Chapter 8 Chapter 4 Prolonged distal ischemia (zone IV) occurs after reperfusion in the MS‐TRAM, establishing IR as the underlying cause for PFL and FN. An increased perfusion is seen in zone IV in the course of several hours, indicating the opening of choke vessels between the angiosomes of the flap. In chapter 4, perioperative microcirculation and physiological adaptation within the flap after IR injury were investigated. In this prospective study, the microcirculation with the MS‐TRAM flap on its pedicle, after IR, and the first 5 hours after reconstruction were measured in zone I and zone IV. The results in this study show that after IR, the distal part of the flap remains ischemic after reperfusion and the microcirculation distally in the flap gradually increases over the course of several hours. This renders the distal part of the flap to ischemia and target of IR injury. This study demonstrates for the first time that the recovery of microcirculatory flow within zone IV is significantly delayed. This predisposes distal parts of the flap vulnerable to IR injury and as consequence PFL/FN. Chapter 5 High flap weight and smoking independently predisposes the distal parts of the flap to increased ischemia and IR and, therefore, more PFL and FN. In chapter 5, possible risk factors and their influence on microcirculatory blood flow using the LDF and the clinical outcome were investigated in a prospective study. In addition, the literature on flap complications and the risk factors was also reviewed. Preoperative active smoking, morbid obesity (body mass index >30 kg/m2), and postoperative radiation are commonly associated with flap complications. Literature review revealed PFL in 0%–37.5% and FN in 6%–42% of the cases. Flap complications occurred in nine patients (43%) (PFL and/or FN). Twenty‐one patients with the MS‐TRAM flap were included, and smoking was a significantly associated with flap complications. Our clinical studies reveal a high rate of flap‐related complications. The cause may lie in the fact that there is no consensus in reporting PFL and FN. In more recent literature and in our clinic, the incidence of PFL is decreased because of more primary breast reconstruction, where skin sparing mastectomy is performed with direct reconstruction. In addition, with preoperative imaging and planning, dominant perforator selection is facilitated, and flap design can be adapted using the best perforators. Zone IV is excised and all parts of the flap, showing marginal perfusion are commonly removed to minimize flap complications. Despite this, flap 116
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