What's the remedy for the distal necrosis of DIEP flap, better venous drain or more arterial supply?

Yi Zhang,Jiasheng Dong,Jiao Wei,Tingliang Wang,Hua Xu,Tao Wang,Ying Liu,Jinguang He,Fabio Santanelli

doi:10.1371/journal.pone.0171651

Yi Zhang, Jiasheng Dong + Show 7 more

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https://doi.org/10.1371/journal.pone.0171651

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Abstract

BackgroundWe developed a novel pedicled DIEP flap model in rat to explore the possible remedy for the distal necrosis of the flap.MethodsA deep inferior epigastric perforator (DIEP) flap, based on the second right cranial perforator (P2) as the main pedicle, was elevated in 48 Sprague-Dawley rats. The rats were randomized into 4 groups: group I, the left P2 remaining intact as supercharging; group II, the left P2 artery alone kept as supercharging; group III, the left P2 vein alone kept as supercharging; group IV, no supercharging. Transcutaneous oxygen pressure (TcPO2) and transcutaneous carbon dioxide pressure (TcPCO2) were measured immediately after flap elevation, protein level of Hif-1a was measured 48 hours later, and flap survival was assessed 7 days postoperatively.ResultsBlockade of artery led to significantly lower TcPO2, higher TcPCO2, and higher expression level of Hif-1a in the distal side of the flap in group III and group IV, than those of group I and group II. At 7 days post surgery, significantly lower flap survival rates were observed in group III (81.9 ± 5.7%) and group IV (78.4 ± 6.5%), compared to observed in group I (97.2 ± 3.0%) and group II (94.2 ± 6.2%).ConclusionsIt might be arterial insufficiency, not venous congestion, which mainly caused the distal necrosis of the DIEP flap in rat. Arterial instead of venous supercharging might be a more effective procedure that improves circulation to zone IV of the flap.

Highlights

The deep inferior epigastric perforator (DIEP) flap has become an increasingly popular flap choice for the reconstructive surgeries [1,2,3], since its first introduction in 1989 by Koshima et al [4]
At 7 days post surgery, significantly lower flap survival rates were observed in group III (81.9 ± 5.7%) and group IV (78.4 ± 6.5%), compared to observed in group I (97.2 ± 3.0%) and group II (94.2 ± 6.2%). It might be arterial insufficiency, not venous congestion, which mainly caused the distal necrosis of the DIEP flap in rat
Some literatures presumed that the venous congestion is the main cause of the zone IV necrosis of DIEP or transverse rectus abdominis myocutaneous (TRAM) flaps [10,11], while other literatures demonstrated that the arterial inflow had a marked effect on the survival of the distal part of the flaps [12,13]

Summary

Introduction

The deep inferior epigastric perforator (DIEP) flap has become an increasingly popular flap choice for the reconstructive surgeries [1,2,3], since its first introduction in 1989 by Koshima et al [4]. Our previous work has demonstrated the reconstruction of a ptotic breast using double-pedicle DIEP flap, in which a contralateral perforator (including an artery and venae comitante) is preserved as supercharging by microvascular anastomosis [8,9]. Some literatures presumed that the venous congestion is the main cause of the zone IV necrosis of DIEP or TRAM flaps [10,11], while other literatures demonstrated that the arterial inflow had a marked effect on the survival of the distal part of the flaps [12,13]. We developed a novel pedicled DIEP flap model in rat to explore the possible remedy for the distal necrosis of the flap

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