Aesth Plast Surg (2009) 33:327–335
DOI 10.1007/s00266-008-9272-1
ORIGINAL ARTICLE
Improving Outcomes in Autologous Breast Reconstruction
W. M. Rozen Æ M. W. Ashton
Received: 13 August 2008 / Accepted: 10 October 2008 / Published online: 27 November 2008
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2008
Abstract Autologous breast reconstruction can often
provide a more aesthetic outcome than other options for
breast reconstruction because breast volume and shape can
be extensively modified based on individual need, the
texture of the reconstructed breast is a closer match to the
native breast, and complications such as capsular contrac-
ture are avoided. However, with these benefits come the
potential for complications unique to autologous tissue
transfer. While overall complications are low, there are
ways to maximize operative success and minimize the risk
of complications. Deep inferior epigastric artery perforator
(DIEP) flaps, the current mainstay in choice of autologous
reconstruction, provide generally good outcomes. How-
ever, improvements in outcomes can still be achieved with
a better understanding of individual anatomy. Perforator
size, location, intramuscular and subcutaneous course, and
association with motor nerves are all factors that can sig-
nificantly affect operative technique, length of operation,
and operative outcomes. With significant variation between
individuals, preoperative imaging has become an essential
element of DIEP flap surgery. Computed tomography
angiography (CTA) is currently the gold standard but
evolving techniques such as magnetic resonance angiog-
raphy (MRA) and image-guided stereotaxy are rapidly
contributing to improved outcomes.
W. M. Rozen and M. W. Ashton contributed equally to this work.
W. M. Rozen (&)
M. W. Ashton
Jack Brockhoff Reconstructive Plastic Surgery Research Unit,
Department of Anatomy and Cell Biology, The University of
Melbourne, Room E533, Grattan St., Parkville, VIC 3050,
Australia
e-mail: warrenrozen@hotmail.com
Keywords Breast reconstruction
Autologous

Deep inferior epigastric artery
DIEP flap

Computed tomography angiography
Perforator flap
Autologous breast reconstruction is often sought by
patients and clinicians because potentially it can provide a
more aesthetic outcome than other breast reconstruction
techniques. Breast volume and shape can be extensively
modified based on individual need, the texture of the
reconstructed breast is a closer match to the native breast,
and complications such as capsular contracture are avoi-
ded. However, with these benefits come the potential for
complications unique to autologous tissue transfer. While
overall complications are low, there are ways to maximize
operative success and minimize the risk of complications.
The abdominal wall as the donor site has become the
popular option for autologous reconstruction. While the
breast can be reconstructed from a range of donor sites, the
abdominal wall integument can provide versatility in flap
volume and design, with particularly good donor site out-
comes [1–4]. Its use is popular for both delayed and
immediate reconstruction and can be achieved after both
skin-sparing mastectomy (Fig. 1) and routine mastectomy
with full skin excision (Fig. 2). Despite this, potential
complications still remain, including flap-related viability
issues and donor site morbidity [5–17]. To minimize these
risks, the procedure has been modified over time from the
transverse rectus abdominis myocutaneous (TRAM) flap,
which necessitated the sacrifice of one or both rectus ab-
dominis muscles [18–22], to the muscle-sparing deep
inferior epigastric artery (DIEA) perforator (DIEP) flap
[1, 23–25]. With the need to include only one or two
perforators in its vascular supply, this technique can
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Fig. 1 Postoperative photograph of a deep inferior epigastric artery
perforator (DIEP) flap breast reconstruction following skin-sparing
mastectomy
Fig. 2 Postoperative photograph of a deep inferior epigastric artery
perforator (DIEP) flap breast reconstruction following traditional
skin-sacrificing mastectomy
improve donor site morbidity by sparing rectus abdominis
fibers during flap harvest (Fig. 3).
To further improve the outcome of DIEP flap surgery,
much research has been done to find the ‘‘optimal’’ perfo-
rators to use. Optimal perforators are those that provide
sufficient blood supply to the flap while minimizing their
intramuscular dissection [26–28]. These perforators must be
large, centrally located in the flap, have a broad subcutaneous
branching pattern, and have a short intramuscular course. A
short longitudinal intramuscular course increases the ease
and speed of dissection and the likelihood of fewer muscular
branches requiring ligation.
