Introduction have the poorest perfusion and was called zone IV (Figure 1.1). Zone IV, when included in the flap, is commonly affected by PFL or FN. Albeit to a lesser extent, FN and PFL are still quite common with reported rates of 6%–35% in the literature.64,66‐68 FN, a sequellum of necrosis, leads to palpable lump formation, which is occasionally accompanied by pain in some patients. This can be an emotional burden in breast cancer patients and lead to secondary corrective surgery. Although zone IV can be safely included in some patients, in most cases, zone IV is completely removed, and zone III is usually partially removed based on clinical judgement of impaired perfusion.69 Figure 1.1 The original four perfusion zones by Scheflan and Hartrampf to the unipedicle transverse rectus abdominis with a centrally perfused skin with declining perfusion of its peripheral ends based on clinical observations. Anatomical knowledge of the lower abdomen, including skin angiosomes, venosomes, and perforators, has improved in coincidence with flap design change from the pedicled TRAM flap to the perforator DIEP flap. Holm et al. changed the Hartrampf concept of a centrally perfused skin ellipse with the declining perfusion of its peripheral ends. Instead, they proposed that the ipsilateral half has an axial pattern of perfusion, whereas the contralateral half shows a random pattern with an individually variable blood supply (Figure 1.2). Therefore, the classic Hartrampf zones were rearranged, splitting the lower abdomen in midline and switching zones II and III.70 Venous insufficiency on the contralateral side (zones III and IV) is the most common cause of flap failure and may be attributed to the lack of sufficient connecting vessels in the midline of the DIEP/TRAM flap.64,68,71,72 17
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