We read with great interest the article entitled “Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction.”1 We congratulate on the authors on finding the predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.
Adequate blood flow is one of the key elements of successful free flap reconstruction.2 According to the authors’ assumption, the pressure differential was between a theoretical 120 and 80 mmHg to simulate systolic and diastolic blood pressures, viscosity was 40 mP for blood, and the length was 1 mm. As a result, the authors were able to calculate the flow rate from vessel calibers based on the Poiseuille law. However, we wonder if it is still applicable in terms of hypertension patients. For patients with hypertension, especially poorly controlled hypertension, the pressure differential is certainly way out of the assumed range. Therefore, we think it might not be a proper way to calculate the flow rate. The study by Feng et al.2 disclosed that color Doppler ultrasound offers hemodynamic information about perforator quality, such as velocity, caliber, resistance index, and detailed anatomical information. We would love to know if it would be better to adopt the duplex ultrasound to directly measure blood flow velocity and take independent blood pressure measurements, as some other studies2–4 have done.
In terms of perforator selection, the authors classified the row of perforators as medial, lateral, or both. However, it is a rough classification, and does not take into consideration the superior versus inferior row and the central versus peripheral row. It would have been of greater help if the authors had made a more detailed comparison for other practitioners when designing the flap based on the row of the perforator.
Apparently, in their study the authors evaluated only fat necrosis in terms of recipient-site complications. We would ask the authors whether they have further studied the relationship of the potential factors with some other complications, such as flap loss, venous congestion, and hematoma/seroma.
The authors have no financial interest to declare in relation to the content of this communication. There was no funding for this work.
Yunzhu Li, M.D.
Xiao Long, M.D.
Division of Plastic and Reconstructive Surgery
Peking Union Medical College Hospital
Beijing, People’s Republic of China
1. Hembd A, Teotia SS, Zhu H, Haddock NT. Optimizing perforator selection: A multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg. 2018;142:583–592.
2. Feng S, Min P, Grassetti L, et al. A prospective head-to-head comparison of color Doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg. 2016;137:335–347.
3. Jin SJ, Suh HP, Lee J, Hwang JH, Hong JPJ, Kim YK. Lipo-prostaglandin E1 increases immediate arterial maximal flow velocity of free flap in patients undergoing reconstructive surgery. Acta Anaesthesiol Scand. 2019;63:40–45.
4. Innocenti M, Santini M, Dreassi E, et al. Effects of cutaneous negative pressure application on perforator artery flow in healthy volunteers: A preliminary study. J Reconstr Microsurg. 2019;35:189–193. E-published ahead of print August 15, 2018.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.