Chapter 4 peri‐ and postoperative period in the proximal part (zone I) and the distal part (zone IV) of the free TRAM flap. Patients and methods We prospectively evaluated 30 patients in this clinical study. The institutional ethical committee of the Maastricht University Hospital approved the study protocol. Written informed consent was obtained from all patients. Exclusion criteria were a lower vertical laparotomy scar and a disproportional abdominal mass compared to the volume needed for breast reconstruction. These patients were excluded because the blood flow measurement location was expected to be discarded (medial border of zone IV). In addition only patients with a secondary breast reconstruction with no surplus of skin at the recipient site were included. Trimming of the flap started with removal of zone IV beyond the measurement site of zone IV. If not needed distal parts to the location of the perforator vessels of zones III, II and I were also discarded. These steps ensured the use of the skin tissue of the flap and preservation of the measurement sites in zone I and the medial border of zone IV. As a result all patients who were included in the study had both measurement sites intact for the duration of the study (Figure 4.1). Flap blood flow zones were named in accordance with our own clinical experience and recent literature with zones I and II on the ipsilateral side of donor vessels and zones III and IV on the contralateral side.22 Figure 4.1 Zone classification and LDF measurement sites. I–IV=Blood flow zones. ○=Laser Doppler flowmetry sites. Black dots in the centre of the circle represent the blood flow measurement sites in zones I and IV. Ipsilateral to the vascular pedicle, the LDF probe holder in zone I is sutured between the medial and lateral row of the perforators, whereas the second holder is sutured at the medial border in zone IV. The shaded area represents the part of the flap (zones III and IV) which is usually discarded. If needed, distal parts to the perforator vessels were also discarded in zone II and zone I. This method ensured a measurement location in zone I and zone IV. 58
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