title: Perforator flaps--how many perforators are necessary to keep a flap alive?
abstract: Perforator flaps are becoming increasingly important in reconstructive microsurgery because of their reduced donor-site morbidity. However, one drawback is partial necrosis caused by vasospasm or inconsistency of delicate perforator vessels. In this study we have evaluated the number and capacity of perforator vessels with respect to the size of a flap, and the influence of vascular endothelial growth factor (VEGF) on the capacity of perforators in a standard animal model. We realised an epigastric perforator flap 4cm×7cm in 36 rats. In 3 control groups (n=6 in each), flaps were raised based on 4, 2, or 1 perforator vessel(s), while all other perforators as well as the epigastric vessels were ligated. In three study groups (n=6 in each), set up in the same way as the control groups, we also injected a single dose of VEGF into the wound area. After one week, all areas of necrosis were assessed planimetrically. We also evaluated the wounds by laser Doppler flowmetry preoperatively and after one week, and by histological and immunohistochemical examination. An increased number of perforators, together with VEGF, was associated with a significant reduction in the areas of necrosis. This observation was particularly true in flaps based on only one perforator. The inclusion of additional perforators has a more important role in the success of a flap than theoretical models suggest. Proangiogenetic factors may improve the viability of perforator flaps.
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany.
authors.forename: Andreas M
authors.initials: AM
authors.lastname: Fichter
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany.
authors.forename: Anna
authors.initials: A
authors.lastname: Borgmann
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany.
authors.forename: Lucas M
authors.initials: LM
authors.lastname: Ritschl
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany.
authors.forename: David A
authors.initials: DA
authors.lastname: Mitchell
authors.affiliation: Institute for Medical Biometriy, Epidemiology and Medical Informatics, Universität des Saarlandes, Homburg, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Wagenpfeil
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany.
authors.forename: Ulf
authors.initials: U
authors.lastname: Dornseifer
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany.
authors.forename: Klaus-Dietrich
authors.initials: KD
authors.lastname: Wolff
authors.affiliation: Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich 81675, Germany. Electronic address: th.mucke@gmx.de.
authors.forename: Thomas
authors.initials: T
authors.lastname: Mücke
mesh_terms: D043925:Angiogenesis Inducing Agents / Q000494:pharmacology; D000818:Animals; D001783:Blood Flow Velocity / Q000502:physiology; D019074:Epigastric Arteries / Q000473:pathology / Q000601:surgery; D006085:Graft Survival / Q000187:drug effects / Q000502:physiology*; D006454:Hemoglobins / Q000032:analysis; D017078:Laser-Doppler Flowmetry / Q000379:methods; D008297:Male; D023421:Models, Animal; D009336:Necrosis; D020556:Neutrophil Infiltration / Q000502:physiology; D010101:Oxygen Consumption / Q000502:physiology; D061525:Perforator Flap / Q000098:blood supply* / Q000473:pathology; D019408:Platelet Endothelial Cell Adhesion Molecule-1 / Q000032:analysis; D011897:Random Allocation; D051381:Rats; D017208:Rats, Wistar; D012039:Regional Blood Flow / Q000502:physiology; D013997:Time Factors; D060053:Transplant Donor Site / Q000473:pathology / Q000601:surgery; D042461:Vascular Endothelial Growth Factor A / Q000494:pharmacology; D014841:von Willebrand Factor / Q000032:analysis
chemical_list: D043925:Angiogenesis Inducing Agents; D006454:Hemoglobins; D019408:Platelet Endothelial Cell Adhesion Molecule-1; D042461:Vascular Endothelial Growth Factor A; C467498:vascular endothelial growth factor A, rat; D014841:von Willebrand Factor
keywords: Animal model; Area of necrosis; Epigastric flap model; Laser Doppler flowmetry; Perforator flap; Vascular endothelial growth factor