The Pfannenstiel scar and its implications in DIEP flap harvest: a clinical anatomic study

Background: Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption. 

Methods: A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators. 

Results: A total of 959 perforators were identified, with 319 perforators identified in the ‘Pfannenstiel scar’ group and 640 perforators in the ‘no abdominal scar’ group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p = 0.2819); however, perforators of the ‘Pfannenstiel scar’ group were of larger mean diameter than the ‘no abdominal scar’ group (0.96 vs 0.85 mm (p = 0.0027). 

Conclusions: The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes. 

Level of Evidence: Level III, risk / prognostic study.