Chapter 7 sufficient muscle cuff is available to prevent kinking of the pedicle. The skin is closed over a pliable custom‐made sterilized polyethylene sheet to prevent vascular ingrowth and is sutured intracutaneous with Monosof 6‐0 (Tyco®, USA) (Figure 7.1C). After the surgery, the TRAM flap is theoretically divided in four perfusion zones as determined by clinical studies (Figure 7.2). The animals were housed in an incubator with a set temperature of 27°C for 24 hours. Thereafter, the animals were housed in a controlled environment with a temperature of 23°C–24°C. Food and water were given ad libitum directly after surgery and throughout the study. PFL was determined on day 4 by visual inspection based on color, eschar formation, and lack of capillary refill. Digital photographs of the flaps and ruler were obtained (Figure 7.1D). The PFL area was calculated using the ImageJ® program (U.S. National Institutes of Health, Maryland, USA). In order to eliminate contraction as a confounding factor, flap survival was assessed as the percentage of PFL in relation to the whole flap. In addition, the location of PFL (zones I–IV) was also recorded. Flap survival was expressed as mean standard error of the mean (SEM). Data between the experimental groups were compared using a two‐tailed Mann‐Whitney U test. Results were considered significant at P<0.05. Statistical Package for the Social Sciences (SPSS) program (version 18, UK) was used for the statistical analysis. Figure 7.2 Tram flap perfusion zones. DIEAV = deep inferior epigastric artery and vein. Zone I is located ipsilaterally from the DIEAV and situated over the rectus abdominus muscle. Zone II is ipsilateral to zone I. Zone III is contralateral to the side from the DIEAV and situated over the rectus abdominus muscle. Zone IV is lateral to zone III. Results One animal died postoperatively in group 1. All the other animals remained in good condition until their sacrifice at the end of the study. Normal behavior was observed, and there were no significant changes in habitual status. In the nonischemia group, PFL was 10.7±4.3%. PFL in this control group is the result of insufficient distal flap perfusion from the vascular pedicle and was mainly located in the 104
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