MRA for Preoperative Planning and Postoperative Management of Perforator Flap Surgeries: A Review.

Perforator flap magnetic resonance angiography (MRA) has emerged as a widely accepted and preferred modality for perforator flap mapping at several institutions. Autologous perforator flaps are a type of reconstructive microsurgical technique that involves transferring skin and fat from one part of the patient's body to another to replace tissue lost due to trauma, cancer resection, or other reasons. Autologous perforator flaps are based on a specific perforating blood vessel perfusing the transferred tissue. Hence, the surgery relies on the precise identification and mapping of perforating vessels to ensure successful outcomes. With its superior soft tissue contrast and multiplanar imaging capabilities, MRA has shown great potential in providing accurate and detailed visualization of perforator anatomy, size, and course. This review article summarizes the current literature on perforator flap MRA, including its technical considerations, imaging protocols, postprocessing, and reporting, specifically for autologous breast reconstructions. The advantages and limitations of MRA in evaluating perforator flaps are discussed, including its role in preoperative planning, intraoperative guidance, and postoperative assessment. Anatomy, brief surgical technique, specific technical modifications, and reporting of most commonly performed autologous breast flaps are described. Recent advancements in Perforator flap surgery and MRA techniques are discussed. Additionally, we examine the emerging role of artificial intelligence and machine learning in improving the accuracy and efficiency of perforator flap MRA interpretation. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 5.

Uni-vs. bilateral DIEP flap reconstruction - A multicenter outcome analysis.

OBJECTIVE: Over the past decade numbers of bilateral mastectomy have increased steadily. As a result, bilateral breast reconstruction is gaining popularity. The presented study compares complications and outcomes of unilateral and bilateral DIEP free-flap breast reconstructions using the largest database available in Europe. METHODS: Female breast cancer patients (n = 3926) receiving DIEP flap breast reconstructions (n = 4577 free flaps) at 22 different centers were included in this study. Free flaps were stratified into two groups: a unilateral- (UL) and a bilateral- (BL) breast reconstruction group. Groups were compared with regard to surgical complications and free flap outcome. RESULTS: Mean operative time was significantly longer in the BL group (UL: 285.2 ± 107.7 vs. BL: 399.1 ± 136.8 min; p < 0.001). Mean ischemia time was comparable between groups (p = 0.741). There was no significant difference with regard to total (UL 1.8% vs. BL 2.6%, p = 0.081) or partial flap loss (UL 1.2% vs. BL 0.9%, p = 0.45) between both groups. Rates of venous or arterial thrombosis were comparable between both groups (venous: UL 2.9% vs. BL 2.2%, p = 0.189; arterial: UL 1.8% vs. BL 1.2%, p = 0.182). However, significantly higher rates of hematoma at the donor and recipient site were observed in the UL group (donor site: UL 1.1% vs. BL 0.1%, p = 0.001; recipient site UL 3.9% vs. BL 1.7%, p < 0.001). CONCLUSIONS: The data underline the feasibility of bilateral DIEP flap reconstruction, when performed in a setting of specialized centers.

Inferior epigastric artery lymph nodes: A pathway for systemic dissemination from peritoneal carcinomatosis?

BACKGROUND AND OBJECTIVES: We report, for the first time in the literature, a metastatic lymphatic pathway along the inferior epigastric vessels, through the inferior epigastric lymph nodes (IELNs), in patients with peritoneal carcinomatosis (PC). Interestingly, these lymph nodes (LNs) in the anterior retroperitoneum were not detectable on preoperative imaging. They may, however, represent a pertinent systemic dissemination pathway for PC. PATIENTS AND METHODS: In patients undergoing indocyanine green-fluorescence imaging during cytoreductive surgery for PC, an incidental finding of a hyperfluorescent LN, harboring metastatic tumorous cells, around the inferior epigastric artery was made. RESULTS: In three out of five patients with clear fluorescent hotspot, the harvested LN was harboring metastatic cancerous cells. None of these nodes, whether negative or positive, was visible on any preoperative imaging modalities. A protocol to sample, in a systematic manner, the IELN in patients with PC, is currently being devised at our institution. CONCLUSION: These lymphatic nodes basin and channels might reveal to be a potential passage from peritoneal metastasis to the extraperitoneal lymphatic compartment, representing an independent pathway for cancerous cell dissemination. This will bring us to further investigate the prevalence and the prognostic significance of these LNs.

Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions.

PURPOSE: As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. METHODS: For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded. RESULTS: A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59-5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14-11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27-3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052). CONCLUSIONS: This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions.

High incidence of recess formation at myopectineal orifice during laparoscopic surgery.

BACKGROUND: Groin hernias are frequently seen in clinical practice. The purpose of this study was to determine the rate of patients who might have latent groin hernia. METHODS: During laparoscopic abdominal surgery, we observed the area around the groin lesion and attempted to evaluate the degree of recess at myopectineal orifice. The classification defining the recess was as follows: Grade 0: no recess, Grade I: slight recess with a visible bottom, Grade II: deep recess with an invisible bottom, Grade III: other organ invaginated into the recess, and Grade IV: confirmed bulging on the body surface. RESULTS: From 2009 to 2011, 46 patients were enrolled. A recess around myopectineal orifice were detected in 20 patients. The lesions were as follows: 11 on the lateral side of the inferior epigastric artery (IEA), five on the internal side of the IEA, three at both sites and one found at the femoral ring. According to the grade classification of these groin hernias, 26 (57%) were Grade 0, 14 (30%) Grade I, 4 (9%) Grade II, 1 (2%) Grade III, and 1 (2%) Grade IV. CONCLUSIONS: This study showed that rate of patients with asymptomatic latent groin hernias is relatively high in Japanese.

A South Indian cadaveric study on obturator neurovascular bundle with a special emphasis on high prevalence of 'venous corona mortis'.

Surgical procedures in the pelvic region are very challenging because of the complex anatomy of this region. "Corona mortis" is a term used to describe retro-pubic anastomosis between the obturator and external iliac vessels. It is considered as a key structure as significant haemorrhage may occur if the vessels are cut accidentally during pelvic surgeries. Earlier studies have documented a high frequency of venous anastomosis compared to its arterial counterpart. The objective of our study was to document the prevalence of venous corona mortis in South Indian human adult cadaveric pelvises. We conducted this study on 73 cadaveric pelvic halves. Out of the 73 hemi pelvises, 36 were normal without any variations of the obturator vessels while 37 hemi pelvises (51%) showed the presence of abnormal obturator vessels which proves to be a very high incidence in terms of variations. Out of the 37 hemi pelvises, 25 (68%) showed the presence of 2 obturator veins, out of which 1 was normal and the other was an abnormal obturator vein. 8 hemi pelvises (22%) had only abnormal obturator vein. Most of the abnormal obturator veins drained into the external iliac vein, while two veins drained into inferior epigastric veins. Venous corona mortis is said to be frequently encountered during surgery and is considered to be as important as arterial corona mortis in its clinical implications. Individual evaluation of this risky anatomical structure should be done prior to any surgical interventions.

Histopathological Differences of the Pedicle Artery in Commonly Used Free Flaps: The Influence of Age, Gender, and Side.

PURPOSE: The increasing use of vascularized free flaps has increased the demand for a specified flap selection. This study investigated histologic differences in the arterial wall of the pedicle for commonly used free flaps and the effect of age, gender, and anatomic side on these differences. MATERIALS AND METHODS: Light microscopic examinations of vessel walls were performed on 245 specimens of the nourishing artery of commonly used free vascularized flaps in preserved cadavers. The peroneal artery (PA), radial artery (RA), inferior epigastric artery (IEA), deep circumflex iliac artery (DCIA), and circumflex scapular artery (CSA) were examined. Differences of histologic changes in the arterial wall and the effect of age, gender, and body side were investigated. RESULTS: All examined vessel specimens (age range, 62 to 98 yr; mean age, 83 yr; 15 female and 12 male) displayed mostly Class II changes. PA showed the greatest atherosclerotic changes, followed by the RA, IEA, DCIA, and CSA. Age had a meaningful effect on PA and RA. Anatomic side was important for PA and DCIA, whereas gender had a minor influence on vessel condition. CONCLUSION: The vessel wall of different flaps showed different atherosclerotic changes depending on age, anatomic side, and gender. These differences should be considered in flap selection.

Intravenous Hyaluronidase with Urokinase as Treatment for Arterial Hyaluronic Acid Embolism.

