Summary & discussion and future perspectives Summary and discussion The use of abdominal tissue for breast reconstruction has evolved from a pedicled myocutaneous flap toward the perforator (deep inferior epigastric perforator DIEP) flap now commonly used. The DIEP flap reduces the chance of donor‐site complications. However, its use has been associated with an increased rate of partial flap loss (PFL) or fat necrosis (FN).1 FN occurs more commonly and is a lesion of scar tissue or fibrosis within the transplanted flap resulting from necrosis of adipose tissue, while the overlying DIEP flap skin or mastectomy skin is normal. This is the result of inadequate intrinsic perfusion of the flap by the vascular pedicle. FN presents as a firm immobile mass within the reconstructed breast. It can mimic cancer recurrence, causing unnecessary anxiety and discomfort for patients and their postoperative surveillance program. It can sometimes cause deep tissue infection requiring excision or drainage in selected cases. This in turn can result in lower patient satisfaction and aesthetic outcome. This thesis addresses partial flap loss (PFL) and fat necrosis (FN) in autologous breast reconstruction. PFL and FN are discussed and assessed in relation to the physiological changes after ischemia‐reperfusion (IR) injury and the role of risk factors. In addition, the use of NO to increase flap blood flow to reduce flap‐related complications was explored. Chapter 2 Anastomosis revision is increased in patients with a high rate of perioperative fluid therapy. In chapter 2, we have analyzed the perioperative data of 100 consecutive patients who received a free muscle sparing transverse rectus abdominis myocutaneous (MS‐TRAM) flap. The role of intravenous fluid and perioperative hemodynamics and the use of vasoactive medication were analyzed in relation to the development of in‐hospital complications in patients undergoing microsurgical breast reconstruction for breast cancer. The MS‐TRAM flap was used for secondary breast reconstruction in all cases. Flap complications were classified as anastomosis compromise and revision, which occurred in 11 cases. Anastomosis revision was successful in 55%, resulting in total flap loss in six patients. PFL was categorized in major or minor PFL and or FN, which occurred in a total of 32 cases. Risk factors such as radiation, chemotherapy, and obesity were not significant risk factors in this study. No significant differences were found in hemodynamics and flap temperature when comparing patients with or without complications. Mean intravenous fluid volume was 4.2±0.14 L. The volume of intravenous fluid perioperatively did not affect the hemodynamic parameters, and the 113
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