This article describes advances in our understanding of
the regional anatomy of the anterior abdominal wall based
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Aesth Plast Surg (2009) 33:327–335
Fig. 3 Intraoperative photograph of a deep inferior epigastric artery
perforator (DIEP) flap being performed for breast reconstruction,
demonstrating perforators (green arrow) traversing the rectus abdo-
minis muscle to supply the overlying integument of the anterior
abdominal wall
on cadaveric and clinical studies, describes variations in
these patterns, and highlights new methods available for
revealing individual anatomy preoperatively.
The Anatomy
The anterior abdominal wall traditionally has been described
as being supplied by a system of deep and superficial named
arteries that run longitudinally and anastomose circumfer-
entially with vessels of adjacent angiosomes [29–33]. The
deep tissues are supplied by the deep superior epigastric
artery (DSEA) and by the deep inferior epigastric artery
(DIEA). The communication between these two systems
occurs within the rectus abdominis muscle, above the
umbilicus. These vessels anastomose laterally with the
intercostal, subcostal, and lumbar arteries and the ascending
branch of the deep circumflex iliac artery (DCIA) (Fig. 1). A
superficial network is similarly present, with longitudinal
supply from the superficial superior epigastric artery (SSEA)
and superficial inferior epigastric artery (SIEA). These ves-
sels anastomose laterally with the superficial system of
intercostal, subcostal, and lumbar vessels, the superficial
circumflex iliac vessels, and inferolaterally with the super-
ficial external pudendal artery.
The DIEA is the dominant vascular supply to the ante-
rior abdominal wall [32, 34], with anterior perforating
branches supplying the skin and subcutaneous tissues of the
lower abdominal wall. These perforators show a strong
periumbilical distribution, with the average number of
perforators per hemiabdomen ranging from 0.8 to 6.8,
depending on the size classification used [28, 29, 35–46].
Recent studies have shown that there is variation in the
intramuscular course of perforators, with particular interest
in this course when harvesting of DIEP flaps [28, 40, 43].
Aesth Plast Surg (2009) 33:327–335
We have conducted anatomical studies in over 100
cadavers with a view toward demonstrating this intramus-
cular course and determining patterns for predicting the
perforators that will have a shorter course for dissection
[43, 46, 47]. These studies illustrated that all DIEA per-
forators have a measurable transverse and longitudinal
intramuscular course. This course is highly variable
between individual perforators and varies between each
hemiabdomen [43]. Further correlation of this intramus-
cular course with the branching pattern of the DIEA
showed that the distances traversed by perforators were
significantly reduced with a bifurcating branching pattern
of the DIEA, particularly for those perforators originating
from the lateral branch, and that the intramuscular course
was greatest with a trifurcating branching pattern [46].
In addition to sparing the rectus abdominis muscle
during perforator dissection, preservation of the motor
nerves that innervate the rectus abdominis muscle is also
essential to prevent denervation of the muscle [48–51]. Our
studies have shown that these nerves encroach upon the
rectus abdominis muscle from its lateral border and run
with the most lateral branch of the DIEA and its perforators
[47, 52]. Medial row perforators were not related to these
motor nerves and, thus, dissection of the lateral row per-
forators is more likely to result in rectus abdominis muscle
denervation. A large motor nerve, at the level of the arcuate
line, is present in most cases and has been implicated as a
cause of lower abdominal bulge after DIEP flaps [47, 53].
Our anatomical studies have demonstrated that perfo-
rators selected from a single-trunk or a bifurcating DIEA
are likely to have the shortest intramuscular course, and
that medial row perforators are more likely to not require
disruption of motor nerves during their dissection.
Imaging Techniques
Because there is significant variation in the anatomy of
each person, and particular anatomical features have been
identified as important to reducing complications, ways to
predict an individual’s anatomy have been sought. Preop-
erative imaging has been investigated as one way to
improve the selection of perforators for a patient. With
advances in imaging technology, higher-resolution images
have been sought and an increasing amount of anatomical
information from those images has become possible.