BACKGROUND: Although injection of hyaluronidase into surrounding tissues was proposed to treat arterial hyaluronic acid embolism, its application is still rather limited. The authors' goal was to investigate whether intravenous use of hyaluronidase can help resolve hyaluronic acid-induced arterial embolism. METHODS: Inferior epigastric arteries, nourishing inferior abdominal skin of rats, were injected with 0.02 ml of hyaluronic acid to create the animal model. The rats were divided randomly into four groups and given different solutions intravenously: hyaluronidase plus urokinase (group A), hyaluronidase (group B), urokinase (group C), or saline (group D). Progression of tissue necrosis in all groups was recorded for 1 week. The flap survival rate and mean percentage of surviving flap area were analyzed. RESULTS: The animal model closely imitated actual hyaluronic acid arterial obstruction cases. Flap necrosis occurrence rates of each group were 10 percent in group A, 70 percent in group B, 80 percent in group C, and 90 percent in group D. The mean surviving flap areas of each group were 92.45 percent (group A), 47.67 percent (group B), 41.41 percent (group C), and 33.19 percent (group D). When hyaluronidase and urokinase were used together, the flap necrosis rate decreased significantly compared with that of the control group (p < 0.05). Even in cases of necrosis, group A had a higher average surviving flap area than did the other groups. CONCLUSIONS: Combined use of hyaluronidase and urokinase can help increase the flap survival rate when administered intravenously in intraarterial hyaluronic acid occlusion cases. Both red thrombus and hyaluronic acid emboli must be dissolved for flap reperfusion. This method shows a promising effect for future application.

Abnormal Vessel Architecture Persists in the Microvasculature of the Massive Weight Loss Patient.

BACKGROUND: Research demonstrates a link between obesity and increased circulating inflammatory cytokines, which lead to changes in the microvasculature. Massive weight loss patients often experience delayed wound healing after body-contouring procedures; however, no studies exist to explore the inflammatory response of massive weight loss on microvasculature. This study hypothesized that massive weight loss patients who undergo body-contouring procedures maintain persistently elevated inflammatory markers in the microvasculature that delay wound healing. METHODS: Superficial inferior epigastric artery vessels were harvested during abdominally based free flap surgery and abdominal contouring surgery for normal weight and massive weight loss patients, respectively. Vessels were histologically assessed using immunohistochemistry and trichome staining to assess and compare vessel architecture. Analysis was performed for intimal proliferation and luminal occlusion ratio. RESULTS: All patients (n = 23) were female. Quantitative analysis of immunohistochemistry stains revealed no difference between normal weight and massive weight loss patients. Trichrome staining demonstrated abnormal vessel architecture in the massive weight loss group. Intimal proliferation was 11.4 ± 4.8 percent for normal weight patients compared with 29.5 ± 4.9 percent for massive weight loss patients (p < 0.0001). Occlusion ratio for normal weight patients was 29.9 ± 3.9 percent compared with 46.2 ± 8.1 percent for massive weight loss patients (p < 0.0001) CONCLUSIONS:: Despite the return to normal levels of inflammatory markers after massive weight loss, trichrome staining demonstrated irregular composition in the tunica adventitia and tunica media and increased intimal proliferation and occlusion ratio. This suggests vasculopathy that could explain delayed wound healing in the massive weight loss population.

The Protective Effects of Botulinum Toxin A Against Flap Necrosis After Perforator Twisting and Its Underlying Molecular Mechanism in a Rat Model.

PURPOSE: The purpose of this study was to examine our hypotheses that botulinum toxin A (BoTA) protect necrosis of perforator flap from perforator twisting. METHODS: Twenty-four rats were randomly divided into 2 groups. Twelve International Units of BoTA versus 1.2 mL normal saline was injected subdermally 3 days before flap elevation. In each group, bilateral before deep inferior epigastric perforator (DIEP) flaps, 5 × 3 cm in size, were created. The right and left (180 and 360 degrees of perforator twisting) DIEP flaps were separated. At 1 and 3 days postoperatively, skin above the perforator of the DIEP flaps was harvested to examine the degrees of gene expressions. Final survival percentage of flap and histology were assessed at postoperative day 5. RESULTS: The survival percentage of flap was significantly higher in the BoTA group than in the control group at both DIEP flaps after 180 and 360 degrees of perforator twisting at postoperative day 5 (95.23 ± 2.85% vs 91.00 ± 3.77%; P = 0.021 and 91.59 ± 2.87% vs 30.03 ± 6.91%; P < 0.001, respectively).Higher fibroblast density, enhanced epithelial necrosis, and inflammation were noted in the control group than in the BoTA group. In 180 degrees of perforator twisting group, BoTA may augment angiogenesis possibly via nuclear factor-κB-induced destabilization and the nuclear factor-κB/hypoxia-inducible factor 1-α/vascular endothelial growth factor pathway, whereas in the 360 degrees of perforator twisting group, the mechanistic target of rapamycin/hypoxia-inducible factor 1-α/vascular endothelial growth factor pathway may participate in BoTA-induced effective angiogenesis. CONCLUSIONS: We demonstrated that pretreatment with BoTA protects perforator flap caused by perforator at the pathological and molecular level using an experimental rat model.

