Summary & discussion and future perspectives complications, such as FN, still occur, and its incidence in the literature using sensitive objective methods is 30%.15 A recent analysis of the literature by Lie et al.16 showed that the range for reporting PFL was categorized using cutoff points for inclusion, with a range of skin loss between 5% and up to 20%. FN also has a wide range of definitions for inclusion in the literature. In our study, every skin loss or palpable lump was reported and further categorized in minor and major flap complications. There is a need for consensus on the reporting of PFL and FN to prevent ambiguity and to allow a more objective comparison of surgical outcome among centers and for research purposes. A reduced perfusion was demonstrated in zone IV in patients with a high flap weight after reperfusion. Smoking was also associated with reduced perfusion in zone IV after reperfusion. Perfusion increased in zone IV, during the first 5 hours after reperfusion as described in chapter 4. However, this gradual increase in perfusion was delayed compared with patients with a lower flap weight and nonsmokers. We concluded that a high flap weight and smoking independently predisposes distal parts of the flap to increased ischemia and IR and, therefore, more PFL and FN. Obese patients should be advised to lose weight, and for smokers cessation prior to surgery is recommended. Chapter 6 Arginine supplementation reduces the prolonged ischemic period that occurs in the distal part of the MS‐TRAM flap after reperfusion injury In chapter 6, an intervention study in a double‐blind, randomized clinical trial (RCT) set‐ up was conducted with arginine. Because IR injury is a complex and multifactorial pathology, multiple strategies have proven to reduce IR in surgical flaps. L‐Arginine (an NO precursor), NO direct donors, or (selective) NO synthase inhibition has proven successful in multiple experimental studies as reviewed in chapter 3. Microsurgical breast reconstruction is a relatively safe and successful procedure despite its (minor) flap complications. Therefore, interventions aiming to reduce flap complications need to be safe and have a low cost. Previous studies with arginine have shown that clinical administration is safe and, therefore, arginine supplementation was chosen in this RCT.17 The effect on microcirculation in the flap and the results on clinical outcome were investigated in this RCT. Patients received either L‐arginine or control L‐alanine in a double‐blind fashion. There were no significant differences between the patients and the flap characteristics between the study groups. PFL and/or FN occurred in 30% of patients. Two of these patients were allocated in the arginine group, and the flap complications were minor and were all treated conservatively. Five of these patients were allocated in the alanine group. Two patients had minor flap complications and 117
Microsoft Word - chapter 0 v1 DB.doc
To see the actual publication please follow the link above