Chapter 8 Future perspectives This thesis (re)addresses the fact that flap‐related complications are not only related to vascular anatomy and surgical technique. Breast reconstruction remains a complex procedure where a team approach in accordance with perioperative care, patient comorbidity, risk factors, and surgical experience is important. Autologous breast reconstruction is a relatively safe procedure, while flap complications remain a problem despite advances in knowledge of the anatomy, surgical technique, and preoperative planning. IR injury is the underlying cause for PFL and FN. Therefore, interventions aimed to reduce IR injury and subsequent flap complications in autologous breast reconstruction should be applied without compromising safety and significantly increased costs. Change of perspective: From technical advances toward basic biological approach The field of plastic and reconstructive surgery has evolved enormously since its start after World War I. During the last decades of this development plastic surgeons have been in the frontline when it comes to developing new techniques. Many flaps were described and used in conjunction with the increase and refinement of surgical instruments. These instruments combined with the technical and medical advancements have changed the profession enormously during the second part of the 20th century. During the last decades, numerous experimental studies using various strategies aimed at specific processes in IR injury have been investigated. They have shown significantly increased survival rates of surgical flaps after long ischemia periods and, consequently severe IR injury.25‐31 Despite this significant improvement in surgical flap survival in the literature, no RCT’s have been conducted so far. Strategies aimed at reducing IR‐mediated damage in the myocardium have been conducted in the clinical setting with variable success.32 A pharmacological intervention may be the last step to eradicate flap‐related complications such as PFL and FN. Arginine has shown promising results in our study. However, this is just a start, and more research, preferably in a multicenter RCT, should be performed. Because primary DIEPs with skin sparing mastectomy are performed more commonly, the study design has to be adapted with more sensitive methods such as ultrasound or MRI to quantify FN. A key to success may be a combination of interventions aimed at various specific processes in IR injury because IR injury is a complex and multifactorial process involving inflammation, immune system, complement system, reactive oxygen species (ROS) and ROS scavengers, and apoptosis. Therefore, a combination approach may have a synergistic effect and be far more effective. 120
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