Understanding the vascular anatomy of zone IV in DIEA perforator flaps a review of the literature and anatomical studies

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Felicity V Connon
G Ian Taylor AO
Adam C Gascoigne
Russell Corlett
Mark W Ashton


epigastric arteries, mammaplasty, perforator flap, drainage, fascia, abdominal wall


Introduction: Due to a longstanding controversy over the perfusion reliability of zone IV current this area is routinely discarded despite the mechanism behind zone IV necrosis not being fully understood. The authors review and investigate the vascular anatomy of zone IV with the aim of outlining the reasons for necrosis.

Methods: A literature search and review of archival injection studies performed by the authors was undertaken to identify the arterial and venous maps of the abdomen. Unembalmed abdominal wall and full body specimens were used for cadaveric studies to demonstrate the arterial anastomotic patterns and venous drainage pathways of the deep inferior epigastric, superficial inferior epigastric, superficial circumflex iliac and intercostal systems.

Results: Cadaveric injection studies demonstrated the presence of true and choke anastomoses between all lower abdominal arterial branch systems. Venous studies found that the dominant venous drainage is through large caliber superficial epigastric and circumflex iliac veins, a system which is interrupted in flap elevation and redirected to the perforator venae comitantes, with inter-territory communicating oscillating veins also becoming a limiting factor between territories.

Conclusion: The mechanism behind the common failure of zone IV in the DIEP flap is explained with studies demonstrating both potential arterial and venous limiting factors. The authors conclude that the mechanism is indeed multifactorial, however suggest that when zone IV in DIEP tissue transfer is required, fat below Scarpa’s fascia is excised and the contralateral SIEV is preserved for use as an additional venous anastomosis.

