Surgical and Radiologic Anatomy

, Volume 40, Issue 8, pp 873–879 | Cite as

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations

  • Yujin Myung
  • Bomi Choi
  • Sang Jun Yim
  • Bo La Yun
  • Heeyeon Kwon
  • Chang Sik Pak
  • Chanyeong Heo
  • Jae Hoon JeongEmail author
Anatomic Bases of Medical, Radiological and Surgical Techniques



Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap.


We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients’ characteristics, such as abdominal surgery history.


CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm).


Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.


Epigastric arteries Rectus abdominis Reconstructive surgical procedures Free tissue flaps Angiography 



This study was supported by Grant no. 02-2013-109 from the SNUBH (Seoul National University Bundang Hospital) Research Fund.

Author contributions

YM: Protocol development, data collection, manuscript writing. BC: Data collection, data analysis. SJY: Manuscript writing, illustration. BLY: Protocol development, manuscript writing. HK: Data collection, manuscript editing. CSP: Manuscript editing. CH: Protocol development, manuscript editing. JHJ: Protocol development, data collection, manuscript writing.

Compliance with ethical standards

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this article.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Institutional Review Board of the Committee on Clinical Investigation of Seoul National University Bundang Hospital (B-1702-382-105).

Informed consent

All patients provided written consent for the use of their photographs.


  1. 1.
    Asko-Seljavaara S (1998) Delayed breast reconstruction. Clin Plast Surg Apr 25(2):157–166Google Scholar
  2. 2.
    Colohan S, Maia M, Langevin CJ et al (2012) The short- and ultrashort-pedicle deep inferior epigastric artery perforator flap in breast reconstruction. Plast Reconstr Surg 129(2):331–340CrossRefPubMedGoogle Scholar
  3. 3.
    Feng LJ (1997) Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels. Plast Reconstr Surg 99(2):405–416CrossRefPubMedGoogle Scholar
  4. 4.
    Franklin B, Gasco J, Uribe T, VonRitschl RH, Hauck E (2010) Diagnostic accuracy and inter-rater reliability of 64-multislice 3D-CTA compared to intra-arterial DSA for intracranial aneurysms. J Clin Neurosci 17(5):579–583CrossRefPubMedGoogle Scholar
  5. 5.
    Gray H, Standring S, Anand N et al (2016) Gray’s anatomy: the anatomical basis of clinical practice. Elsevier, OxfordGoogle Scholar
  6. 6.
    Heo C, Yoo J, Minn K, Kim S (2008) Circummuscular variant of the deep inferior epigastric perforator in breast reconstruction: importance of preoperative multidetector computed tomographic angiography. Aesthetic Plast Surg 32(5):817–819CrossRefPubMedGoogle Scholar
  7. 7.
    Jakubowicz M, Czarniawska-Grzesinska M (1996) Variability in origin and topography of the inferior epigastric and obturator arteries. Folia Morphol (Warsz) 55(2):121–126Google Scholar
  8. 8.
    Karunanithy N, Rose V, Lim AK, Mitchell A (2011) CT angiography of inferior epigastric and gluteal perforating arteries before free flap breast reconstruction. Radiographics 31(5):1307–1319CrossRefPubMedGoogle Scholar
  9. 9.
    Larson DL, Yousif NJ, Sinha RK, Latoni J, Korkos TG (1999) A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution. Plast Reconstr Surg 104(3):674–680CrossRefPubMedGoogle Scholar
  10. 10.
    Li S, Mu L, Li Y et al (2002) Breast reconstruction with the free bipedicled inferior TRAM flap by anastomosis to the proximal and distal ends of the internal mammary vessels. J Reconstr Microsurg 18(3):161–168CrossRefPubMedGoogle Scholar
  11. 11.
    Moon HK, Taylor GI (1998) The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82(5):815–832CrossRefGoogle Scholar
  12. 12.
    Moran SL, Nava G, Behnam AB, Serletti JM (2003) An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg 111(6):1876–1882CrossRefPubMedGoogle Scholar
  13. 13.
    Park YJ, Kim EK, Yun JY, Eom JS, Lee TJ (2014) The influence of pfannenstiel incision scarring on deep inferior epigastric perforator. Arch Plast Surg 41(5):542–547CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Phillips TJ, Stella DL, Rozen WM, Ashton M, Taylor GI (2008) Abdominal wall CT angiography: a detailed account of a newly established preoperative imaging technique. Radiology 249(1):32–44CrossRefPubMedGoogle Scholar
  15. 15.
    Rozen WM, Ashton MW, Grinsell D (2010) The branching pattern of the deep inferior epigastric artery revisited in-vivo: a new classification based on CT angiography. Clin Anat Jan 23(1):87–92Google Scholar
  16. 16.
    Rozen WM, Ashton MW, Grinsell D, Stella DL, Phillips TJ, Taylor GI (2008) Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators. Microsurgery 28(5):306–313CrossRefPubMedGoogle Scholar
  17. 17.
    Rozen WM, Ashton MW, Pan WR, Taylor GI (2007) Raising perforator flaps for breast reconstruction: the intramuscular anatomy of the deep inferior epigastric artery. Plast Reconstr Surg 120(6):1443–1449CrossRefPubMedGoogle Scholar
  18. 18.
    Saber AA, Meslemani AM, Davis R, Pimentel R (2004) Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 239(2):182–185CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Scheufler O, Andresen R, Kirsch A, Banzer D, Vaubel E (2000) Clinical results and color-coded duplex ultrasound findings 4 years after conditioned TRAM flap-plasty. Zentralbl Chir 125(1):60–67PubMedGoogle Scholar
  20. 20.
    Takeishi M, Shaw WW, Ahn CY, Borud LJ (1997) TRAM flaps in patients with abdominal scars. Plast Reconstr Surg 99(3):713–722CrossRefPubMedGoogle Scholar
  21. 21.
    Tan O, Yuce I, Aydin OE, Kantarci M (2014) A radioanatomic study of the internal mammary artery and its perforators using multidetector computed tomography angiography. Microsurgery 34(4):277–282CrossRefPubMedGoogle Scholar
  22. 22.
    Tuinder S, Dikmans R, Schipper RJ et al (2012) Anatomical evaluation of the internal mammary vessels based on magnetic resonance imaging (MRI). J Plast Reconstr Aesthet Surg 65(10):1363–1367CrossRefPubMedGoogle Scholar
  23. 23.
    Won HS, Won HJ, Oh CS, Han SH, Chung IH, Kim DH (2012) The inferior epigastric artery arising from the internal iliac artery via a common trunk with the obturator artery. Anat Cell Biol 45(4):285–287CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Plastic and Reconstructive SurgerySeoul National University Bundang HospitalSeongnamRepublic of Korea
  2. 2.Department of Diagnostic RadiologySeoul National University Bundang HospitalSeongnamRepublic of Korea

Personalised recommendations