Doppler Ultrasound
For many years ultrasound has been the mainstay of pre-
operative imaging since the handheld Doppler probe was
introduced into widespread use for perforator mapping in
1990 [54]. To this day, the handheld unidirectional Doppler
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probe has remained a key tool for preoperative imaging
because it is cheap, quick, and easily applied by the surgeon,
and its findings can be directly compared to postoperative
Doppler findings. Even when more advanced imaging is
used preoperatively, the Doppler probe can be used
adjunctively. However, significant time is associated with
perforator mapping with the Doppler probe, and, more
importantly, it has been shown to have low accuracy and
high interobserver variability [54–57]. Therefore, unidirec-
tional Doppler has not been embraced as a suitable
preoperative imaging modality and formal perforator map-
ping with Doppler alone has been considered insufficient.
The addition of directional flow to ultrasound technology
has been widely incorporated into perforator mapping.
Duplex Ultrasound
Two-dimensional color added to Doppler ultrasound has
been shown to significantly improve unidirectional Doppler
[55–59]. This technique has greater sensitivity and speci-
ficity in identifying perforators and is highly accurate in
differentiating between arteries and veins. As such, duplex
ultrasound has been widely used for perforator mapping.
Although there is a significant degree of false positives and
false negatives with its use, duplex ultrasound is
widely available and inexpensive. However, its limitations
include long scanning times and significant interobserver
variability.
Computed Tomography Angiography
Noninvasive imaging techniques have been able to eliminate
the interobserver variability and long scanning times asso-
ciated with ultrasound. Computed tomography angiography
(CTA) has been used as a noninvasive and effective tool for
mapping the vascular supply to various body regions,
including the head and lower limb [60–64]. We sought to
compare duplex ultrasound with abdominal wall CTA in the
imaging of DIEA perforators [59]. In a study of ten con-
secutive patients who were to undergo DIEP flaps for breast
reconstruction, we found that duplex ultrasound was sig-
nificantly inferior to CTA in identifying the major branches
and perforators of the DIEA, at demonstrating the superficial
inferior epigastric artery (SIEA), and displaying the image
intraoperatively. There was greater agreement with the
operative findings with CTA versus ultrasound.
CTA is increasingly considered the gold standard for
preoperative imaging for DIEP flaps [26, 44, 45, 59, 65–72].
It is readily available in most centers, is relatively inex-
pensive, has extremely fast scanning times (seconds), and
has low interobserver variability. While the main limitation
is the availability of the CTA scanner itself and associated
software, this is not an issue for most institutions. We have
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achieved high-quality images with a wide range of multi-

detector row scanners (from 4- to 64-slice). The only
contraindications for the use of CTA is severe claustro-
phobia (although scan times are only seconds), sensitivity to
the intravenous contrast agent, or severe renal impairment.
Unlike the previously described modalities, CTA is asso-
ciated with radiation exposure and, although it must be
taken into consideration, it is not as significant as initially
thought. Our studies of the radiation dose have shown that it
is less than 6 mSV, which is considerably less than a
standard abdominal CT scan and is the dose associated with
three abdominal plain films (ImPACT CT Patient Dosim-
etry Calculator ver. 0.99w, ImPACT, St. George’s Hospital,
London, UK) when the scan is limited to the appropriate
scanning range [26, 70, 71].
