General discussion 4. Perforating veins communicating with the superficial venous network: venous congestion was one of the more significant sequelae of DIEP flaps. Therefore the evaluation of the venous anatomy was considered to be as important as or even more important than the evaluation of the arterial supply. Venous congestion occurred frequently whenever a communication between the deep and superficial venous systems was not evident on pre- operative angiography. 5. Broad subcutaneous segment and ramification of perforators into the flap: these characteristics improved flap vascularity and flap design. 6. Long subfascial segment: in many cases this was associated with a short intramuscular course and determined a longer pedicle. 7. Tendinous intersections: these were avoided, as they were associated with difficult dissections. Of all of these factors, the last two factors were considered the least impor- tant for perforator selection, although still valuable to take into consideration. The preoperative imaging gives the possibility to analyse more aspects than the anatomical dissection as for example to study the venous network and the course in the adipose subcutaneous tissue accompanying the perforator. In this thesis we focused our attention particularly on the intramuscular course of perforators: there are perforators running between two muscles (septocutaneous). These perforators are easier to dissect because they run into a loose areolar tissue in a separating plane between two muscles. We described this technique for the anterolateral thigh flap, the superior gluteal artery perforator flap and the septocutaneous tensor fasciae latae perforator flap. The presence of septocutaneous perforators coming from the superior gluteal artery determined a shift of the preoperative drawing just cranially to that for the standard S-GAP to include them, with a better aesthetic result than the standard flap. However not every patient has septocutaneous per- forators coming from the superior gluteal artery: therefore the preoperative screening with MRA is imperative as holds also for the sc-TFL. Equally important in perforator flaps surgery are the receptor vessels. We analysed in chapter 9 the topographical anatomy of the internal mammary vessels, usually used in breast reconstruction surgery and sometimes in the head and neck surgery. The study showed that the second intercostal space is most likely the best approach to the internal mammary vessels for micro- anastomosis using a rib-sparing technique because of wider intercostal space and larger diameter of the artery and vein5,6. 168
5. lay-out phd DEFINITIEF_digitaal2
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