Reply: Outcomes of DIEP Flap and Fluorescent Angiography: A Randomized Controlled Clinical Trial

Abstract

Sir: We appreciate the authors’ comment on our work.1 The authors note that it is possible that the deepest part of a deep inferior epigastric perforator flap is less vascularized as compared with the most superficial areas, especially the skin. This could be subject to further investigation, as we performed the acquisition tangentially to the flap. We do not know whether the vascularization of the superficial and deep fat layers can actually be distinguished in a tangential acquisition. However, one should note that we did not evaluate the deeper tissues in either experimental group, but evaluated the brightness of the skin and the subdermal layer. Intraoperative angiographic evaluation of the flap can display where the fluorescence ends. The limits of flap vascularization can be determined using a relatively straightforward maneuver. Bright and dark zones determine the limit between well-perfused and poorly perfused tissue in a qualitative manner. A threshold fluorescence intensity value was not set for tissue excision because excision was guided only by qualitative criteria. The angiography session was recorded for subsequent quantitative analysis in a computer setting. Finally, we understand that preoperative computed tomography would have some benefits for selecting a muscle-sparing transverse rectus abdominis myocutaneous flap that included more perforators instead of a deep inferior epigastric perforator flap, and this could lower the occurrence of fat necrosis globally. For design purposes, we elected to undergo a fair comparison with similar conditions. As a further step, it will be interesting to know whether the vascular anatomy of perforators (single versus multiple) randomly produces different outcomes in abdominal flaps trimmed under fluorescent angiography. DISCLOSURE There are no sources of support that require acknowledgment. The authors have no financial or personal relationships with other people or organizations that could influence (bias) this work inappropriately. Ramon Varela, M.D.Luis Landin, M.D., Ph.D.Fib/HULP IdiPazPlastic and Reconstructive SurgeryHospital Universitario La PazMadrid, Spain

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