To determine the accuracy of CTA, we performed both
cadaveric and clinical studies, comparing imaging findings
to dissection or operative findings [44, 45, 73, 74]. In ten
cadaveric hemiabdominal walls, we injected the DIEA with
Fig. 4 Computed tomography angiogram (CTA) with volume-ren-
radiographic contrast and performed CTA and subsequent dered technique (VRT) reformat showing the vasculature of the
dissection. We found that of 154 perforators seen on CTA, anterior abdominal wall. Multiple large (blue arrows) and small
there were eight false positives and six false negatives, all (yellow arrows) deep inferior epigastric artery (DIEA) perforators are
seen with perforators less than 1 mm, and 100% concor- seen emerging from the anterior rectus sheath
dance for all perforators larger than 1 mm. Thus, for major
perforators, there was a calculated sensitivity of cadaveric
CTA of 100% and a positive predictive value of 100%. We
replicated this study in the clinical setting, comparing the
CTA findings of 42 consecutive patients to intraoperative
findings. Of 160 perforators larger than 1 mm seen on CTA,
there was one false positive and one false negative, with an
overall sensitivity of CTA of 99.6% and a positive predic-
tive value of 99.6% for perforator mapping. Subsequently,
we prospectively imaged with CTA 110 consecutive
patients who were to undergo breast reconstruction with
DIEP flaps and found that CTA maintained this high level
of accuracy. It has become the gold standard in preoperative
imaging. The images produced with CTA can generate
three-dimensional representations of the perforators them-
selves (Fig. 4). Also, CTA can apply a grid based at the
umbilicus for reference measurements (Fig. 5). In addition
to the accurate identification of the location of perforators,
CTA can reveal the caliber and course of the DIEA and all
of its major branches, it can provide in three dimensions the
Fig. 5 Computed tomography angiogram (CTA) with volume-ren-
course of perforators throughout their intramuscular, sub- dered technique (VRT) reformat showing the vasculature of the
fascial, and subcutaneous courses (Fig. 6), it can provide a anterior abdominal wall, with two-dimensional grid applied for
sense of the abdominal wall’s competence and the fascial location measurements, based at the umbilicus
layers of the abdominal wall, and it can provide information
on the SIEA and other adjacent vessels [26, 71, 75]. This is Magnetic Resonance Angiography
particularly useful for cases of bilateral breast reconstruc-
tion, where donor site morbidity is of increasing concern Magnetic resonance imaging, without intravenous contrast,
and where ‘‘ideal’’ perforators can be selected preopera- has been attempted in the past for perforator mapping but
tively (Fig. 7), which avoids long intramuscular dissections with inadequate results [76]. With more recent exploration
and potential muscle damage (Fig. 8). into the role of MRA, the prospect of using MRA for

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Aesth Plast Surg (2009) 33:327–335
Fig. 6 Computed tomography angiogram (CTA) with volume-ren-
dered technique (VRT) reformat showing the vasculature of the
anterior abdominal wall. The subcutaneous course of individual
perforators can be visualized by rotating the scan volume in three
dimensions
Fig. 7 Computed tomography angiogram (CTA) with volume-ren-
dered technique (VRT) reformat showing the vasculature of the
anterior abdominal wall prior to a bilateral deep inferior epigastric
artery perforator (DIEP) flap for breast reconstruction. A single large
paramedian perforator is seen for each hemiabdomen
perforator mapping has now become more realistic. We
have begun to study MRA in trials, and although the out-
comes do not yet reach the resolution and accuracy of
CTA, the results suggest that MRA may yet evolve into
clinical use [77].
331
Fig. 8 Computed tomography angiogram (CTA) with axial maxi-
mum intensity projection (MIP) reformat showing the vasculature of
the anterior abdominal wall prior to a bilateral deep inferior epigastric
artery perforator (DIEP) flap for breast reconstruction (same patient as
in Fig. 7). The intramuscular course of each paramedian perforator is
shown
The main benefit of MRA is its lack of ionizing radia-
tion, and thus it is a significant rival to ultrasound. It has
significant benefits over ultrasound in that it has greater
resolution, less interobserver variability, the potential for
greater accuracy, and can visualize a greater breadth of
anatomical information. However, unlike ultrasound, MRA
is expensive, not as available, can cause claustrophobia,
and intravenous contrast is needed. With future develop-
ments and improvements in this modality, we expect MRA
to become a significant rival to duplex ultrasound, partic-
ularly for those patients wishing to avoid radiation
exposure. International interest in this modality is
increasing, with several recent presentations at interna-
tional conferences suggesting that MRA images are able to
be improved with new contrast media, new scanning pro-
tocols, and increasingly high-resolution scanners [78–80].
