Hallock Geoffrey G, Rice David C
Division of Plastic Surgery, Department of Advanced Clinical Technologies, The Lehigh Valley Hospital, Allentown, PA, USA.
Plast Reconstr Surg. 2005 Aug;116(2):551-5; discussion 556. doi: 10.1097/01.prs.0000172889.62564.e1.
An insidious risk with the use of muscle perforator flaps is the possibility of venous outflow compromise. Congestion in deep inferior epigastric perforator (DIEP) flaps in particular is not infrequent. On an empiric basis, their salvage has been accomplished by augmenting venous drainage through alternative outflow tracts. The validity of this clinical maneuver can now best be tested in a rat DIEP flap model.
The rat DIEP flap is a modification of the rat ventral abdomen flap. Flap perfusion can be based on a single rectus abdominis musculocutaneous perforator. No muscle is included with the flap. Three groups of five male Sprague-Dawley rats each were used. The conventional DIEP flap group had only a solitary perforator artery and venae comitantes and served as the control. The contralateral superficial inferior epigastric vein was included with the flap in the other two groups as a distinctly separate venous outflow tract. The latter two groups differed in that the perforator venae comitantes were either retained or deleted.
Mean flap survival in the control DIEP flap group was 80.8 +/- 16.3 percent. Retention of the contralateral superficial inferior epigastric vein resulted in a statistically significant enhancement in flap viability (p < 0.027) whether the perforator venae comitantes were left intact (99.8 +/- 0.4 percent) or had been intentionally ablated (99.6 +/- 0.5 percent).
Venous supercharging of the rat DIEP flap ensures greater flap survival. As a corollary, this supports the efficacy of prior anecdotal experiences in which an alternative venous outflow tract, preferably from the superficial system, had been used to overcome venous congestion. It is advisable for any muscle perforator flap to always try to retain a second outflow source to allow the potential for venous supercharging, if later indicated.
使用肌肉穿支皮瓣存在一种潜在风险，即静脉回流可能受损。尤其是腹壁下深动脉穿支（DIEP）皮瓣充血的情况并不少见。根据经验，通过增加其他流出道的静脉引流来挽救皮瓣。现在，这种临床操作的有效性最好在大鼠DIEP皮瓣模型中进行测试。
大鼠DIEP皮瓣是大鼠腹侧腹部皮瓣的一种改良。皮瓣灌注可基于单一的腹直肌肌皮穿支。皮瓣不包含肌肉。每组使用5只雄性Sprague-Dawley大鼠，共三组。传统DIEP皮瓣组只有一条单独的穿支动脉和伴行静脉，作为对照组。另外两组将对侧腹壁浅静脉作为明显独立的静脉流出道包含在皮瓣中。后两组的不同之处在于是否保留穿支伴行静脉。
对照组DIEP皮瓣的平均存活率为80.8±16.3%。无论穿支伴行静脉是否完整保留（99.8±0.4%）或有意切除（99.6±0.5%），保留对侧腹壁浅静脉均使皮瓣存活率有统计学意义的提高（p<0.027）。
大鼠DIEP皮瓣的静脉增压可确保更高的皮瓣存活率。由此推论，这支持了先前的经验性做法的有效性，即使用替代的静脉流出道，最好是来自浅静脉系统，来克服静脉充血。对于任何肌肉穿支皮瓣，建议始终尝试保留第二个流出源，以便在后期需要时进行静脉增压。
