J reconstr Microsurg
DOI: 10.1055/s-0038-1676605
Letter to the Editor
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Tissue Oximetry Monitoring for Free Deep Inferior Epigastric Perforator Flap Viability: Factors to be Considered toward Optimizing Postoperative Outcome

Marzia Salgarello
1  Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy
,
Domenico Pagliara
1  Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy
,
Giuseppe Visconti
1  Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy
,
Liliana Barone-Adesi
1  Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy
› Author Affiliations
Funding None.
Further Information

Publication History

28 September 2018

16 October 2018

Publication Date:
17 December 2018 (eFirst)

We would like to thank the authors for their insightful comments regarding our article.[1] We agree on the potential mismatch between the sensor size and the skin flap area related to misreading in near-infrared spectroscopy (NIRS) monitoring of flaps with small monitor islands, as we already discussed.

In our article we described the flap resection method using the intraoperative indocyanine infrared angiography (photodynamic eye [PDE]). Previously, Holm et al also applied indocyanine green in the deep inferior epigastric perforator (DIEP) flap to assess the perfusion of the skin island.[2] The use of intraoperative fluorescence angiography was validated as a reliable tool to assess flap perfusion and to lead the surgical decision making.[3] Therefore, in a consolidated trend of our surgical practice after elevating the flap and before ligating the vascular pedicle, we use the PDE to obtain a real-time information of DIEP flap perfusion and to identify the no-stained (not enhanced within 60 seconds) area that will be cut out.

Our standard to establish the sensor position on the flap refers to currently most updated criteria for free-flap NIRS monitoring as proposed by Akita et al.[4]

In our sample we always used the area enhanced within 10 seconds (early-stained area) for sensor location,[4] to obtain a standardization of the monitoring site.

The last question concerns the ischemia time and the underestimation of postoperative complications. As widely known, an increased rate in fat necrosis was observed in flaps with ischemia time exceeding 99.5 minutes.[5] Usually, we maintain a flap off–flap on time within 60 minutes. In our sample no flap had an ischemia time of more than 60 minutes and we did not report immediate vascular complications or late complication such as fat necrosis. Of course a reperfusion injury must be considered in the assessment of regional oxygen saturation (rSO2) values when the ischemia time is prolonged, but further studies should validate a more specific threshold value for this case.