Improvement in Outcomes
With the breadth of anatomical information available pre-
operatively, such imaging has the potential to significantly
affect patient outcomes. From a surgical point of view,
patients with unfavorable anatomy can be selected pro-
spectively, the hemiabdomen of choice can be selected
preoperatively saving operative time, and the perforator(s)
of choice can be selected individually, which can maximize
the vascularity of the flap while minimizing rectus abdo-
minis muscle damage. With the use of CTA, we have been
able to modify the operative technique by being able to
select from among a TRAM, DIEP, or SIEA flap; we have
encountered cases where previous surgery has precluded
the use of an abdominal wall flap; and we have had cases
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where other comorbidities have been identified (such as
renal and hepatic masses and abdominal wall hernias) and
that have been further investigated and treated based on
preoperative imaging [71].
We reviewed 104 consecutive breast reconstructions in
88 patients with the goal of determining whether there was
any significant improvement in outcome with the use of
CTA, including benefits to flap survival, donor site mor-
bidity, length of operation, and overall length of hospital
stay [70]. We compared consecutive patients, who under-
went equivalent surgery performed by the same surgeons,
with respect to preoperative imaging with and without
CTA. Those patients who underwent preoperative CTA
showed an improvement in surgical outcomes compared to
those who did not, with statistically significant findings for
a reduction in flap-related complications (flap loss and fat
necrosis), donor site complications (abdominal wall
weakness and bulge), and intraoperative surgical stress.
This demonstrates that by identifying the precise location
of perforators and selecting those with a reduced intra-
muscular course, operative dissection time is minimized.
Similarly, perforators that are selected based on size and
subcutaneous course can provide improved blood supply to
flaps and reduce flap-related complications. In addition,
perforators that have reduced intramuscular courses result
in less muscle sacrifice, and the selection of larger but
fewer perforators results in reduced muscle and nerve
sacrifice, all resulting in reduced donor site morbidity.
The Future
Both CTA and MRA are evolving technologies, and with
further advances in the resolution attainable through
improved scanners and improved software, increasingly
fine levels of anatomical detail become available to the
surgeon. A recent addition to the use of these advanced
imaging technologies is the use of image-guided naviga-
tion. Image-guided stereotactic navigational systems are a
relatively recent advancement in imaging technology. They
allow the surgeon to achieve extremely accurate intraop-
erative anatomical localization of an imaging finding in
real-time using data from either a preoperative MR or a CT
study. The technique involves ‘‘registering’’ a patient in
real-time to a previous scan, using infrared signals relayed
between markers attached to the patient and a receiver that
digitally compares the locations to the scan data. Stereo-
tactic navigational systems have revolutionized the fields
of neurosurgery, orthopedic surgery, and ear, nose, and
throat surgery, with published data showing improved
operative safety, decreased operative morbidity, and
improved preoperative planning. However, the use of these
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Aesth Plast Surg (2009) 33:327–335
systems has not been explored in the field of plastic and
reconstructive surgery [81–86].
Perforator flaps are well suited for image-guided ste-
reotactic navigation, because precise preoperative
awareness of perforator location and course can improve
both flap design and operative safety. We explored the use
of these technologies in DIEP flap surgery, describing the
use of frameless CTA-guided stereotaxy and comparing it
to standard CTA techniques [87]. We found that CTA-
guided stereotaxy was a successful technique in all patients
and was more accurate than conventional CTA. The use of
three-dimensional recording of data and a ‘‘live’’ patient
during data acquisition reduced the error margin associated
with perforator location measurements.
These stereotactic techniques are a useful adjunct to
preoperative imaging because they do not require any
additional scanning and can improve the accuracy of
perforator localization. In addition, the surgeon can
immediately navigate preoperatively or even intraopera-
tively, eliminating communication errors introduced when
radiologists report on scan data, and allowing surface
markings to be made by the surgeon.
Conclusion
Although there are generally good outcomes associated
with DIEP flaps for autologous breast reconstruction,
improvements in outcomes can still be achieved with
improved understanding of a patient’s anatomy. Perforators
should be selected based on size, location, intramuscular
and subcutaneous courses, and their association with motor
nerves. With significant variability between individuals,
preoperative imaging has become an essential element of
DIEP flap surgery. Adequate imaging can help patient
selection, plan the operative technique, reduce operating
time, and improve operative outcomes. While CTA is
currently the gold standard, evolving techniques such as
MRA and image-guided stereotaxy may further improve
outcomes.
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