Background: Using ex vivo intraoperative angiography to analyze 14 flaps from 12 breast reconstruction patients, the authors investigated the vascular architecture of free transverse rectus abdominis musculocutaneous (TRAM) flaps nourished by the deep inferior epigastric artery.
Methods: Contrast medium was injected through the deep inferior epigastric artery and flaps were radiographed to observe their vascular patterns.
Results: TRAM flaps showed one or two segmental arteries stained on their ipsilateral side (zones 1 and 3) and serving as the flap's axial artery. These segmental arteries directly connect to the large perforators (axial perforators) and emerge not only from the paraumbilical perforators but also from the caudal branches of the deep inferior epigastric artery. Arterial density is always lower in the contralateral area (zones 2 and 4) than in the ipsilateral area (zones 1 and 3).
Conclusions: Because the cephalic half of zone 2 and all of zone 4 remain unstained, these areas are prone to skin or fat necrosis, especially in high-risk patients. Ex vivo angiography, by providing specific information about the individual flap and by reflecting its flow physiology, enables one to observe and to chart the vascular architecture of free TRAM flaps nourished by the deep inferior epigastric artery.