ Brussel,
Address for correspondence Moustapha Hamdi, MD, PhD, Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Laarbeeklaan 101, Brussels 1090, Belgium (e-mail: [email protected]).
Jette, Belgium J Reconstr Microsurg 2014;30:475–482.
Abstract
Keywords
► perforator flap ► superior epigastric artery perforator flap ► chest wall reconstruction
Introduction To reduce donor site morbidity in anterior chest wall reconstruction, a flap based on perforators of the superior epigastric artery (SEA) was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction. Materials and Methods We combined our anatomical and clinical experience with superior epigastric artery perforator (SEAP) flap with a PubMed search of the English language literature for articles published on “SEAP flap”. Reference lists of the articles found were then checked for other related articles of interest. Articles were compared looking at flap indication, preoperative imaging, perforator morphology, SEA integument area, surgical approach, and outcome of the flaps. Results The four best perforators were most frequently encountered in an area 2 to 6 cm from the midline and 0 to 10 cm below the xiphoid process. The territory of the SEAPs depends on the location of the perforator. Controversy exists in the current literature concerning preferable SEAP flap orientation. Although tip necrosis is the major complication, this can often be treated conservatively without affecting outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint between the xiphisternum and the umbilicus. Conclusion The SEAP flap provides a useful approach for reconstruction of defects of the anterior chest, or of the abdominal wall. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, and spares donor site morbidity.
In anterior chest wall reconstruction, the most commonly used pedicled muscle flaps are the latissimus dorsi, pectoralis major, and rectus abdominis.1–3 The omentum makes an excellent option for soft tissue reconstruction of poorly vascularized wound beds in that area but has potential intra-abdominal complications, therefore increasing the risk associated with harvesting of this flap.4 To reduce donor site morbidity in anterior chest wall reconstruction, efforts have been made to spare the rectus abdominis (RA) muscle and/or the fascia.5,6 However, it still involves sacrifice of a
segment of RA muscle. In our department, myocutaneous flaps have been progressively replaced by perforator flaps, which spare the whole muscle and fascia, for the repair of contour defects and extensive skin–fat replacement. Similarly, as deep inferior epigastric artery perforator (DIEAP) flaps that evolved from the transverse rectus abdominis myocutaneous (TRAM) flap, a flap based on perforators of the superior epigastric artery (SEA) was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction and presented in our previous publication in 2009.7
received February 24, 2014 accepted March 4, 2014 published online June 9, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1376399. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Superior Epigastric Artery Perforator Flap: Anatomy, Clinical Applications, and Review of Literature
WSRM Special Topic Issue: Flaps, Flaps, Flaps
Hamdi et al.
These perforators have been used in the past as the basis for vertical and TRAM flaps,8–11 and for thoracoepigastric fasciocutaneous flaps.12 Bohmert13 and Lejour and De Mey14 both described the use of pedicled epigastric flaps based on branches from the SEA.
of interest. Articles were compared looking at flap indication, preoperative imaging, perforator morphology, SEA integument area, surgical approach, and outcome of the flaps.
Results Anatomical Studies
Materials and Methods We combined our anatomical and clinical experience with SEAP flap with a PubMed search of the English language literature for articles published on “SEAP flap” (superior epigastric artery perforator flap). Reference lists of the articles found were then checked for other related articles
According to previous anatomical studies,8,9,15 the SEA continues inferiorly along the same line as the internal thoracic artery and may send a large superficial branch (diameter 1.0 mm) through the origin of the RA muscle to supply the overlying skin. Manchot16 originally described this branch as the superficial SEA. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
476
Fig. 1 A 76-year-old male patient who developed an infected sternal wound postoperatively after coronary artery bypass graft surgery. Despite multiple debridements, the patient developed a chronic fistula. A pedicled superior epigastric artery perforator (SEAP) was planned using a multidetector computed tomography. (A) The wound after debridement and the SEAP flap design based on the computed tomographic findings. A dominant SEAP was found at the right side. The flap (20 8 cm 2 ) was designed parallel to the subcostal area. (B) An anterior incision was used to explore the perforator. (C) The rectus abdominis fascia was incised and the perforator was freed up to the main pedicle (SEAP). (D–F) the flap was rotated in propeller way to reach the defect. (G) Complete wound closure was done with primary closure of the donor site. Journal of Reconstructive Microsurgery
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10, 10–15, and 5–20 cm) on the Y-axis. Their findings were recently confirmed in a cadaver study by Schmidt et al17: emerging perforators with a calibre of > 0.5 mm were most frequently encountered in an area 2 to 6 cm from the midline and 0 to 10 cm below the xiphoid process. The reference point
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
The total number, calibre, and localization and branching of the perforators were evaluated by Hamdi et al.7 The distribution of the four best perforators—the dominant perforators— in each patient was then evaluated within four zones (0–5, 5–
Hamdi et al.
