Tyge T. Tindholdt

Microcirculatory evaluation of deep inferior epigastric artery perforator flaps with laser Doppler perfusion imaging in breast reconstruction

Abstract We have made a quantitative analysis of the microcirculation in the classic perfusion zones of the deep inferior epigastric artery perforator (DIEAP) flap on 10 consecutive women having breast reconstruction with a unilateral DIEAP. Laser Doppler perfusion imaging was used for operative scans. Data were recorded 10 minutes after successful microanastomosis. The mean (SD) perfusion for each perfusion zone was calculated. Zone I = 44.2 (6.2); zone II = 35.1 (10.3); zone III = 39.9 (9.2); and zone IV = 21.9 (10.0). There were significant differences between zones I, II, and III and zone IV (p < 0.001), and zones I and II (p = 0.02). However, there was no significance between zones I and III (p = 0.9), and zones II and III (p = 0.6). The perfusion of zone IV was significantly lower than those in all other zones, which is in keeping with clinical practice in which zone IV is normally discarded to avoid partial necrosis of the flap in unilateral breast reconstruction. Higher values are expected in zone I than zone III, and in zone II than zone III. However, we could not confirm this. We conclude that there are no differences in skin perfusion between zones I and III, and zones II and III. However, the perfusion of zone IV was significantly less than that in all other zones immediately after revascularisation of the DIEAP flap.

Monitoring microcirculatory changes in the deep inferior epigastric artery perforator flap with laser Doppler perfusion imaging.

Microcirculatory changes were monitored in 20 deep inferior epigastric artery perforator (DIEAP) flaps during unilateral breast reconstruction until the seventh postoperative day using laser Doppler perfusion imaging. Measurements were recorded according to the zonal classification by Scheflan and Dinner. The cutaneous territory zone IV was discarded during insetting due to marginal circulation. The highest perfusion levels were found the first postoperative day for both zones I and III. Postoperative perfusion values were significantly higher for these zones compared with zone II. Immediately after revascularization, zone I was significantly better perfused than both II and III. However, the perfusion in zone III stabilized at the level of zone I in the postoperative phase. Evaluating microcirculatory changes in the DIEAP flap with laser Doppler perfusion imaging showed that zones I and III have higher perfusion levels than zone II in the postoperative phase.

Spontaneous reinnervation of deep inferior epigastric artery perforator flaps after secondary breast reconstruction

The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard of free flaps in breast reconstruction. However, until now little attention has been paid to reinnervation of the flap. The aim of this study was to examine the spontaneous reinnervation of the DIEAP flap after breast reconstruction. The study was cross-sectional, and included 29 women who had all previously had secondary reconstruction with a DIEAP flap after mastectomy for breast cancer. Pressure thresholds were analysed on the skin island of the flap using Semmes-Weinstein monofilaments. The measurements showed measurable sensation in 29 of the 30 flaps. Nine patients had normal or diminished light touch in one or more areas. We also found significant better pressure sensitivity when the medial was compared to the lateral side and the inferior to the superior side of the flap. Our data showed that DIEAP flaps reinnervate after breast reconstruction although there is no sensory nerve repair. We suggest that nerve ingrowth takes place from the sides and this seems to be more pronounced in the inferomedial part of the flap.

Patient-reported outcomes after breast reconstruction with deep inferior epigastric perforator flaps.

We assessed patient-reported outcomes in 34 women who had had their breasts reconstructed with a deep inferior epigastric perforator (DIEP) flap, and compared them with those of 24 patients who were waiting for breast reconstruction. Both groups completed the Short Form 36 (SF-36) questionnaire. The DIEP flap group also assessed their preoperative conditions retrospectively and completed a study-specific questionnaire. The DIEP group reported higher SF-36 mental health scores after the operation than before, but no difference on other SF-36 scales. There was no difference on any SF-36 scale between patients who had had DIEP flaps and those waiting for reconstruction. Most of the DIEP group was satisfied with their bodies, the appearance of their breasts after reconstruction, and would have chosen operation again. In conclusion, there was little improvement in generic health-related quality of life after reconstruction with a DIEP flap. However, patients’ satisfaction was high after the procedure.

Green urine after surgical treatment of pressure ulcer.

We describe a 58-year-old man who developed green urine after operation on a pressure ulcer. The discolouration disappeared gradually after two days. We think that the use of methylene blue dye during the revision of the wounds and the use of the sedative propofol could have caused it.