[MASSIVE HEMORRHAGE FROM THE FISTULA FORMATION BETWEEN CUTANEOUS URETEROSTOMY AND INFERIOR EPIGASTRIC ARTERY: A CASE REPORT].

A 87-year-old man received radical nephroureterectomy for right renal pelvic cancer in 2009 and left cutaneous ureterostomy after radical cystectomy for bladder cancer in 2013. He visited the hospital for exchanging a 7 or 8 Fr single-J catheter every 2 to 4 weeks. Eleven months after the 2nd operation, massive bleeding from the stoma occurred when ureteral catheter was exchanged. Contrast-enhanced computed tomography showed that left inferior epigastric artery was located close to left ureter. Angiography of the left inferior epigastric artery didn't show an obvious fistula, but revealed the stoma was surrounded by ramified new blood vessels from left inferior epigastric artery. We suspected a rupture of the vessels and performed embolization for the branch of inferior epigastric artery to left ureter. This embolization made it possible for the bleeding to be controlled. Massive bleeding from the branch of inferior epigastric artery is very rare, and we report the case and review the literature.

Inferior epigastric artery pseudoaneurysms.

INTRODUCTION: Inferior epigastric artery (IEA) pseudoaneurysms are recognised complications of abdominal wall procedures, and a variety of approaches including surgical excision and ligation, percutaneous procedures and conservative management have been employed in treating this rare complication. METHODS: We describe a case of an IEA pseudoaneurysm diagnosed on computed tomography (CT) angiography, 14 days following a laparoscopic assisted low anterior resection, which was managed successfully with surgical excision and ligation. A review of the literature identified 32 reports of this complication since 1973 with 69% of cases occurring since 2000. FINDINGS: The main aetiology of IEA pseudoaneurysm was abdominal surgery (n=20); 65% of cases were attributable to abdominal wound closure or laparoscopic surgery. Two-thirds (66%) of patients presented between 11 and 63 days, and all except 1 case presented with discomfort, abdominal mass or haemodynamic instability. Colour Doppler ultrasonography was the imaging modality of choice (n=18), either alone or in combination with computed tomography and/or angiography. Surgical ligation and excision and percutaneous coil embolisation formed the mainstay of attempted treatments (69%), particularly following treatment failure using an alternative technique. CONCLUSIONS: The incidence of iatrogenic IEA pseudoaneurysms appears to be increasing. Awareness of this rare complication is of clinical importance to avoid excessive morbidity for affected individuals.

Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping.

BACKGROUND: Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. METHODS: We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. RESULTS: In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. CONCLUSION: Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation.

Microsurgical breast reconstruction in thin patients: the impact of low body mass indices.

BACKGROUND: The purpose of this investigation was to examine patients with low body mass index (BMI) regarding the feasibility to perform autologous breast reconstruction in such patients, as well as to determine optimal donor sites and evaluate outcomes accordingly. PATIENTS AND METHODS: All patients undergoing microsurgical breast reconstruction were divided into three cohorts based on BMI. Group 1 included patients with BMI greater than or equal to 22 kg/m(2) and was defined "low-normal BMI." Patients with BMI 22 to 25 kg/m(2) were placed in Group 2, labeled as "high-normal BMI." Group 3, defined as "overweight," included patients with BMI greater than 25 kg/m(2), but less than 30 kg/m(2). Patients were then analyzed based on demographics, breast cancer history, intraoperative details, complications, and revisionary surgeries. F-tests, chi-square goodness-of-fit tests, and Freeman-Halton extension of the Fisher exact tests were used for statistical analysis. RESULTS: During the study period, a total of 259 reconstructions were performed. Group 1 included 30 patients (n = 49 flaps), Group 2 included 58 patients (n = 98 flaps), and Group 3 included 69 patients (n = 112 flaps). Patients undergoing nipple-areolar sparing mastectomy were more likely to be in Groups 1 (39% [n = 19]) and 2 (37% [n = 37]) as compared with Group 3 (14.2% [n = 16]) (p < 0.001) as compared with the overweight cohort. Patients with increasing BMI were more likely to undergo abdominally based free flaps as compared with alternative donor sites (Group 1 = 2.26, Group 2 = 7.9, Group 3 = 27 [p < 0.001]). CONCLUSIONS: Abdominally based free flaps are possible in the majority of patients, however alternative harvest sites have to be used more frequently in low BMI patients.

