Iain, Whitaker

Iain Whitaker

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 Cronfa -  Swansea University Open Access Repository   _____________________________________________________________   This is an author produced version of a paper published in :Plastic and Reconstructive Surgery                                              Cronfa URL for this paper:http://cronfa.swan.ac.uk/Record/cronfa18898_____________________________________________________________ Paper:Rozen, W., Whitaker, I. & Ashton, M. (2011).  A Combined Anatomical and Clinical Study for Quantitative Analysis ofthe Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap. Plastic andReconstructive Surgery, 128(3), 821-822.http://dx.doi.org/10.1097/PRS.0b013e3182221525        _____________________________________________________________  This article is brought to you by Swansea University. Any person downloading material is agreeing to abide by theterms of the repository licence. Authors are personally responsible for adhering to publisher restrictions or conditions.When uploading content they are required to comply with their publisher agreement and the SHERPA RoMEOdatabase to judge whether or not it is copyright safe to add this version of the paper to this repository. http://www.swansea.ac.uk/iss/researchsupport/cronfa-support/  time the incidence of problems such as late seromarequiring surgery and contracture of a double capsulewill increase. I can only hope that someday the U.S.Food and Drug Administration (and Canadian HealthProtection Branch) will approve an implant that allowstrue tissue ingrowth (without separation of the coating)such as the newer polyurethane implants that theseauthors have available in Italy.DOI: 10.1097/PRS.0b013e31822215eeElizabeth J. Hall-Findlay, M.D.P.O. Box 2009317 Banff Avenue, Suite 340Banff, Alberta T1L 1B7, Canadaehallfindlay@banffplasticsurgery.caA Combined Anatomical and Clinical Study forQuantitative Analysis of the Microcirculation inthe Classic Perfusion Zones of the DeepInferior Epigastric Artery Perforator FlapSir:We read with interest the article by Rahmanian-Schwarz et al., “A Combined Anatomical andClinical Study for Quantitative Analysis of the Micro-circulation in the Classic Perfusion Zones of the DeepInferior Epigastric Artery Perforator Flap.”1 Althoughthe study itself is well designed and well reported, andcertainly adds some valuable anatomical and physio-logic information to our understanding of deep infe-rior epigastric artery (DIEA) perforator (DIEP) flaps,we would like to comment on the terminology used inthemapping of perfusion zones of the lower abdominalwall.The authors make the statement that “since the de-scription of the vascular territories of the DIEP flap waspublished in 1983, many surgeons have used it for theselection of well-perfused tissue in microvascular au-tologous breast reconstruction. Our study disputes agenerally accepted definition of the classic perfusionzones of the DIEP flap.” In making this statement, theauthors appear to have confused the previously de-scribed perfusion zones of the transverse rectus ab-dominis myocutaneous (TRAM) flap with the DIEPflap. The TRAM flap perfusion zones are based on skinperfusion by means of all the cutaneous perforators ofthe DIEA, whereas a DIEP flap is necessarily perfusedby only one or several perforators. The terminology inthe recent literature has thus changed from the TRAMperfusion zones (or the angiosome of the DIEA) to theDIEP perfusion zones (or the perforator angiosome ofDIEA perforators), based on a range of cadaveric andclinical studies performed by both ourselves and byWong et al. and Saint-Cyr et al.2–4 When describing theperfusion of the abdominal wall based on one or severalperforators, the perfusion zones aremarkedly differentfrom the TRAM perfusion zones.In our clinical and cadaveric studies,2 in which welooked at 200 hemiabdominal walls from both cadaversand patients, analyzing over 1500 DIEA perforators, wefound that there is a specific “perforator” angiosomefor each individual perforator, and that these differbetween medial and lateral row perforators. “Perfora-tor angiosomes” mirror the angiosome patterns de-scribed by Taylor and Palmer5; however, the subangio-somes of individual perforators present some uniquefeatures. We found that each DIEA perforator has itsown territory of supply, independent of the zone ofsupply by the source vessel. Of these, lateral row per-forators and medial row perforators have fundamentaldifferences in their zones of perfusion. Figure 1 dem-onstrates the perforator angiosomes of the DIEP flap,with several key features evident:1. Zone I of medial row perforators is larger, hasmore extensive branching, and has larger calibervessels than lateral row perforators.2. Zone I of medial row perforators is centered overthe position of perforators as they emerge fromthe anterior rectus sheath, as they have a rela-tively direct course to the Scarpa fascia, at whichFig. 