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1. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989; 42(6): 645-648. https://doi.org/10.1016/0007-1226(89)90075-1
2. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994; 32(1): 32-38. https://doi.org/10.1097/00000637-199401000-00007
3. Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010; 30(1): 1-7. https://doi.org/10.1002/micr.20684
4. Wong C, Saint-Cyr M, Mojallal A et al. Perforasomes of the DIEP flap: vascular anatomy of the lateral versus medial row perforators and clinical implications. Plast Reconstr Surg. 2010; 125(3): 772-782. https://doi.org/10.1097/PRS.0b013e3181cb63e0 PMid:20195105
5. Scheflan M, Dinner MI. The transverse abdominal island flap. Part I: indications, contraindications, results, and complications. Ann Plast Surg. 1983; 10(1): 24-35. https://doi.org/10.1097/00000637-198301000-00005 PMid:6219607
6. Scheflan M, Dinner MI. The transverse abdominal island flap. Part II: surgical technique. Ann Plast Surg. 1983; 10(2): 120-129. https://doi.org/10.1097/00000637-198302000-00007 PMid:6838117
7. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982; 69(2): 216-225. https://doi.org/10.1097/00006534-198202000-00006 PMid:6459602
8. 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. https://doi.org/10.1016/0007-1226(87)90185-8
9. Dinner MI, Dowden RV, Scheflan M. Refinements in the use of thetransverse abdominal island flap for postmastectomy reconstruction. Ann Plast Surg. 1983; 11(5): 362-372. https://doi.org/10.1097/00000637-198311000-00002
10. Holm C, Mayr M, Höfter E, Ninkovic M, Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006; 117(1): 37-43. https://doi.org/10.1097/01.prs.0000185867.84172.c0
11. Gill PS, Hunt JP, Guerra AB et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004; 113(4): 1153-1160. https://doi.org/10.1097/01.PRS.0000110328.47206.50
12. Cheng MH, Robles JA, Ulusal BG, Wei FC. Reliability of zone IV in the deep inferior epigastric perforator flap: a single center's experience with 74 cases. Breast 2006; 15(2): 158-166. https://doi.org/10.1016/j.breast.2005.06.006 PMid:16061383
13. Healy C, Ramakrishnan V. Autologous microvascular breast reconstruction. Arch Plast Surg. 2013; 40(1): 3-10. https://doi.org/10.5999/aps.2013.40.1.3 PMid:23362474 PMCid:PMC3556531
14. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg. 1999; 52(2): 104-111. https://doi.org/10.1054/bjps.1998.3033
15. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg. 2011; 127(4): 1447-1459. https://doi.org/10.1097/PRS.0b013e318208d21b
16. Schaverien M, Saint-Cyr M, Arbique G, Brown SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg. 2008; 121(6): 1909-1919. https://doi.org/10.1097/PRS.0b013e31817151f8
17. Losken A, Zenn MR, Hammel JA, Walsh MW, Carlson GW. Assessment of zonal perfusion using intraoperative angiography during abdominal flap breast reconstruction. Plast Reconstr Surg. 2012; 129(4): 618e-24e. https://doi.org/10.1097/PRS.0b013e3182450b16
18. Bailey SH, Saint-Cyr M, Wong C et al. The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results. Plast Reconstr Surg. 2010; 126(3): 739-751. https://doi.org/10.1097/PRS.0b013e3181e5f844 PMid:20811209
19. Ireton JE, Lakhiani C, Saint-Cyr M, Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review. Plast Reconstr Surg. 2014; 134(5): 810e-21e. https://doi.org/10.1097/PRS.0000000000000625
20. Heitmann C, Felmerer G, Durmus C, Matejic B, Ingianni G. Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg. 2000; 53(3): 205-208. https://doi.org/10.1054/bjps.1999.3257
21. Rahmanian-Schwarz A, Rothenberger J, Hirt B, Luz O, Schaller HE. A combined anatomical and clinical study for quantitative analysis of the microcirculation in the classic perfusion zones of the deep inferior epigastric artery perforator flap. Plast Reconstr Surg. 2011; 127(2): 505-513. https://doi.org/10.1097/PRS.0b013e3181fed543 PMid:21285755
22. 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. https://doi.org/10.1097/00006534-198811000-00015
23. Laungani AT, Van Alphen N, Christner JA et al. Three-dimensional CT angiography assessment of the impact of the dermis and the subdermal plexus in DIEP flap perfusion. J Plast Reconstr Aesthet Surg. 2015; 68(4): 525-530. https://doi.org/10.1016/j.bjps.2014.12.004
24. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg. 2006; 59(6): 571-579. https://doi.org/10.1016/j.bjps.2006.01.004
25. Blondeel PN, Arnstein M, Verstraete K. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000; 106(6): 1295-1299. https://doi.org/10.1097/00006534-200011000-00009 PMid:11083558
26. Lie KH, Barker AS, Ashton MW. A classification system for partial and complete DIEP flap necrosis based on a review of 17,096 DIEP flaps in 693 articles including analysis of 152 total flap failures. Plast Reconstr Surg. 2013; 132(6): 1401-1408. https://doi.org/10.1097/01.prs.0000434402.06564.bd PMid:24281570
27. Lie KH, Taylor GI, Ashton MW. Hydrogen peroxide priming of the venous architecture: a new technique that reveals the underlying anatomical basis for venous complications of DIEP, TRAM, and other abdominal flaps. Plast Reconstr Surg. 2014; 133(6): 790e-804e. https://doi.org/10.1097/PRS.0000000000000228
28. Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body: experimental study and clinical implications. Plast Reconstr Surg. 1990; 86(2): 185-213. https://doi.org/10.1097/00006534-199008000-00001 PMid:2367570
29. Rozen WM, Ashton MW. The venous anatomy of the abdominal wall for deep inferior epigastric artery (DIEP) flaps in breast reconstruction. Gland Surg. 2012; 1(2): 92-110.
30. Schaverien MV, Ludman CN, Neil-Dwyer J. Relationship between venous congestion and intraflap venous anatomy in DIEP flaps using contrast-enhanced magnetic resonance angiography. Plast Reconstr Surg. 2010; 126(2): 385-392. https://doi.org/10.1097/PRS.0b013e3181de2313 PMid:20679824
31. Wechselberger G, Schoeller T, Bauer T, Ninkovic M, Otto A, Ninkovic M. Venous superdrainage in deep inferior epigastric perforator flap breast reconstruction. Plast Reconstr Surg. 2001; 108(1): 162-166. https://doi.org/10.1097/00006534-200107000-00026 PMid:11420520
32. Villafane O, Gahankari D, Webster M, Superficial inferior epigastric vein (SIEV): 'lifeboat' for DIEP/TRAM flaps. Br J Plast Surg. 1999; 52(7): 599.
33. Chang H, Minn KW, Imanishi N, Minabe T, Nakajima H. Effect of venous superdrainage on a four-territory skin flap survival in rats. Plast Reconstr Surg. 2007; 119(7): 2046-2051. https://doi.org/10.1097/01.prs.0000260590.44798.9c
34. Van Landuyt K, Blondeel P, Hamdi M, Tonnard P, Verpaele A, Monstrey S. The versatile DIEP flap: its use in lower extremity reconstruction. Br J Plast Surg. 2005; 58(1): 2-13. https://doi.org/10.1016/j.bjps.2004.06.003
35. Rothenberger J, Amr A, Schiefer J, Schaller HE, Rahmanian-Schwarz A. A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein (SIEV) supercharging. J Plast Reconstr Aesthet Surg. 2013; 66(1): 67-72. https://doi.org/10.1016/j.bjps.2012.08.020
36. Smit JM, Audolfsson T, Whitaker IS, Werker PM, Acosta R, Liss AG. Measuring the pressure in the superficial inferior epigastric vein to monitor for venous congestion in deep inferior epigastric artery perforator breast reconstructions: a pilot study. J Reconstr Microsurg. 2010; 26(2): 103-107. https://doi.org/10.1055/s-0029-1243294 PMid:20013590