Reply: Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography

Abstract

Sir: We thank Drs. Chevray and Hatef for their thoughtful comments regarding our recently published article, “Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography.”1 Our algorithm for deep inferior epigastric artery perforator (DIEP) flap harvest is similar to that of many large series. Our preference is for single-perforator DIEP flap harvest where there is an obvious dominant perforator whose adequate perfusion of the flap can be demonstrated intraoperatively; where this is not available, multiple perforators within the same intramuscular septum are included to allow sufficient arterial inflow and venous outflow for safe flap harvest. Where inclusion of multiple perforators is necessary but they lie in different intramuscular septae, we have a low threshold for harvesting a muscle-sparing transverse rectus abdominis musculocutaneous flap to avoid damage to the perforators during dissection, to maintain linking vessels between the perforators within the muscle, and for speed of harvest. This algorithm ensures that the flap is adequately perfused while minimizing donor-site morbidity by preserving muscle continuity and the motor nerves to the rectus, and we agree with the authors that inclusion of multiple perforators may be necessary where the anatomy is unfavorable. Our findings have suggested that where a single dominant perforator is not present, inclusion of multiple perforators may increase the chance of including a perforator that adequately drains the flap through a direct venous connection to the superficial inferior epigastric vein. We read the recently published article by Baumann et al. with great interest and hypothesize that this factor may partially explain the decreased rate of fat necrosis seen in multiperforator DIEP flaps in their study,2 although further research will be necessary to determine this. Mark V. Schaverien, M.R.C.S. Stephen J. McCulley, F.C.S.(S.A.)Plast., F.R.C.S.(Plast.) Department of Plastic Surgery Nottingham University Hospitals NHS Trust Nottingham, United Kingdom DISCLOSURE The authors have no financial interests with respect to the content of this communication or the article being discussed.