Chapter 5 used for reconstruction (FW) and percentage of the original abdominal flap used for reconstruction was recorded (FWU). FWU was recorded because it represents the inclusion of the zones (especially zone IV) of the TRAM flap. Inclusion of zone IV is also considered as a risk factor. The duration of ischemia period during the anastomosis was recorded. In addition, influencing factors on blood flow such as hemodynamics and room, patient, and flap temperature were recorded for analysis. Perioperative fluid management and haematocrit levels were analyzed due to the possible effect of haemodilution on blood viscosity and blood flow. FC used for analysis in this study were photographed and percentage of necrosis was calculated using planimetry. Partial flap loss was classified as minor when less than 3% skin loss occurred with or without its underlying subcutaneous tissue (m‐PFL). Major partial flap loss was classified as major when more than 3% skin loss occurred with or without its underlying subcutaneous tissue (M‐PFL), this group represented a more severely affected group which required surgical debridement and secondary wound closure in the operating theater. FN incidence was recorded at the outpatient clinic for up to 3 months after the surgery. FC represents the cumulative number of patients with either PFL or FN. Cutaneous microcirculatory blood flow was measured using the Periflux 5000 system (Perimed). This is a reliable noninvasive method for evaluating microcirculatory blood flow and has been described previously.27–32 Blood flow is presented in arbitrary units. Laser Doppler flow (LDF) measurements were performed intermittently for 5 days simultaneously in zones I and IV with the Periflux 5000 system (Table 5.3). Room temperature was standardized during the first 24 hours of the study (OR and recovery). All measurements were performed at absolute rest and for a period of 3 minutes. 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 5.1). 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. At this point, the entire flap is supplied by the deep inferior epigastric vessels, which lead to the categorization of the flap zone (I–IV). A 10‐ minute interval was chosen to have a standard time elapse, with no manipulation of dissected the flap. This may lead to false high‐blood‐flow values. In our own experience and a recently performed study (submitted), this acclimatization period takes, however, much longer. A longer acclimatization period was not used, because it would increase the duration of the surgery and may negatively affect the outcome. After successful transplantation, LDF was hourly measured, starting 1 hour after completion of the anastomosis. From the first to the fourth postoperative day, LDF was measured 3 times a day (Table 5.3). 74
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