Microcirculation in single and multiple-based perforator flaps in an experimental model of rats.

Our aim was to evaluate the effect of single and multiple-based perforator flaps on the microcirculation in rats. Two symmetrical abdominal flaps were raised around the midline in 17 rats, and sutured into their original positions after dissection. All major perforators in the flap were left intact on one side, and on the opposite side only one perforator was retained. The microcirculation in the flaps was measured with laser Doppler perfusion imaging at different time intervals. Before dissection of the flap the mean (SD) microcirculation was 5.5 (1.6) units in the multiple-based perforator flap and 5.5 (1.4) in the single-based perforator flap. Within the first two hours after the flap had been raised the highest microcirculation was found after 30 minutes with 7.3 (1.3) units in the multiple-based perforator flap compared with 6.5 (1.4) units in the single-based perforator flap (p=0.002). We conclude that the microcirculation in the single-based perforator flap was not reduced after dissection. However, a reactive hyperaemic response was found only in the multiple-based perforator flap.

Skin burned by contact with flagstones made of cement

Chemical burns account for few admissions to burns units. A well-known but rare cause is wet cement. We present a case where a man had a full-thickness skin burn after contact with flagstones made of cement.

Donor site sensitivity after breast reconstruction with deep inferior epigastric artery perforator flap.

The aim of this study was to examine pressure sensitivity at the donor site after breast reconstruction with deep inferior epigastric artery perforator (DIEAP). In a cross-sectional survey, 2 groups of patients were analyzed. The DIEAP group consisted of 30 women who had previously had secondary breast reconstruction with DIEAP flap after mastectomy for breast cancer. The control group consisted of 7 women with no previous abdominal incisions planned for secondary breast reconstruction with DIEAP. Pressure thresholds were tested within the margins of the abdominal wall using Semmes-Weinstein monofilaments. In the DIEAP group a pattern of higher pressure thresholds was observed in the proximity of the scar. Comparing the 2 groups, significant higher pressure thresholds were found in the DIEAP group in the scar on both sides and in the midline from the scar to the umbilical level. Our data show that the abdominoplasty performed during breast reconstruction with DIEAP reduces cutaneous sensitivity in the donor site area.

Skin viability and wound strength in single and multiple based perforator flaps in an experimental rat model

Our aim was to evaluate the effect of single and multiple based perforator flaps on the skin viability and wound strength in rats. We used 17 Wistar rats in which two symmetrical abdominal flaps were raised around the midline. On one side all major perforators to the flap were left intact, and on the other side only one perforator was retained. After dissection, the flaps were sutured back in their original position. After seven days each rat was killed and the skin viability and wound strength were measured. The multiple based perforator flap had a mean skin viability of 98% compared with 95% in the single based perforator flap (p=0.08). The mean (SD) wound strength was 3.8 (0.9) N in the multiple based perforator flap compared with 3.0 (1.1) N in the single based perforator flap (p=0.02). We conclude that there is significantly greater wound strength at day 7 with the multiple based perforator flap than with the single one.

Microcirculatory Evaluation of the Abdominal Skin in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap

Background: No studies have assessed the perfusion of the undermined abdominal skin in breast reconstruction with deep inferior epigastric artery perforator flap. A greater understanding of the procedure’s impact on the perfusion of the abdominal skin can be valuable in predicting areas susceptible to necrosis. Methods: Microcirculatory changes were monitored in the abdominal skin of 20 consecutive patients undergoing breast reconstruction with a deep inferior epigastric artery perforator flap. Quantitative mapping was performed with laser Doppler perfusion imaging at 7 set intervals. Measurements were taken and recorded within 4 standardized zones covering the skin between the xiphoid process and the upper incisional boundary of the flap (zones 1–4; cranial to caudal). Results: Before commencing surgery, a significantly higher perfusion was registered in zones 3 and 4 when compared with zone 1. After undermining the abdominal skin, the perfusion in zones 1–3 increased significantly. After the abdominal closure, the perfusion dropped in all 4 zones and only the perfusion level in zone 1 remained significantly higher than preoperative mean. Postoperatively, the perfusion of each zone stabilized at a significantly higher level compared with preoperative values. No tissue necrosis was observed in any of the zones. Conclusions: Although perforators are divided during undermining of the abdominal skin, there seems to be a reactive hyperemia that exceeds the blood supply delivered by the perforators. Thus, due to microcirculatory mechanisms, the undermining of the abdomen during the procedure does not seem to present any great risk of tissue necrosis.