Perforating blood vessel selection in deep inferior epigastric artery perforator flaps

RD Surgery

Douglas, Helen E. ; Horgan, Paul

University:University of Glasgow

Department:School of Medicine, Dentistry & Nursing

关键词: DIEP, flap perfusion, perforator number, perforator location, zone IV, pedicle flow;   

Others  :  http://theses.gla.ac.uk/5516/1/2014DouglasPhD.pdf

来源: University of Glasgow

【 摘 要 】

Introduction: The DIEP flap is a popular choice for breast reconstruction, though selection ofwhich perforating blood vessel(s) to supply the flap is still largely based on surgeon preference,with little evidence to support numbers or location of perforators. In addition, many surgeonsroutinely discard zone IV of the flap, limiting the size of transferrable tissue. The aim of thisresearch was to investigate the effect of number and location of perforators within a DIEP flap, on the total pedicle flow and perfusion of zone IV fat and skin.Methods: This research comprised of two studies; an animal model and a patient study:1) 20 cranially-based abdominal epigastric perforator flaps were raised in Wistar rats on twoperforators. The perforators were sequentially clamped and released in a randomised order andtotal pedicle flow (measured using microvascular flow-probes) and skin perfusion (measuredusing laser Doppler Flowmetry) was recorded on the following perforator combinations:• P1 (superior perforator)• P2 (inferior perforator)• P1+2 (both perforators)In addition, half of the animal flaps were randomised to receive a single (15 minute) period ofpedicle-clamped ischaemic preconditioning after raising, with all measurements repeated toobserve any effect.2) 13 DIEP flaps were raised in post-mastectomy patients requiring breast reconstruction on twoperforators. These were clamped and released as before to assess perfusion of fat and skin inzone IV using SPY Indocyanine-green-fluorescence-angiography scans on the same perforatorcombinations as in our animal study, listed above.Results: All data were analysed using non-parametric analyses and revealed that in our animalmodel, total pedicle flow was significantly (p<0.001) greater on a single perforator compared totwo but no significant differences were identified in the flap skin perfusion. In our clinical studya single superior perforator supplied zone IV significantly (p=0.039) better than bothperoforators, though this was not observed with the single inferior perforator. No significantdifferences were seen in zone IV skin perfusion. A single period of ischaemic preconditioningsignificantly (p<0.05) increased the total pedicle flow, but not the skin perfusion in our ratmodel.Conclusions: Possible reasons for these observed differences could be related to the flowdynamics and resistances specific to perforator flap anatomy and physiology and the possibilityof vessel shunting in the subcutis.