Chapter 1 Figure 1.2 More commonly used perfusion classification introduced by Holm et al. in which an ipsilateral half of the flap has an axial pattern of perfusion, whereas the contralateral half shows a random pattern with an individually variable blood supply. The arterial and venous anatomy has been extensively studied with preoperative imaging, which facilitates dominant perforator selection using either CT73,74 or MRI.75 Preoperative imaging, especially of clinical value in preoperative DIEP flap planning, can accurately identify the dominant arterial perforator size, its course through the rectus muscle, and the perforator location at the level of the fascia. Preoperative imaging can also identify features of venous anatomy, such as the identification of SIE veins, its connection to the deep venous system, and the degree of midline crossover.72 Insufficient venous drainage may be a cause for partial perfusion failure in the contralateral abdomen and presumable precedes PFL and FN. Therefore, several attempts to increase contralateral venous drainage have been made with some success.76,77 Supercharging the contralateral side of the DIEP with an additional venous anastomosis with the SIE vein has demonstrated increased venous drainage of the contralateral abdomen.78 Enjanet et al. demonstrated that the additional venous anastomosis reduced the incidence of venous congestion completely without, however, significant effect on PFL or FN. Thus, contralateral venous congestion may not necessarily be the primary cause for flap complications. In bilateral DIEP flap breast reconstruction, dividing the lower abdomen in two DIEP flaps with both solely zone I and zone II, PFL still occurs in 12.5% of the cases, which is comparable with unilateral breast reconstruction. Ischemia‐reperfusion injury and PFL Anatomical variation and clinical interventions to reduce venous congestion only partially explain the pathophysiology of PFL and FN. PFL and FN may have other 18
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