Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction

Background. Many studies demonstrate direct patient benefits from use of preoperative computed tomography angiograms (CTA) for abdominal tissue-based breast reconstruction. We present a novel classification schema to translate imaging results into further clinical relevance. Methods. Each hemiabdomen CTA was classified into a schema that addressed findings of expected anatomy, anatomy that necessitates a change in operative technique and anatomy that suggests less morbid procedures may be considered. Results. Eighty-six patients (172 hemiabdomens) were available for study. Of the reconstructions performed in this time period, 40 (47%) were bilateral and 46 (53%) unilateral. Based on perforator size and location, relative perimuscular anatomy, and continuity of vessels, five categories were defined: type I ‘‘Traditional’’ anatomy (n 5 150, 87%), type II ‘‘Highly Favorable’’ anatomy (n 5 11, 6.4%), type III ‘‘Altered-Superiorly Translocated’’ anatomy (n 5 9, 5.2%), type IV ‘‘Superficial Dominant’’ anatomy (n 5 26, 15%), and type V ‘‘Hostile’’ anatomy (n 5 4, 2.3%). The additive total is greater than 100%, because vessels may fall into more than one category. Discussion. In providing the microsurgeon with a preoperative vascular map that has the potential to influence the preoperative, operative, and postoperative course, abdominal CTAs should be considered a worthy adjunct to the diagnostic armamentarium of the reconstructive surgeon. These classifications and their clinical impacts become even more important in centers performing increasing numbers of bilateral reconstructions. We believe that our simple schema can facilitate effective use of this powerful tool, aiding in overall care of the breast reconstruction patient. V V C 2010 Wiley-Liss, Inc. Microsurgery 00:000–000, 2010. For women desiring free autologous tissue transfer breast reconstruction, abdominal-based perforator flaps are frequently considered as a primary option. The ability to perform this procedure depends on uninterrupted delivery of arterial inflow and venous outflow from either the deep inferior or superficial inferior epigastric vessels. This situation does not always exist, and, when it does, the anatomy can be variable. 1,2 Surgical successes may depend on correct perforator choice. Previous authors have demonstrated that use of preoperative computed tomographic angiograms (CTA) translates to significant operative time and money savings and a reduction of postoperative complications. 2–5 The use of this technique therefore has the potential ability to significantly improve outcomes. The mechanisms for these noted benefits are presumed to be the ability to target perforators of choice, which leads to decreasing the need for intraoperative inspection and temporary preservation of candidate perforators, decreasing frequency of time consuming and morbid intramuscular dissection, increasing the ability to identify potential flap failures prior to creating donor site incisions, and increasing the accuracy of choice of perforators that are capable of maximum perfusion. 2,6 This study was designed to classify the clinically relevant anatomic scenarios identifiable from preoperative vascular maps obtained through CTA of the abdomen in women, undergoing perforator-based breast reconstruction. We further designed this project to determine the relative frequencies of findings that could potentially prevent intraoperative procedure failures as well as the relative frequencies of findings that could potentially convert procedures to those with minimal abdominal wall donor site disruption. METHODS