A study of perfusion of the distal free TRAM flap Operations were performed by experienced plastic surgeons. The muscle‐sparing free TRAM flap was used in all patients for breast reconstruction; with this procedure a small medial part of the rectus abdominis was harvested along with several lateral (two to three) and medial (one to two) perforators.23 In all patients the internal mammary vessels were used for the anastomosis. Relative risk factors were not considered as exclusion criteria. Incidence of various risk factors included in the study was: smoking (8/30; 27%), obesity defined as a BMI equal to or greater than 28 (9/30; 30%), chest wall irradiations (12/30; 40%) and chemotherapy (23/30; 77%). Flap characteristics, e.g. flap weight, reconstructed breast weight and ischemia period were also recorded. In addition, influencing factors on blood flow such as hemodynamics, room, patient and flap temperature were analyzed. Fluid management and haematocrit levels were analyzed, due to the possible effect of haemodilution on blood viscosity and blood flow. Flap complications (FC) were carefully recorded according to the definition used (Table 4.1). Table 4.1 Definition and abbreviations used for Flap complications. 1. Fat necrosis (FN) A palpable hard mass in the reconstructed breast without loss of cutaneous tissue. 2. PFL 5% (PFL<5) Loss of a cutaneous portion of the flap with or without fat necrosis. Skin necrosis is less than 5% of the skin surface used in the reconstructed breast. Can be treated conservatively without adverse outcome. 3. PFL 5%‐10% (PFL 5‐10) Same as PFL<5 but with 5%‐10% loss of skin surface. Surgical intervention was necessary for a good aesthetic outcome. 4. PFL > 10% (PFL>10) Same as PFL<5 but with more than 10% loss of skin surface. Surgical intervention with significant reduction in reconstructed breast and contralateral breast in order to achieve a good aesthetic outcome. 5. Flap Complications (FC) Flap Complications (FC). All the with either FN and/ or a degree of PFL Cutaneous microcirculatory blood flow was measured using the Periflux 5000 system (Perimed®). This is a reliable non‐invasive method for evaluating microcirculatory blood flow and has been described previously.17‐20,24‐25 Laser Doppler flow measurements were performed intermittently for 5 days simultaneously in zones I and IV with the Periflux 5000 system (Table 4.2). Room temperature was standardized during the first 24 h of the study (operating theatre and recovery room). All measurements were performed at absolute rest and for a period of 3 min. Probe holders were sutured to the flap to ensure identical measurement sites during the study. The probe of zone I was placed between the lateral and medial row of perforators, whereas the second probe was placed at the medial border in zone IV (Figure 4.1). Laser Doppler flowmetry (LDF) was first measured during surgery with the flap on its pedicle. This was performed after the muscle‐sparing TRAM flap was completely dissected and solely connected to the vascular pedicle (with a standard acclimatization period of 10 min). At this point the 59
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