Fig. 2 A 71-year-old female patient presented with major fat necrosis after a pedicled latissimus dorsi flap was used for partial breast reconstruction. A pedicled superior epigastric artery perforator (SEAP) flap was planned based on the multidetector computed tomography (MDCT) exam. (A, B) Preoperative views. (C, D) The MCDT images show two large SEAP originating from the right pedicle. (E) A SEAP flap was vertically designed (27 7 cm2 ). (F) The debridement of the fat necrosis within the right breast. (G) The more distal SEAP was dissected. (H) The flap was transferred to the defect with primary closure of the donor site. (I) The result at 1 year postoperatively with complete wound healing. Journal of Reconstructive Microsurgery
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used by Hamdi et al7 was more cranial: namely, at the junction between sternal body and the xyphoid bone. The mean external diameter of the perforators in the Schmidt et al study17 were somewhat smaller in diameter compared with what Hamdi et al7 and Mah et al18 who found both studied SEAP anatomy by using multidetector row computed tomographic scans (MDCT). In CT scans, however, vessel diameter is very often overestimated because of the partial volume effect. Every dissected perforator was accompanied by a minimum of one single vein. Two accompanying veins were present in 11% of perforators.
Superior Epigastric Artery Integument Area SEA integument area measured 150 40 cm2 according to Offman et al19 and 65 31.4 cm2 according to Schmidt et al17 although in vivo dynamic perforasomes might be even larger (21 12 cm2) as demonstrated by Ziegler et al.20 The area seemed to stop two fingers above the umbilicus with an oblique extension toward the breast axis.7 Necrosis can occur at the distal end of the flap caudal to the umbilicus due to venous congestion, possibly because of imbalanced choke vessel communication with the DIEA system around the umbilicus, or with that of the intercostal arteries.7,21 The territory of the SEAP depends on the location of the perforator; for example, a SEAP flap that is based on a perforator located 2 to 3 cm superior to the umbilicus can be extended caudally beyond the umbilicus. On the contrary, a flap that is based on SEAP that is located higher up may not be able to carry a flap extending beyond the umbilicus. Mah et al18 has shown that the linea semilunaris is the lateral limit for supply by deep SEAPs, however, this may be extended using delay.12 Lateral to this, posterior intercostal arteries provide the principal blood supply, and this is the zone (particularly lateral to the anterior axillary line) that has contributed to flap tip necrosis in our series.7 Similarly, the zone below the midpoint between the xiphoid process and the umbilicus is supplied primarily by DIEAP, which has contributed to tip necrosis in the vertical deep SEAP flap.7,21 Controversy exists in the current literature concerning preferable SEAP flap orientation. Distal flap necrosis has been reported specifically in vertically designed SEAP flaps.7,21,22The Schmidt et al study17 corroborates that a mediolateral orientation of subcostal SEAP angiosomes yields
better outcomes than a craniocaudal direction. This is in agreement with Boyd et al8 who studied the vascular territory of the SEA and DIEA in detail in 1983. The SEA connects to the DIEA in a watershed area midway between the xyphoid process and the umbilicus. A vertically oriented SEAP flap design reaching supraumbilical skin will include neighboring DIEAP angiosomes supplied by at least two choke anastomoses, thus predisposing for distal flap vascular compromise. Consequently, a vertical SEAP flap design extending into the periumbilical region with the nourishing perforator located far proximally in the substernal region might lead to distal flap necrosis. Thus, a vertical flap design might be safer for more caudally located perforators or reduced vertical flap length. A similar situation is found with the skin paddle of the musculocutaneous gracilis flap. Whereas in the initial description of this flap the vertically oriented skin island was prone to tip necrosis, the change to a transverse orientation resulted in safer and wider field of application.23 Thus, a transversely oriented SEAP flap based on infraxyphoidal/subcostally emerging perforators seems to be of special clinical interest.
