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Gacto-Sánchez, Purificación M.D.; Sicilia-Castro, Domingo M.D., Ph.D.; Lagares, Araceli M.D.; Collell, Teresa M.D.; Suarez, Cristina D.B.D.I.; Parra, Carlos D.B.D.I.; Leal, Sandra D.B.D.I.; Infante-Cossío, Pedro M.D., Ph.D.; de la Higuera, Jose María M.B.B.S.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 681-682
doi: 10.1097/PRS.0b013e3181df7243
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We would like to thank Karsten Knobloch et al. for their helpful comments regarding our publication on the role of computed tomographic angiography with a three-dimensional software program versus Doppler ultrasonography for preoperative perforator mapping.1

In response to their questions, we would like to make the following comments. First, all our patients in the control group [undergoing deep inferior epigastric artery perforator (DIEP) flap surgery between May of 2004 and December of 2007] underwent unidirectional Doppler ultrasonography preoperatively. This mapping method was performed by the primary and assisting surgeons themselves on the day before surgery. Time of acquisition consisted of 10 to 15 minutes, depending on the case.

Hofer et al. carried out a learning curve analysis of 175 DIEP flaps for breast reconstruction.2 They observed that surgical complications were significantly decreased after the 30 first DIEP flaps (40 percent incidence of surgical complications versus 13.8 percent). In the same way, Busic et al. reported a reduction in surgical complications after the first 65 breast reconstructions with DIEP flaps.3 We found no published literature regarding learning curves involved in surgical time reductions.

Although learning curves may vary from one surgical team to another and are no doubt operator-dependent, we can assume that our learning curve must be similar to those described before regarding surgical complications in accordance with the number of operations. Before the introduction of VirSSPA software, approximately 100 DIEP breast reconstructions had been performed in our unit. During that period, no significant decreases in surgery time or complications were observed. Taking this into account, it seems more likely that the current decrease in operating time can be attributed directly to the introduction of VirSSPA. Nevertheless, we assume that one limitation of this study was the selection criteria: the experimental group had surgery after the control group. Whether our results are attributable to the introduction of VirSSPA or other factors such as increased experience, improved theater setup, and patient selection is therefore unknown.

We take into account the suggestion by Karsten Knobloch et al. regarding the surgeon's stress level evaluation when harvesting DIEP flaps comparing preoperative Doppler ultrasonography versus computed tomographic angiography. We look forward to hearing more from these and other investigators who develop further innovative applications of perforator mapping.

Purificación Gacto-Sánchez, M.D.

Domingo Sicilia-Castro, M.D., Ph.D.

Araceli Lagares, M.D.

Teresa Collell, M.D.

Cristina Suarez, D.B.D.I.

Carlos Parra, D.B.D.I.

Sandra Leal, D.B.D.I.

Pedro Infante-Cossío, M.D., Ph.D.

Jose María de la Higuera, M.B.B.S.

Hospitales Universitarios Virgen del Rocío

Hospital de Rehabilitación y Traumatología

Sevilla, Spain


1. Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cia T, et al. Computed tomographic angiography with VirSSPA three-dimensional software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg. 2010;125:24–31.
2. Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA. A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg. 2007;59:137–142.
3. Busic V, Das-Gupta R, Mesic H, Begic A. The deep inferior epigastric perforator flap for breast reconstruction, the learning curve explored. J Plast Reconstr Aesthet Surg. 2006;59:580–584.

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