Since the evolution of plastic surgery, the lower abdomen has been an abundant and reliable source of well vascularised material. Originally, pedicled and tubed flaps were used to transfer this tissue to distant sites. The lower abdominal skin and fat was then discovered to be the ideal material for breast reconstruction and the transverse rectus abdominis musculo-cutaneous (TRAM) flap was introduced. The pedicled TRAM was subsequently replaced by the free TRAM because this offers better tissue perfusion from the dominant deep inferior epigastric system.
In the mid-1980’s, it became apparent that a single large peri-umbilical perforating vessel (fig.1) originating from the deep inferior epigastric artery was adequate for complete flap perfusion. This was confirmed in 1989 when Isao Koshima (Tokyo) first published two cases of “deep inferior epigastric skin flaps without rectus abdominis muscle”. Robert Allen (New Orleans, U.S.A.) and Phillip Blondeel (Gent, Belgium) then expanded the use of the deep inferior epigastric artery perforator (DIEAP) flap for breast reconstruction and technically refined the procedure. The DIEAP flap quickly gained popularity as it produced comparable results to the TRAM flap but without the added morbidity of rectus abdominis muscle sacrifice.
Fig. 1: Schematic representation of perforator vessels traversing muscle to reach the overlying fat and skin.
The lower abdomen is supplied by both the deep and superficial inferior epigastric arteries and surgeons then transferred the same anatomical unit based on the superficial inferior epigastric artery (fig. 2). James Grotting (Birmingham, U.S.A.) in 1991 was the first to use the superficial inferior epigastric artery (SIEA) flap for breast reconstruction. The SIEA flap has even less donor site morbidity than the DIEAP flap, as the fascia overlying the rectus abdominis muscle is not breached.
Fig. 2: Vascular anatomy of the trunk: DIEA: Deep Inferior Epigastric Artery; SIEA: Superficial Inferior Epigastric Artery; SEA: Superior Epigastric Artery; IMA: Internal Mammary Artery (recipient vessels for free flap surgery).
In this era of rapidly evolving scientific discovery, these perforator flaps represent the current gold standard in soft tissue reconstruction. They offer the best potential results to patients with the least donor site morbidity. In our opinion, the DIEAP and SIEA flaps should therefore be the first reconstructive options considered for breast reconstruction in appropriately selected patients.