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How Many Perforators in a Deep Inferior Epigastric Artery Perforator Flap? The Salvage of a Perforator Sir:
account the physiologic changes in the vasculature that occur in a living patient2; this concept is explained by Saint-Cyr et al.,3 who define the perforasome theory and explain how skin areas are linked between them by direct vessels and indirect vessels (recurrent flow from the subdermal plexus). Unfortunately, there is no evidence regarding the number and dimensions of the perforator vessels related to the prediction of flap survival. During the dissection of a DIEP flap, the choice of the perforator is a crucial step, and we prefer to include more than one perforator, when possible, in the same row, in this way increasing the blood supply to the flap. The risk of injuring the vessel during intramuscular dissection is always present. The procedure should be performed by a surgeon with great experience in perforator dissection. Also, resorting to more than one perforator leads to a higher risk. How should the surgeon behave in front of a vessel cut in a deep inferior epigastric artery perforator flap? The surgeon can solve the problem through different ways, including the following: (1) rely on other perforators; (2) use the contralateral side; and (3) convert the perforator flap to a musculocutaneous flap. The perforator-to-perforator anastomosis (Fig. 1) is another viable solution to untie the problem, especially if we do not prefer to convert to a musculocutaneous flap and when we cannot resort to other solutions as, for example, if we need to perform a bilateral DIEP flap or if there are no other available perforators. Moreover, the perforator-to-perforator anastomosis is an excellent option if we are not sure about the flap perfusion or if the perforator is accidentally injured during dissection. The anastomosis of the injured perforator for a DIEP flap was reported in 2012 by Miyamoto et al.4 for partial damage of the vessel (vein or artery). We report perforator anastomosis for both vessels (vein and artery). In the absence of an evidence-based approach to perforator selection and dissection that limits the likelihood of injuring the vessel, salvage of the perforator is a reliable procedure that should be attempted, when possible, despite the fact that it requires a high level of microsurgical skill and is associated with the risk of anastomotic thrombosis.5 DOI: 10.1097/PRS.0000000000001293
e read with great interest the article by Ireton et al. entitled “Vascular Anatomy of the Deep Inferior Epigastric Artery Perforator Flap: A Systematic Review.”1 We appreciate the meticulous methods of developing this article showing the great variability of the vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap. Further studies will allow us to obtain an evidence-based perforator selection. The studies on perfusion territory show a discrepancy in findings between vascular mapping studies and clinical observation because they do not take into Copyright © 2015 by the American Society of Plastic Surgeons
Giuseppe A. G. Lombardo, M.D. Rosario E. Perrotta, M.D., Ph.D. Plastic and Reconstructive Surgery University of Catania Cannizzaro Hospital Catania, Italy
Jiri Vesely, M.D., Ph.D. Clinic of Plastic and Reconstructive Surgery St. Anne’s University Hospital Brno Brno, Czech Republic Correspondence to Dr. Lombardo Department of Medical and Surgical Specialties Section of Plastic Surgery
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015
Fig. 1. The perforator-to-perforator anastomosis in a DIEP flap. Artery (A) and vein (V) were repaired using the simple interrupted suture with 10-0 nylon. In this case, the flap was based on another safe perforator, but we were not sure about the vascularization of the flap, so we decided to perform the anastomosis of the perforator accidentally injured to obtain a two-perforator–based flap (original magnification, × 10). University of Catania Cannizzaro Hospital Via Messina, 829 95126 Catania, Italy [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: A systematic review. Plast Reconstr Surg. 2014;134:810e–821e. 2. Wong C, Saint-Cyr M, Arbique G, et al. Three- and fourdimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124:18–27. 3. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544. 4. Miyamoto S, Sakuraba M, Nagamatsu S. Inadvertent injury of critical perforator vessels during perforator flap surgery. J Reconstr Microsurg. 2012;28:95–98. 5. Hong JP. The use of supermicrosurgery in lower extremity reconstruction: The next step in evolution. Plast Reconstr Surg. 2009;123:230–235.
Reply: How Many Perforators in a Deep Inferior Epigastric Artery Perforator Flap? The Salvage of a Perforator Sir:
We would like to thank Dr. Lombardo and colleagues for their interest in our recent article entitled “Vascular Anatomy of the Deep Inferior Epigastric Artery
Perforator Flap: A Systematic Review.”1 The authors are to be congratulated for their elegant case presentation where deep inferior epigastric artery perforator (DIEP) flap vascularity was augmented by anastomosing a nonintended (and previously injured) perforator to the intended DIEP flap perforator. The authors also point out key steps to follow in the event of a DIEP flap perforator injury during dissection. Another option to add to this list would be the use of the superficial inferior epigastric vein/artery system. The superficial inferior epigastric artery flap can be used as a bailout in cases of irreparable perforator injury or inability to convert to a muscle-sparing transverse rectus abdominis myocutaneous flap in bilateral cases. A simple and safe approach to DIEP flap harvest includes the early identification of the most dominant perforator within the DIEP flap. We perform almost exclusively bilateral DIEP flaps, and identification of the single most dominant perforator within the hemi abdomen is essential not only for arterial perfusion but, most importantly, for venous outflow. This also allows the ability to harvest hemi-DIEP flaps based on a single perforator only. Once the dominant perforator is identified, either from the lateral or medial row, dissection is carried out as usual. The uninvolved row (e.g., entire lateral row if a medial row perforator is selected) is not dissected and kept intact in case of injury. Keeping the opposite row intact and nondissected saves time, avoids traction injury while dissecting the dominant perforator, and leaves the option of using additional perforators or converting to a muscle-sparing transverse rectus abdominis myocutaneous if perforators are too small. Preoperative computed tomography can help identify the most radiologically dominant perforator, and we certainly agree with the authors that radiologic dominance is static and should always be confirmed with realtime in vivo perfusion dominance. When preoperative
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