1. The perforator perfusion zones. Perfusion zones of thelowerabdominal flaparesuppliedbyamedial rowperforator (redarrow, above) or a lateral row perforator (red arrow, below). (Re-producedwithpermission fromRozenWM,AshtonMW, LeRouxCM, Pan WR, Corlett RJ. The perforator angiosome: A new con-cept in the design of deep inferior epigastric artery perforatorflaps for breast reconstruction.Microsurgery 2010;30:1–7.)Volume 128, Number 3 • Letters821point branching occurs; whereas zone I of lateralrow perforators is centered lateral to the locationof the perforator at the anterior rectus sheath, asthere is a lengthy lateral course traversed by lat-eral row perforators before reaching the Scarpafascia and branching.3. The primary zones (zones I and II) of medial rowperforators routinely cross the midline to perfusethe medial parts of the contralateral hemiab-dominal wall, whereas lateral row perforators donot primarily communicate with branches thatcross the midline.4. Zones I and II (the territories of maximal perfu-sion within a perforator flap) comprise morethan the entire ipsilateral hemiabdomen for amedial row perforator, but are more limited for alateral row perforator.These findings match similar studies by Wong et al.,and a close look at the results of the current studydemonstrate that Rahmanian-Schwarz et al. have sim-ilar findings themselves: the perfusion studies in theirFigure 6 demonstrate very nicely the “perforator an-giosome” of a single perforator—shown nicely to notfill an entire TRAM flap zone.DOI: 10.1097/PRS.0b013e3182221525Warren M. Rozen, M.B.B.S., B.Med.Sc., Ph.D.Iain S. Whitaker, M.A.Cantab., M.B.B.Chir., Ph.D.Mark W. Ashton, M.B.B.S., M.D.Jack Brockhoff Reconstructive Plastic Surgery ResearchUnitDepartment of AnatomyUniversity of MelbourneParkville, Victoria, AustraliaCorrespondence to Dr. RozenJack Brockhoff Reconstructive Plastic Surgery ResearchUnitRoom E533Department of AnatomyUniversity of MelbourneGrattan StreetParkville 3050, Victoria, Australiawarrenrozen@hotmail.comREFERENCES1. Rahmanian-Schwarz A, Rothenberger J, Hirt B, Luz O,Schaller HE. A combined anatomical and clinical study forquantitative analysis of the microcirculation in the classic per-fusion zones of the deep inferior epigastric artery perforatorflap. Plast Reconstr Surg. 2011;127:505–513.2. Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ.The perforator angiosome: A new concept in the design ofdeep inferior epigastric artery perforator flaps for breast re-construction. Microsurgery 2010;30:1–7.3. Wong C, Saint-Cyr M, Mojallal A, et al. Perforasomes of theDIEP flap: Vascular anatomy of the lateral versus medial rowperforators and clinical implications. Plast Reconstr Surg. 2010;125:772–782.4. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ.The perforasome theory: Vascular anatomy and clinical im-plications. Plast Reconstr Surg. 2009;124:1529–1544.5. Taylor GI, Palmer JH. The vascular territories (angiosomes)of the body: Experimental study and clinical applications. Br JPlast Surg. 1987;40:113–141.Reply: A Combined Anatomical and ClinicalStudy for Quantitative Analysis of theMicrocirculation in the Classic Perfusion Zonesof the Deep Inferior Epigastric ArteryPerforator FlapSir:It is with great honor that we reply to such interestingcommentary and insightful observations made by ouresteemed colleagues, Drs. Rozen, Whitaker, andAshton. We appreciate their ongoing productive as-sessment and work in the field of plastic and recon-structive surgery.The aim of our study was not necessarily to rede-fine the zones of the deep inferior epigastric arteryperforator (DIEP) flap but rather to combine a clin-ical and cadaveric study and to assess the perfusiondynamics and vascular anatomy of these two distinctstudy types. The authors intentionally chose to useHartrampf’s zones, as these are familiar to most plas-tic and reconstructive surgeons.1 Furthermore, thishas been the standard for research and has been usedbyWong et al., Holm et al., and Baily et al. to comparetheir results.2–4Our study showed that there is a difference be-tween cadaveric and clinical perfusion of the DIEPflap.5 We speculate that the differences between an-atomical and clinical results could be attributable tosystemic and local mediator processes that are onlyfound in living tissue or may even be released aftercircumcision and raising of a flap. As discussed in ourpublication, we further hypothesize that the cause ofsuch dynamic perfusion phenomena is related to thechoke vessels mentioned by de Weerd et al.6 Theydescribe choke vessels between the angiosomes oneach side of the midline that form a greater resis-tance for circulation than the choke vessels betweenthe ipsilateral angiosomes.Wong et al. demonstrated in their ex vivo study “Per-forasomes of the DIEP Flap: Vascular Anatomy of theLateral versus Medial Row Perforators and Clinical Im-plications” that the medial row perforators demon-strated a regular perfusion across the midline andrarely any perfusion across themidline from lateral rowperforators.3,4 There is a vast difference in results whenthis is compared with our clinical (i.e., in vivo) mea-surements. Our intraoperative measurements, usingthe O2C device, show no significant differences in theperfusion of zones II and III (Fig. 1).5We acknowledge similarities with the results ofRozen et al. and Holm et al.7,2 Nonetheless, we wouldlike to point out the major differences in the carryingout of the clinical studies. Our measurements werecarried out preoperatively and intraoperatively, that is,after the circumcision and raising of the flap on aPlastic and Reconstructive Surgery • September 2011822

A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap

A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap

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