Blondeel, Phillip

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Ghent University Academic Bibliography

DiscussionEfficacy of Venous Supercharging of the Deep InferiorEpigastric Perforator Flap in a Rat ModelDiscussion by Phillip N. Blondeel, M.D., Ph.D.Gent, BelgiumThe work of Geoff Hallock and David Rice isunique in that they describe the only animalmodel for rectus abdominis perforator flaps inrats. They have shown that valuable informa-tion can be learned about the physiology ofblood flow in perforator flaps. Unfortunately,the rat model cannot be extrapolated to thedeep inferior epigastric perforator (DIEP) flapin humans. In a rat, there is a clear dominanceof the superficial inferior epigastric system inthe lower abdomen in relation to the deepsystem. Almost no rectus abdominis perfora-tors can be found in the lower abdomen. Onthe other hand, there is always a relatively largesuperior epigastric system. In the more proxi-mal part of the abdomen, large perforators ofthe superior epigastric artery can be found anddissected, as shown in this article. The fact thatmore flaps survived when the inferior superfi-cial epigastric vein was used shows that thesuperficial system in a rat is more importantthan the deep system.The safety and, therefore, the success rate liein the surgeon’s ability to recognize the ana-tomical variability between different species aswell as between different individuals of thesame species. For example, in the rat, the skinand subcutaneous tissues are drained by theinferior superficial epigastric system. Althoughthere may be some differences in the vascularanatomy of different rats, this type of vascular-ization is pretty much standard. In humans,much more anatomical variability is observed,both in the arterial system and the venousdrainage. Although the inferior superficial epi-gastric artery can be found in many cases, itscaliber, flow, and branching are often insuffi-cient to provide adequate irrigation of an en-tire DIEP flap. In more than 90 percent ofcases, the large perforators of the deep inferiorepigastric system need to be used if a largeDIEP flap across the midline needs to be har-vested.The same is not always true for the venousdrainage. In more than 80 percent of our pa-tients who had not undergone previous ab-dominal surgery, a decent superficial epigastricvein could be found at the level of the lowerincision of the DIEP flaps. This vein is alwayscapable of draining the entire flap without theneed of the deep epigastric venous system. Al-though this vein is present most of the time, westill prefer to use the deep venous system, be-cause it makes the microsurgical anastomosisand consequent shaping much easier. The su-perficial system is used only in cases of inade-quate venous drainage by the deep system or incase of revision and thrombosis of the deepsystem. Between the extremes of having a dom-inant superficial arterial and venous systemwith no deep perforators at all and cases wherethere is no superficial system and a clear dom-inance of the deep inferior epigastric perfora-tors, there is a wide range of differences invascular anatomy. This variability is very indi-vidual, and it is up to the surgeon to find outbefore he or she starts surgery (or sometimesduring surgery) which vessels to choose to en-sure adequate perfusion of the flap.Phillip N. Blondeel, M.D., Ph.D.Kliniek voor Plastische HeelkundeUniversitair Ziekenhuis GentDe Pintelaan 185B-9000 Gent, Belgiumphillip.blondeel@ugent.beReceived for publication March 7, 2005.DOI: 10.1097/01.prs.0000175221.84548.12556

Efficacy of venous supercharging of the deep inferior epigastric perforator flap in a rat model - Discussion

https://biblio.ugent.be/publication/363998/file/575177

Efficacy of venous supercharging of the deep inferior epigastric perforator flap in a rat model - Discussion

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