How many perforators in a deep inferior epigastric artery perforator flap? The salvage of a perforator.

Abstract

Sir: We read with great interest the article by Ireton et al. entitled “Vascular Anatomy of the Deep Inferior Epigastric Artery Perforator Flap: A Systematic Review.”1 We appreciate the meticulous methods of developing this article showing the great variability of the vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap. Further studies will allow us to obtain an evidence-based perforator selection. The studies on perfusion territory show a discrepancy in findings between vascular mapping studies and clinical observation because they do not take into account the physiologic changes in the vasculature that occur in a living patient2; this concept is explained by Saint-Cyr et al.,3 who define the perforasome theory and explain how skin areas are linked between them by direct vessels and indirect vessels (recurrent flow from the subdermal plexus). Unfortunately, there is no evidence regarding the number and dimensions of the perforator vessels related to the prediction of flap survival. During the dissection of a DIEP flap, the choice of the perforator is a crucial step, and we prefer to include more than one perforator, when possible, in the same row, in this way increasing the blood supply to the flap. The risk of injuring the vessel during intramuscular dissection is always present. The procedure should be performed by a surgeon with great experience in perforator dissection. Also, resorting to more than one perforator leads to a higher risk. How should the surgeon behave in front of a vessel cut in a deep inferior epigastric artery perforator flap? The surgeon can solve the problem through different ways, including the following: (1) rely on other perforators; (2) use the contralateral side; and (3) convert the perforator flap to a musculocutaneous flap. The perforator-to-perforator anastomosis (Fig. 1) is another viable solution to untie the problem, especially if we do not prefer to convert to a musculocutaneous flap and when we cannot resort to other solutions as, for example, if we need to perform a bilateral DIEP flap or if there are no other available perforators. Moreover, the perforator-to-perforator anastomosis is an excellent option if we are not sure about the flap perfusion or if the perforator is accidentally injured during dissection.Fig. 1: The perforator-to-perforator anastomosis in a DIEP flap. Artery (A) and vein (V) were repaired using the simple interrupted suture with 10-0 nylon. In this case, the flap was based on another safe perforator, but we were not sure about the vascularization of the flap, so we decided to perform the anastomosis of the perforator accidentally injured to obtain a two-perforator–based flap (original magnification, × 10).The anastomosis of the injured perforator for a DIEP flap was reported in 2012 by Miyamoto et al.4 for partial damage of the vessel (vein or artery). We report perforator anastomosis for both vessels (vein and artery). In the absence of an evidence-based approach to perforator selection and dissection that limits the likelihood of injuring the vessel, salvage of the perforator is a reliable procedure that should be attempted, when possible, despite the fact that it requires a high level of microsurgical skill and is associated with the risk of anastomotic thrombosis.5 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Giuseppe A. G. Lombardo, M.D. Rosario E. Perrotta, M.D., Ph.D. Plastic and Reconstructive Surgery University of Catania Cannizzaro Hospital Catania, Italy Jiri Vesely, M.D., Ph.D. Clinic of Plastic and Reconstructive Surgery St. Anne’s University Hospital Brno Brno, Czech Republic