Perforator flaps--how many perforators are necessary to keep a flap alive?

Perforator flaps are becoming increasingly important in reconstructive microsurgery because of their reduced donor-site morbidity. However, one drawback is partial necrosis caused by vasospasm or inconsistency of delicate perforator vessels. In this study we have evaluated the number and capacity of perforator vessels with respect to the size of a flap, and the influence of vascular endothelial growth factor (VEGF) on the capacity of perforators in a standard animal model. We realised an epigastric perforator flap 4cm×7cm in 36 rats. In 3 control groups (n=6 in each), flaps were raised based on 4, 2, or 1 perforator vessel(s), while all other perforators as well as the epigastric vessels were ligated. In three study groups (n=6 in each), set up in the same way as the control groups, we also injected a single dose of VEGF into the wound area. After one week, all areas of necrosis were assessed planimetrically. We also evaluated the wounds by laser Doppler flowmetry preoperatively and after one week, and by histological and immunohistochemical examination. An increased number of perforators, together with VEGF, was associated with a significant reduction in the areas of necrosis. This observation was particularly true in flaps based on only one perforator. The inclusion of additional perforators has a more important role in the success of a flap than theoretical models suggest. Proangiogenetic factors may improve the viability of perforator flaps.

Anatomical remodelling of the anterior abdominal wall arteries in obesity.

Obesity is associated with structural alterations in subcutaneous small resistance arteries. The aim of the present work is to study modifications of perforators vessels of abdominal wall and subcutaneous tissue characteristics in obese patients after massive weight loss. An anatomo-radiologic study was carried out on 15 patients (5M, 10F, mean age 54.9 y), who underwent abdominoplasty after massive weight loss. Their pre-operative Computed Tomographic (CT) results of the anterior abdominal wall were compared with CT of 15 normal weighted controls. Anatomo-microscopic and morphometric examinations were conducted on full-thickness specimens of panniculectomy samples. 10 right panniculectomy were sampled from donor cadavers. All the measurements were taken on transverse sections. In patients, at CT the mean luminal diameter (LD) and standard deviation of perforator branches of the deep inferior epigastric artery (DIEA) was 3.7 ± 0.4 mm (control 2.2 ± 0.1 mm; p < 0.05). At microscopic examination, the wall thickness of perforator arteries was 212.7 µ ± 83.9 versus 143.9 ± 32.8 (p < 0.05) deep to the superficial fascia and 120.4 µ ± 74.8 versus 72.3 ± 23.5 (p < 0.05) superficial to it. A thickening of the muscular layer was observable and the tunica media represented 71.4% ± 5.6 of the whole area of the wall (controls 37.1% ± 3.5, p < 0.0001). Our data demonstrate that the major LD of the perforators in patients matches with hypertrophy of the tunica media and we think that the major thickness of perforator walls can facilitate the microsurgical technique in free microsurgical flap reconstruction.

Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography.

OBJECTIVES: Deep inferior epigastric perforator (DIEP) flaps have become the state of the art in breast reconstruction. We compared the diagnostic performance of multidetector computed tomography (CTA) and magnetic resonance angiography (MRA) in DIEP flap planning. METHODS: Twenty-three women (mean age 48.0 years, range 26-72 years) underwent preoperative blinded evaluation using 64-slice CTA and 1.5-T MRA. Perforator identification, measurement of their calibre, intramuscular course (IMC), assessment of direct venous connections (DVC) with main superficial veins, superficial venous communications (SVC) between the right and left hemi-abdomen and deep inferior epigastric artery (DIEA) branching type were performed. Surgery was carried out by the same team. Intraoperative findings were the standard of reference. RESULTS: Accuracy in identifying dominant perforators was 91.3 % for both techniques and mean error in calibre measurement 1.18 ± 0.35 mm for CTA and 1.63 ± 0.39 mm for MRA. Accuracy in assessing perforator IMCs was 97.1 % for CTA and 88.4 % for MRA, DVC 94.4 % for both techniques, SVC 91.3 % as well, and DIEA branching type 100 % for CTA and 91.3 % for MRA. Image acquisition and interpretation time was 21 ± 3 min for CTA (35 ± 5 min for MRA). CONCLUSIONS: In a strategy to optimise DIEP flap planning avoiding radiation exposure, MRA can be proposed alternatively to CTA. KEY POINTS: • Identification of deep inferior epigastric perforators (DIEP) is important before breast reconstruction. • Both CT and MR angiography are accurate in identifying DIEA perforator branches. • CTA and MRA are equivalent in demonstrating perforator-venous connections. • MRA can be proposed as an alternative to CTA in DIEP planning.

