Chapter 4 this study (Table 4.4). Recent studies show that zone IV can be included to a reliable degree in selected patients.10,11 This shows that in selected (slim) patients the whole lower abdomen may be used and therefore keeping autologous reconstruction with sufficient volume safely possible. However, in a patient with risk factors, a smaller reconstructive breast size with removal of zone IV in combination with breast reduction to the contralateral side is the best method to reduce complications and morbidity. In addition, in our experience with DIEP flaps, recently introduced in our clinic, even more careful trimming of the flap is necessary to avoid complications. As a result zone IV in DIEP flaps is systematically discarded at our institution. Even when zone IV is completely removed small complications such as PFL and FN can still occur at the distal part of the flap. Although distal ischemia and subsequent partial flap loss are mainly described in the breast reconstruction studies (using either TRAM or DIEP flaps), they may also occur in other free flap types regardless of tissue type or in local transposition flaps (axial or random pattern). The increased knowledge of regional blood supply has significantly improved flap design and flap choice which we use in a clinical setting. However, despite the optimized flap design and high success rates, distal ischemia will always occur to some extent in either free or pedicled flaps. This is caused by factors that are inevitable due to flap surgery. This article is yet another piece in the understanding of flap physiology. Nevertheless, further basic research in improving the distal blood flow and even further improving the outcome is necessary. Our objective must not merely be survival rates of >95% of (free) flaps, but also to increase the blood flow in the whole flap and thereby further reduce complications with flap surgery such as PFL or FN. 66
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