Surgical Technique Flap Planning Flap planning based on hand-held doppler examination is possible,20 although exact delineation of the perforator by CT helps in more rapid dissection of the flap. Multidetector computed tomography (MDCT)–based imaging has provided detailed information on the quality, course, and localization in three-dimensional images of the perforators. The high sensitivity and specificity make it possible to select the preferred perforator preoperatively, effectively improving surgical strategy and reducing operating time and postoperative complications.24 Hamdi et al7 recommend using the MDCT for salvage cases (e.g., ►Figs. 1 and 2) where perforators could be injured after harvesting a DIEAP flap with abdominal skin undermining. A transversely oriented skin island based on the SEAPs can be designed to cross the midline. The flap’s arc of rotation easily reaches the lower half of the anterior chest wall and the upper half of the abdominal wall. Controversy exists in the current literature concerning preferable SEAP flap
Table 1 Indications for SEAP flaps in published clinical studies Author
Patient n
Uemura 200721
3
Mah et al 200918
3
Hamdi et al 20097
7
3
Woo et al 201025
1
1
1
1
1
1
Ziegler et al 2011 Oni et al 2011
26
20
Trauma
Tumor (primary or recurrence)
Infection sternum
1
2 3 (after CABG) 1 recurrent presternal keloid with chronic fistula
Abbreviations: CABG, coronary artery bypass graft; IMA, internal mammary artery. Journal of Reconstructive Microsurgery
(Radio) necrosis sternum
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0/1
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Abbreviation: MDCT, multidetector computed tomography. No. 7/2014
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0/1 Not specified 1 Partial used of FTG 12 20 cm2 Handheld doppler Ziegler et al 201120
1
0/1 0/1 Not specified Not specified Primary 38 15 cm2 Handheld doppler Oni et al 201126
1 (2 flaps)
0/1 0/1 Not specified 1 Primary 20 10 cm2 Handheld doppler þ MDCT Woo et al 201025
1
0/7 2/7 110 (range, 55– 120) 1 Primary 21.7 6.7 cm 2 Handheld doppler þ MDCT Hamdi et al 20097
7
0/3 2/3 Operation time: 80 Not specified Primary Not specified Handheld doppler þ MDCT
3
Hamdi et al.
Mah et al 200918
1/3 Not specified 2 Primary Handheld doppler Uemura 200721
Patient number
The first anatomic studies of the superior epigastric vascular system were performed by Boyd et al8 in 1984, Taylor and Palmer9 in 1987, Taylor15 in 2003, and Miller et al10 in 1988. Hallock22 was the first to describe a perforator flap based on the SEA. The vascular bases of the SEAP flap and its clinical applications have been evaluated by means of CT angiography scans by Hamdi et al.7 According to these findings7 and supported by Morris et al,27 the superficial branch pierces the rectus fascia directly under the xiphoid toward the skin. Flaps based on the superficial branch have therefore a reasonably short pedicle length but are still very useful for coverage of presternal defects. The main trunk of the SEA (or the so-calledDSEA) enters the RA muscle on its deep surface, approximately 7 cm below the costal margin. Several perforators arise from the branches of the SEA, usually just below the costal margin up to the second tendineous intersection that is situated midway between the costal margin and the umbilicus. The perforators pierce the rectus muscle or sometimes pierce the sheath beside the lateral border of the muscle. Similar findings were reported by Morris et al.27 The artery subdivides into several branches that arborize further to anastomose inferiorly with the DIEA, and laterally with terminal branches of the intercostal arteries. The MDCT can easily
Preop imaging
Discussion
Table 2 SEAP flap planning, surgery and outcome in published clinical studies
The indications for SEAP flaps in the six clinical studies are given in ►Table 1. Abbreviations used are: coronary artery bypass graft and internal mammary artery (IMA). The average flap dimension, number of perforators used, and mean harvesting time in these studies are outlined in ►Table 2.
Author
Flap Outcome
Average flap dimension
Donor site closure
N perforators per flap
Mean harvesting time (min)
We prefer to approach the perforator from the ipsilateral side suprafascially until the perforator is encountered.7 Mah et al18 raised the transverse flap from lateral to medial, at the level of the anterior rectus sheath. He incises the anterior rectus sheath to provide adequate release for reaching the defect. The SEAP usually have a suprafascial course above the deep fascia for 1 to 3 cm. We therefore recommend to open the deep fascia only where the perforator pierces it. RA muscle fibers are then split and the perforator dissection is performed in standard way by clipping or coagulating the side branches until the main pedicle is reached. Dissection of the superior epigastric vessels is performed up to their exit under the rib edge. The flap is transferred into the defect as a V–Y transposition or as a rotation flap. The deep fascia is closed primarily with a braided nonabsorbable running matrass suture and the donor site is closed primarily in layers after limited skin edge undermining, under closed suction drainage.7,18
22.2 6 cm2
Flap Harvesting
3
Distal tip necrosis
Flap failure
orientation, since distal flap necrosis has been reported, especially in vertically designed SEAP flaps.20–22 This design can be used for more caudally located perforators or if moderate flap length is needed. Depending on the skin laxity and indication, the flaps are designed vertically on the paramedian region, or transversely under the inframammary fold or from the midline at the lower edge of the defect.18
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distinguish between perforators arising from the DSEA and those arising from the intercostal or even those from the costomarginal artery, which branches out of the lateral division of the DSEA and its anastomosis with the eighth posterior intercostal artery. Thus, several perforator-based flaps can be raised for trunk reconstruction. Although a diameter of 1 mm is considered to be sufficient, one should be cautious because this diameter is very often slightly overestimated because of the partial volume effect. The veins cannot be seen distally. Up to date, only a handful of cadaver, anatomical, and clinical application studies have been performed. The results of these studies however corroborate, and have contributed to our knowledge of the vascular anatomy of the deep SEA, and may make it as useful as its neighbor the DIEA. More specifically, it can be used for reconstruction of breast, sternal, and abdominal wall defects without disrupting the muscular continuity of the abdominal wall. Deep SEA–based adipocutaneous flaps offer an attractive alternative in sternal wound coverage. In patients with an intact internal mammary artery–deep SEA vascular axis, the use of this flap maintains future use of RA or pectoralis major myocutaneous flaps. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, with reduced donor site morbidity related to muscle harvest or laparotomy. From our experience with the DIEAP flap, we know that a safe length of a perforator flap depends on many factors such as perforator diameter, location, and orientation in the soft tissue. Although tip necrosis is the major complication,7,18 this can often be treated conservatively without affecting outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint between the xiphisternum and the umbilicus.
