A study of perfusion of the distal free TRAM flap Introduction Necrosis of skin flaps, either partial or complete, is a major complication in reconstructive surgery. Increased knowledge of anatomy, physiology and improved surgical technique has changed flap surgery.1‐4 Due to these advances, success rates of microsurgical reconstruction are now well above 90%. However, despite careful trimming of a free flap in order to exclude a questionable part of the flap with poor blood flow (usually minor), complications with flap viability after free tissue transfer can still occur. These complications occur despite successful anastomosis and therefore must be a result of poor blood flow within the flap itself. In addition, random pattern flaps are still widely and regularly used in many (plastic‐) surgical procedures such as abdominoplasty, mammaplasty and skin flaps after mastectomy. All these procedures may be complicated by insufficient blood flow in the flaps.5‐9 The purpose of this study was to investigate the microcirculation changes in the peri‐ and postoperative period in the proximal as well as the distal part (zone IV) of the free flap. In our experience the TRAM flap has a high rate of flap complications (FC) such as fat necrosis and partial flap loss (PFL) if zone IV is incorporated in the reconstructed breast. The low perfusion of zone IV and clinical experience has led some surgeons to systematically discard zone IV for reconstruction. However, recent studies still show the use of zone IV.10‐11 One reason for this might be to achieve adequate volume and projection. Inevitable changes in blood supply to the free flap are due to changes in vascularisation, denervation and ischemia‐reperfusion injury. This leads to complex interactive changes in vascular reactivity which occur at a neural, humoral, physical and metabolic level during flap harvest, transfer and in the post transfer period.12 Macroscopic changes in the blood flow in recipient and donor vessels that occur after free flaps have shown that there is an increase in postoperative flow.13‐15 In addition, arterial flow does not appear to be dependent on the chosen recipient vessel, but mainly on the vascular resistance in the flap.15‐16 The vascular resistance in the flap is controlled by the smaller vessels within the flap itself (arterioles). However, little data are available on the microcirculatory changes in the various parts of the flap during surgery and especially in the following acclimatisation period. Some centres have used measurement of microcirculation with variable success to monitor the free flap postoperatively. In these studies only the (central) proximal part of the flap was monitored.17‐19 In two previous studies by Tuominen et al.20 and Hallock21 microcirculation was assessed during the operation. The studies revealed the deep inferior epigastric artery as the dominant source of blood supply of the TRAM flap over the superior inferior epigastric artery and the superficial epigastric artery. In both studies the differences in microcirculation during surgery in the proximal (zone I) and the distal part (zone IV) have been measured. However, the expected adaptations of the microcirculation in the days after surgery have not yet been investigated. The purpose of this study was to monitor the microcirculation in the 57
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