Congenital absence of the deep inferior epigastric system: a case report

Preoperative computerised tomographic angiography (CTA) in free flap breast reconstruction outlines the deep inferior epigastric perforator (DIEP). It can identify a single or twin system, measure vessel calibre, and identify iatrogenic/congenital anatomical variations. Evidence of the effect of previous abdominal incisions on this vessel system remain inconclusive. We present the case of a congenital absence of the system identified from routine preoperative CTA. A 61-year-old female presented for immediate unilateral breast reconstruction following mastectomy for ductal carcinoma in situ. She previously had a right-sided Kocher's incision performed for an open cholecystectomy and a gridiron incision. Coincidentally, preoperative CTA demonstrated congenital absence of the left DIEP system, and marked atrophy of the upper right rectus abdominis (RA). As a result, the superior gluteal artery perforator (SGAP) flap was planned. Intraoperatively, a 1.318-kg SGAP was raised on three perforators and coupled to the internal mammary vessels. In the postoperative period, there were no complications. Preoperative CTA demonstrated multiple hazards in raising a DIEP flap, CTA permitted surgical planning, improving patient safety and surgical efficiency. Preoperative CTA identifies vessel abnormalities resulting from abdominal scarring. The rate of congenital anomalies is unknown. This incidental discovery highlights the role CTA has in reducing operative time, facilitating a successful free tissue transfer, therefore improving patient safety.Level of Evidence: Level V, diagnostic study.