We thank Drs. Li and Long for their interest and comments on our recent publication, “Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction.”1
We certainly agree with them that there were certain assumptions made when we calculated the total flow rate of these flaps based on the visual estimates of the perforator diameters. We opted to utilize physiologic normal values for blood pressure, blood viscosity, and the general length of an anastomosis or venous coupler. We do agree that a patient with hypertension may have a different total flow rate value versus a normotensive patient, even with the same perforator numbers and perforator diameters.
However, our main aim was to accurately assess the importance of changing perforator diameters on the perfusion of a flap. Previous studies had looked at perforator diameters and sizes and found mixed results, the reason for which we believe is the failure to take into account the exponential increase in blood flow to a flap due to an increasing vessel diameter.2 Several studies have analyzed the role of perforator numbers as well, the additive effect of which would pale in comparison to increasing the diameter of a single perforator based on the Hagen-Poiseuille equation.2–4 Thus, the salient finding comes not from comparing the absolute values of flow rates for each patient based on their respective blood pressure, but rather from comparing the overall trend of how these flow rates changed from adding more perforators versus including larger perforators. This is why we kept the other variables in the Hagen-Poiseuille equation static from patient to patient.
In addition, hypertension was one of the 28 variables we included and controlled for in our statistical analysis.1 If increased blood pressures had indeed confounded the statistical relationship we found between total flow rate and fat necrosis, this would have been elucidated in our multivariable model.
We agree that color duplex ultrasonography is an interesting technology that has promising results for assessing hemodynamic information for perforators. This retrospective study did not utilize this for perforator assessment. Therefore, this would be an avenue for future research. Despite this, we believe our finding that increasing total flow rates of the flap decreased the odds of fat necrosis is significant,1 particularly in the setting of prior evidence suggesting that increasing the number of perforators could have a similar effect. In our study, perforator number was not a significant factor in reducing the odds of fat necrosis.
In addition, we classified the row of perforators as medial, lateral, or both not as a novel scheme for our research, but because it is an established classification system in the literature analyzing fat necrosis in abdominal free flap breast reconstruction for the last several decades.2–11 We agree that it has its limitations in regard to the exact position of perforators within a given flap; however, creating a new classification system or reporting perforator locations in terms of positional measurements not only is outside the scope of this retrospective study but also runs the risk of losing relevance in the current established schema within deep inferior epigastric perforator flap literature.
In regard to their comments about our primary outcome measures, we looked at not only fat necrosis in the free flap itself but also abdominal bulge and abdominal donor-site complications.1 Flap loss rates and venous congestion were not analyzed in this study as primary outcome measures and will be the subject of future publications.
The authors have no commercial or financial associations related to this communication, and no commercial or financial conflicts of interest. No funding was received for the performance of this research or production of this communication.
Nicholas T. Haddock, M.D.
Austin S. Hembd, M.D.
Sumeet S. Teotia, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
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. Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg. 2010;125:1335–1341.
3. Grover R, Nelson JA, Fischer JP, Kovach SJ, Serletti JM, Wu LC. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg. 2014;41:63–70.
4. Kamali P, Lee M, Becherer BE, et al. Medial row perforators are associated with higher rates of fat necrosis in bilateral diep flap breast reconstruction. Plast Reconstr Surg. 2017;140:19–24.
5. Bozikov K, Arnez T, Hertl K, Arnez ZM. Fat necrosis in free DIEAP flaps: Incidence, risk, and predictor factors. Ann Plast Surg. 2009;63:138–142.
6. Mulvey CL, Cooney CM, Daily FF, et al. Increased flap weight and decreased perforator number predict fat necrosis in DIEP breast reconstruction. Plast Reconstr Surg Glob Open. 2013;1:1–7.
7. Lindsey JT. Perforator number does not predict fat necrosis. Plast Reconstr Surg. 2011;127:1391–2; author reply 1392.
8. Lindsey JT. Integrating the DIEP and muscle-sparing (MS-2) free TRAM techniques optimizes surgical outcomes: Presentation of an algorithm for microsurgical breast reconstruction based on perforator anatomy. Plast Reconstr Surg. 2007;119:18–27.
9. Rozen WM, Whitaker IS, Chubb D, Ashton MW. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg. 2010;126:2286–8; author reply 2288.
10. Li L, Chen Y, Chen J, et al. Adjuvant chemotherapy increases the prevalence of fat necrosis in immediate free abdominal flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2014;67:461–467.
11. Douglas HE, Wilkinson MJ, Mackay IR. Effects of perforator number and location on the total pedicle flow and perfusion of zone IV skin and fat of DIEP flaps. J Plast Reconstr Aesthet Surg. 2014;67:212–218.
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.