Effects of verapamil, nifedipine, and daflon on the viability of reverse-flow island flaps in rats.

Reverse-flow flaps are preferable in reconstructive surgery due to their several advantages. However, they may have venous insufficiency and poor blood flow. In this study, effects of various pharmacological agents on the viability of reverse-flow flaps were investigated. Forty Sprague-Dawley rats were used. Superficial epigastric artery- and superficial epigastric vein-based reverse-flow island flaps were preferred. The rats were divided into 4 groups. Group 1 was considered as the control group. Group 2 was given verapamil 0.3 mg/kg per day, group 3 nifedipine 0.5 mg/kg per day, and group 4 Daflon 80 mg/kg per day for 7 days. On day 7, viable flap areas were measured, angiography was performed, serum nitric oxide levels were evaluated, and histopathological examination was done.The mean flap viability rate was 67.59% (±13.12259) in group 1, 77.38% (±4.12506) in group 2, 74.57% (±3.44780) in group 3, and 85.39% (±4.36125) in group 4 (P = 0.001). The mean nitric oxide level was 31.66 µmol/dL (±2.42212) in group 1, 51.00 µmol/dL (±2.96648) in group 2, 34.00 µmol/dL (±2.96648) in group 3, and 47.66 µmol/dL (±2.80476) in group 4 (P = 0.001). On angiography, there were vessel dilations and convolutions in group 2; capillaries became noticeable, and anastomotic vessels extended toward the more distal part of the flaps in group 4. Histological examinations showed severe inflammation in group 3 and minimal inflammation and venous vasodilatation in group 2.Verapamil and Daflon in therapeutic doses significantly increased the viability of reverse-flow island flaps. However, nifedipine did not make a significant contribution to the flap viability. The results of this study will contribute to the literature about the hemodynamics of reverse-flow island flaps and guide further studies on the issue.

Adipose derived stem cells protect skin flaps against ischemia-reperfusion injury.

BACKGROUND: Advances in the treatment of ischemia- reperfusion injury have created an opportunity for plastic surgeons to apply these treatments to flaps and implanted tissues. We examined the capability of adipose derived stem cells (ADSCs) to protect tissue against IRI using an extended inferior epigastric artery skin flap as a flap ischemia- reperfusion injury (IRI) model. METHODS: ADSCs were isolated from Lewis rats and cultured in vitro. Twenty- four rats were randomly divided into three groups. Group I was the sham group and did not undergo ischemic insult; rather, the flap was raised and immediately sutured back (non-ischemic control group). Group II (ischemia control) and group III (ADSCs treatment) underwent 3 h of ischemic insult. During reperfusion group III was treated by intravenous application of ADSCs and group II was left untreated. Five days postoperatively, flap survival and perfusion were assessed. Microvessel density was visualized by immunohistochemistry and semi- quantitative real-time polymerase chain reaction addressed differential gene expression. RESULTS: Treatment with ADSCs significantly increased flap survival (p<0.001) and flap perfusion (p<0.001) when compared to the control group II. Microvessel- density in ADSCs treated group was not significantly increased in any group. No significant differences showed the comparison of the experimental group III and the sham operated control group I. ADSCs treatment (Group III) was accompanied by a significantly enhanced expression of pro-angiogenic and pro-inflammatory genes. CONCLUSION: Overall, our study demonstrates that ADSCs treatment significantly enhances skin flap survival in the aftermath of ischemia to an extent that almost equals surgical results without ischemia. This effect is accompanied with a pronounced and significant angiogenic response and an improved blood perfusion.