Chapter 1 abdomen was popularized as a free flap donor site for breast reconstruction. The free TRAM flap based on the inferior epigastric arteries has better perfusion compared with the pedicled tram flap and fewer flap‐related complications, but the donor site morbidity remains a cause of concern.63 Further techniques have been developed to minimize trauma to the rectus muscle and fascia and to preserve its integrity using muscle‐sparing techniques. In 1992, Allan and Treece performed the DIEP flap, where the vascular pedicle is dissected free from the muscle and the fascia is preserved. Because of the reduced donor site morbidity the perforator flap (DIEP) was further popularized.47,49,64 The superficial inferior epigastric artery (SIEA) flap is also a possible abdomen based flap. The SIEA flap can be elevated without incision of the fascia and abdominal wall musculature, therefore eliminating abdominal wall morbidity. However, the SIEA supplies only the ipsilateral lower abdominal skin and subcutaneous tissue. In addition, because SIEAs are inadequate in up to 70% of cases, SIEA flap use is limited. Its concomitant vein, however, can be used for venous augmentation, as discussed in the next section. Because muscle is preserved in the DIEP flap, there is debate that the flap based on one or a few perforators may have decreased perfusion and lead to an increase in flap‐ related complications such as PFL/FN. A recent meta‐analysis from Man et al.56 suggests that in breast reconstruction compared with the free TRAM FLAP the DIEP flap is associated with reduced abdominal wall morbidity but increased flap‐related complications (PFL/FN). Therefore, some surgeons use the muscle‐sparing TRAM flap for patients with risk factors (smoking, large volume reconstruction, and postoperative radiotherapy).56 The problem: fat necrosis and partial flap loss Anatomical considerations In modern reconstructive surgery, flaps are designed to preferably incorporate one angiosome to increase viability and to reduce complications such as PFL. However, in breast reconstructive surgery where more volume is needed, the flap design incorporates several angiosomes in the lower abdomen. FN, PFL, or both are still common problems and are the consequence of the insufficient perfusion of the distal parts of the flap. The lower abdomen was classically divided in perfusion zones.42 Scheflan et al. assigned the original four zones to the unipedicle transverse rectus abdominis based on clinical observations.65 The perfusion of the ipsilateral central zone was felt to be superior and was called zone I. Perfusion was felt to decline toward the periphery of the flap, and the contralateral central zone (zone II) was felt to have a better perfusion than the ipsilateral lateral zone (zone III). The lateral part contralateral of the pedicle was felt to 16
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