Subfascial Perforator Dissection for DIEP Flap Harvest

Sir: We read with interest the article by Dr. Tregaskiss et al.1 regarding subfascial perforator dissection in deep inferior epigastric perforator (DIEP) flap surgery. We had previously published a similar method for perforator dissection in October of 2007.2 However, the technique had been described even earlier by Stanec et al., in February of 2003.3 We are delighted to see that the method of subfascial perforator dissection seems to be gaining popularity. It does offer many advantages over suprafascial dissection alone, as discussed in all of the previous articles. One of the main advantages of this technique is that it allows direct visualization of the perforators before the final intraoperative commitment on perforator selection and dissection is made. Since the publication of our technique, several imaging modalities have been gaining traction for the identification of perforators in DIEP flap surgery. In theory, imaging modalities may have the potential to lessen the need for subfascial dissection, as the perforators would be identified and selected either preoperatively or intraoperatively. They could be directly dissected quickly and directly with advance knowledge of their location. Currently, computed tomographic angiography, magnetic resonance angiography, and laser-assisted indocyanine green fluorescent imaging have been used for this purpose. All of the above imaging modalities are currently being investigated at multiple microsurgery centers worldwide, and all seem to have great potential in helping the microsurgeon with perforator dissection. Currently, intraoperative indocyanine green angiography is performed on all of the microsurgical breast reconstruction cases (largely DIEP and muscle-sparing free transverse rectus abdominis musculocutaneous flaps) at our institution. We have found that laser-assisted indocyanine green fluorescent dye angiography appears to provide important information that has helped to guide intraoperative decision making in our microsurgical reconstructive cases. It has been helpful in determining perforator location (Fig. 1), venous outflow, patency of the anastomoses (Fig. 2), and viability of the flap after inset.Fig. 1.: Red arrows show perforator locations. U, umbilicus.Fig. 2.: Patent anastomosis.The use of the DIEP flap for breast reconstruction is now well established, and we look forward to new advances in the dissection and applications of this operation. Benny K. H. Tan, M.D. Department of Plastic Surgery Florida Hospital Orlando, Fla. Martin I. Newman, M.D. Kimberly A. Swartz Michel C. Samson, M.D. Department of Plastic Surgery Cleveland Clinic Florida Weston, Fla. DISCLOSURES Dr. Newman and Dr. Samson are consultants for Novadaq Technologies, Inc.