Conclusion
2 Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of
500 consecutive patients. Plast Reconstr Surg 1996;98(5):804–810 3 Shibata T, Hattori K, Hirai H, Fujii H, Aoyama T, Seuhiro S. Rectus
4
5
6
7
8
9
10
11
12
13
14
Our clinical experience indicates that the SEAP flap provides a useful approach for reconstruction of defects of the anterior chest wall or breast reconstruction, or for abdominal wall reconstructive purposes. CT-based imaging allows for assessment of the perforators of the SEA. Moreover, MDCT scan improves preoperative planning in salvage cases. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, and spares donor site morbidity related to muscle harvest or laparotomy. Although tip necrosis is quite often seen, this can often be treated conservatively or even be avoided by either limiting flap length, or by transverse orientation of the flap.
15 16 17
18
19
20
Disclosure The authors have no financial interest in any medical device or product mentioned in this article.
21 22
References
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abdominis myocutaneous flap after unsuccessful delayed sternal closure. Ann Thorac Surg 2003;76(3):956–958 Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results. Ann Plast Surg 2001;46(3):242–249 Erni D, Harder YD. The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath. Br J Plast Surg 2003;56(4):395–400 Clugston PA, Gingrass MK, Azurin D, Fisher J, Maxwell GP. Ipsilateral pedicled TRAM flaps: the safer alternative? Plast Reconstr Surg 2000;105(1):77–82 Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62(9):1127–1134 Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73(1):1–16 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40(2):113–141 Miller LB, Bostwick J III, Hartrampf CR Jr, Hester TR Jr, Nahai F. The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study. Plast Reconstr Surg 1988;81(5):713–724 Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82(5):815–832 Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for recurrent breast cancer. Plast Reconstr Surg 1974;53(1):52–54 Bohmert H. Experience in breast reconstruction with thoracoepigastric and advancement flaps. Acta Chir Belg 1980;79(2): 105–110 Lejour M, De Mey A. Experience with 33 epigastric rectus flaps in breast reconstruction. Handchir Mikrochir Plast Chir 1983;15(4): 257–260 Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30(3):331–342, v Manchot K. Die Hautarterien des Meslichen Korpers. Leipzig: FCW Vogel; 1889 Schmidt M, Tinhofer I, Duscher D, Huemer GM. Perforasomes of the upper abdomen: an anatomical study. J Plast Reconstr Aesthet Surg 2014;67(1):42–47 Mah E, Rozen WM, Ashton MW, Flood S. Deep superior epigastric artery perforators: anatomical study and clinical application in sternal reconstruction. Plast Reconstr Surg 2009;123(6): 1719–1723 Offman SL, Geddes CR, Tang M, Morris SF. The vascular basis of perforator flaps based on the source arteries of the lateral lumbar region. Plast Reconstr Surg 2005;115(6):1651–1659 Ziegler K, Schmidt M, Huemer GM. A pedicled superior epigastric artery perforator (SEAP-) propeller flap for 2-cavity reconstruction after oncologic rib resection. Microsurgery 2011;31(4): 335–336 Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120(1):1e–5e Hallock GG. The superior epigastric (RECTUS ABDOMINIS) muscle perforator flap. Ann Plast Surg 2005;55(4):430– 432 Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008;122(1): 29–38
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detector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006;59(6):594–599 25 Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ’propeller’ flap for abdominal wall reconstruction: A case report. J Plast Reconstr Aesthet Surg 2010; 63(7):1223–1226
epigastric pedicle perforator flaps for total chest wall coverage. J Plast Reconstr Aesthet Surg 2011;64(8):1104–1107 27 Geddes CR, Tang M, Yang D, et al. Anatomy of the integument of the trunk. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, ed. Perforator flaps, anatomy, technique & clinical application. St. Louis, MO: Quality Medical Publishing; 2013;443:e68
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24 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multi-
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