title: Refining perforator selection for deep inferior epigastric perforator flap: the impact of the dominant venous perforator.
abstract: BACKGROUND
  This article aims to investigate the critical role of the venous-perforator in the decision-making process of choosing the best suitable perforator-complex in a deep inferior epigastric perforator (DIEP) flap.
  
  
  METHODS
  Forty consecutive DIEP breast reconstructions were pre-operatively evaluated by CT-Angiography to identify the dominant and centrally located abdominal wall perforators. The CTA results were used as a guide to conduct a Color-Duplex-Ultrasound examination that was mainly focused on investigating the accompanying venous-perforator. In group-A (n = 20) perforator-complex selection was based on the size of the arterial-perforator, whilst in group-B (n = 20) it was based on the size of the venous-perforator.
  
  
  RESULTS
  All single perforator-complex DIEP flaps survived. No significant differences were recorded concerning the size of arterial-perforator between the two groups; however the size of venous-perforator was significantly larger in group-B (P < 0.05). In group-A, four flaps showed vascular compromise intraoperative that was salvaged by flap supercharge with the superficial inferior epigastric system. In contrast, in group-B, all flaps were re-vascularized uneventfully (P < 0.05). Physical examination revealed a palpable mass in one patient and ultrasound investigation added three cases with a firm area of scar tissue in group-A, but no fat necrosis was detected in group-B (P < 0.05).
  
  
  CONCLUSIONS
  The CTA-guided duplex ultrasonography could direct the perforator-complex selection according to the size of the venous-perforator, and may reduce the intraoperative problems and the incidence of fat necrosis.
authors.affiliation: Department of Plastic Surgery, Microsurgery and Burn Center "J. Ioannovich," General State Hospital of Athens "G. Gennimatas," 11527, Athens, Greece.
authors.forename: Andreas
authors.initials: A
authors.lastname: Gravvanis
authors.forename: Dimosthenis
authors.initials: D
authors.lastname: Tsoutsos
authors.forename: George
authors.initials: G
authors.lastname: Papanikolaou
authors.forename: Ahmed
authors.initials: A
authors.lastname: Diab
authors.forename: Penelope
authors.initials: P
authors.lastname: Lambropoulou
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Karakitsos
mesh_terms: D000328:Adult; D000792:Angiography / Q000379:methods; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply*; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed; D018615:Ultrasonography, Doppler, Color; D018616:Ultrasonography, Doppler, Duplex; D016217:Ultrasonography, Mammary