Reply: A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap

Department of Plastic, Reconstructive, Hand, and Burn Surgery, BG-Trauma Center (Rahmanian-Schwarz, Amr, Rothenberger) Institute of Anatomy (Hirt) Department of Plastic, Reconstructive, Hand, and Burn Surgery, BG-Trauma Center, Eberhard Karls University, Tuebingen, Germany (Schaller).
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 09/2011; 128(3):822-3. DOI: 10.1097/PRS.0b013e31822215c7
Source: PubMed
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    ABSTRACT: Perfusion dynamics of 16 free DIEP flaps and 4 free SIEA flaps were studied during the first, third, and sixth postoperative day using dynamic infrared thermography (DIRT). For both flap types the zone positioned over the perforator is perfused first, followed by the adjacent ipsilateral zone, and finally the contralateral zones. Perfusion of the subdermal plexus of all zones preceded the perfusion of the subcutaneous layer of all zones. While the initial hyperemia subsided with time, the total number of hot spots increased with time. Perfusion of free DIEP and SIEA flaps during the first postoperative week is a dynamic process. The perfusion shows a stepwise progression at the level of the subdermal plexus and at the level of the subcutaneous layer each with its own time sequence and with the midline as an area of resistance for circulation.
    Annals of plastic surgery 02/2009; 62(1):42-7. DOI:10.1097/SAP.0b013e3181776374 · 1.46 Impact Factor
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    ABSTRACT: The establishment of the perfusion zones for the deep inferior epigastric artery perforator (DIEP) flap is still under debate. Specifically, differences between clinical and anatomical studies have often been described. The purpose of this combined study was to evaluate the characteristics of a DIEP zoning in both clinical and anatomical settings by quantitatively assessing the perfusion dynamics and vascular anatomy. In the first part of the study, the perfusion dynamics of 16 patients undergoing DIEP flap breast reconstruction were assessed, determining cutaneous oxygen supply and blood flow using an Oxygen to See device. In the second part of the study, 11 flaps were harvested from fresh female cadavers. All specimens were subjected to dynamic computed tomographic scanning to simulate single-perforator DIEP flaps. The perfusion dynamics of DIEP flaps show no significant difference (p ≤ 0.05) between the two immediately adjacent zones, regardless of the use of lateral or medial perforator rows. However, use of the cadaver medial row perforator more often illustrated a vascular pattern across the midline (zone II, 86.4 percent) as compared with the lateral row-perfused DIEP flap. The authors' combined study showed varying perfusion characteristics between anatomical and clinical settings, which could be caused by a number of complex systemic and local processes. Thus, the selection of the DIEP zones should be assessed individually depending on the anatomy in question and the characteristics of the perforators until the mentioned issues are clarified in detail.
    Plastic and Reconstructive Surgery 02/2011; 127(2):505-13. DOI:10.1097/PRS.0b013e3181fed543 · 3.33 Impact Factor
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    ABSTRACT: A clear understanding of the vascular anatomy of an individual perforator relative to its vascular territory and flow characteristics is essential for both flap design and harvest. The authors investigated the three-dimensional and four-dimensional arterial vascular territory of a single perforator, termed a "perforasome," in major clinically relevant areas of the body. A vascular anatomy study was performed using 40 fresh cadavers. A total of 217 flaps and arterial perforasomes were studied. Dissection of all perforators was performed under loupe magnification. Perforator flaps on the anterior trunk, posterior trunk, and extremities were studied. Flaps underwent both static (three-dimensional) and dynamic (four-dimensional) computed tomographic angiography to better assess vascular anatomy, flow characteristics, and the contribution of both the subdermal plexus and fascia to flap perfusion. The perfusion and vascular territory of perforators is highly complex and variable. Each perforasome is linked with adjacent perforasomes by means of two main mechanisms that include both direct and indirect linking vessels. Vascular axis follows the axiality of linking vessels. Mass vascularity of a perforator found adjacent to an articulation is directed away from that same articulation, whereas perforators found at a midpoint between two articulations, or midpoint in the trunk, have a multidirectional flow distribution. Each perforator holds a unique vascular territory (perforasome). Perforator vascular supply is highly complex and follows some common guidelines. Direct and indirect linking vessels play a critical part in perforator flap perfusion, and every clinically significant perforator has the potential to become either a pedicle or free perforator flap.
    Plastic and Reconstructive Surgery 11/2009; 124(5):1529-44. DOI:10.1097/PRS.0b013e3181b98a6c · 3.33 Impact Factor