Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications

The first 150 consecutive DIEP free flaps: Lessons learnt and a guide to efficiency for the junior plastic surgeon

Introduction

The deep inferior epigastric artery perforator (DIEP) free flap is the gold-standard for breast reconstruction but is technically demanding, resource intensive and time-consuming, making it a daunting task for the junior surgeon.

Aim

To report the lessons learnt from the experience of a single surgeon performing their first 150 DIEP reconstructions as a guide for junior surgeons.

Methods

Data regarding patient demographics and surgical outcomes from April 2021 to October 2022 were collected retrospectively from medical records. Surgical outcomes were analysed using Microsoft Excel.

Results

Over 17 months, 150 flaps were completed in 97 patients by the senior author (BS). Operative duration was negatively correlated with case number for unilateral DIEPs (r = -0.73, p < 0.05) and for bilateral DIEPs (r = -0.67, p = 0.14). Raise time and ischaemic time were also negatively correlated with case number (r = -0.82, p < 0.05 and r = -0.79, p < 0.05, respectively). There were 10 complications and no flap losses.

Discussion

The data demonstrate an expected improvement in surgical efficiency with increased experience. We describe the key factors contributing to efficiency in our series, such as preoperative CT angiography, surgical markings prior to the day of surgery, a two-team approach with three diathermy sets, flap raise using monopolar diathermy, preference towards choosing a single dominant perforator and early commitment to perforator choice. This case series acts as a guide for the junior plastic surgeon in achieving safe, aesthetic and efficient results when completing free DIEP flap breast reconstructions.

Evaluating Artificial Intelligence's Role in Teaching the Reporting and Interpretation of Computed Tomographic Angiography for Preoperative Planning of the Deep Inferior Epigastric Artery Perforator Flap

Background

Artificial intelligence (AI) has the potential to transform preoperative planning for breast reconstruction by enhancing the efficiency, accuracy, and reliability of radiology reporting through automatic interpretation and perforator identification. Large language models (LLMs) have recently advanced significantly in medicine. This study aimed to evaluate the proficiency of contemporary LLMs in interpreting computed tomography angiography (CTA) scans for deep inferior epigastric perforator (DIEP) flap preoperative planning.

Methods

Four prominent LLMs, ChatGPT-4, BARD, Perplexity, and BingAI, answered six questions on CTA scan reporting. A panel of expert plastic surgeons with extensive experience in breast reconstruction assessed the responses using a Likert scale. In contrast, the responses' readability was evaluated using the Flesch Reading Ease score, the Flesch-Kincaid Grade level, and the Coleman-Liau Index. The DISCERN score was utilized to determine the responses' suitability. Statistical significance was identified through a t-test, and P-values < 0.05 were considered significant.

Results

BingAI provided the most accurate and useful responses to prompts, followed by Perplexity, ChatGPT, and then BARD. BingAI had the greatest Flesh Reading Ease (34.7±5.5) and DISCERN (60.5±3.9) scores. Perplexity had higher Flesch-Kincaid Grade level (20.5±2.7) and Coleman-Liau Index (17.8±1.6) scores than other LLMs.

Conclusion

LLMs exhibit limitations in their capabilities of reporting CTA for preoperative planning of breast reconstruction, yet the rapid advancements in technology hint at a promising future. AI stands poised to enhance the education of CTA reporting and aid preoperative planning. In the future, AI technology could provide automatic CTA interpretation, enhancing the efficiency, accuracy, and reliability of CTA reports.

Oncologic Staging Computed Tomography with IV Contrast Has Similar Efficacy to Dedicated Computed Tomography Angiography for Preoperative DIEP Flap Planning

Background

Due to variations in perforator vasculature, deep inferior epigastric artery perforator (DIEP) flap preoperative imaging can minimize operative time required to locate the most suitable perforators. Dedicated computed tomography angiography (CTA) has been the gold standard; however, many patients have already undergone a staging computed tomography (CT) per oncologic workup. The benefits from CTA may also be realized with a staging CT or CT with IV contrast.

Methods

Ten patients who underwent DIEP flap reconstruction with staging CT and CTA within 3 years of one another were included in this study. Reviewers evaluated axial views of both imaging modalities separately to identify each visible perforator in reference to the pubic symphysis from the xiphoid to the pubic symphysis. An intraclass correlation coefficient (ICC) was used to determine agreement in location of perforators between the two imaging studies. Statistical analysis was performed using an ICC and Wilcoxon signed rank-tests.

Results

The identified perforators within the patient cohort had an excellent correlation between their location on CT and CTA based upon ICC. The mean number of perforators identified in the CT group was 15.3 (SD 4.9) and in the CTA group was 18.8 (SD 6.4), which was not statistically different (P = 0.247).

Conclusions

CT has similar efficacy in identifying number of perforators and perforator location to dedicated CTA for preoperative planning in DIEP flaps. This has the potential for decreased patient contrast and ionizing radiation exposure as well as improved patient and healthcare resource utilization.

Transforming breast reconstruction: the pioneering role of artificial intelligence in preoperative planning

Autologous breast reconstruction surgery is a vital part of the recovery process for patients with breast cancer. While various reconstructive options exist, the deep inferior epigastric artery perforator (DIEP) flap is often favoured for its ability to closely mimic natural breast tissue. However, the complex vascular anatomy associated with the deep inferior epigastric artery (DIEA) presents challenges for surgeons during DIEP flap execution. Preoperative imaging, such as computed tomography angiography (CTA), is commonly used to understand vascular architecture and aid in selecting appropriate perforators. Conventional reporting of CTA scans is a labour-intensive process that can be challenging and requires specific expertise. The integration of artificial intelligence (AI) and machine learning (ML) algorithms in medical imaging has the potential to address these challenges. AI can enhance CTA through improved data acquisition, image post-processing, and potentially interpretation. By automating the perforator selection process, AI applications can significantly reduce the time spent on preoperative imaging analysis and potentially improve accuracy and reliability. While AI shows promise in optimizing efficiency, accuracy, and reliability in breast reconstruction planning, challenges and ethical considerations need to be addressed. This article explores the challenges, opportunities, and future directions of using AI in the preoperative planning of autologous breast reconstruction.

Vascular Mapping for Abdominal-Based Breast Reconstruction: A Comprehensive Review of Current and Upcoming Imaging Modalities

Background

Preoperative vascular imaging is a very common element of surgical planning for abdominal-based breast reconstruction (ABBR). Surgeons must tailor which flap is best suited for each respective patient based on the patient's health and vascular anatomy. The goal of this review is to give surgeons practical tools for choosing which imaging technology best suits their patient's needs for successful breast reconstruction.

Methods

A review of literature was undertaken on Google scholar to assess preoperative imaging modalities used for ABBR. Search terms included breast reconstruction, deep inferior epigastric perforator (DIEP) flap, and abdominal imaging. Articles were included based on relevance and significance to ABBR. Advantages and disadvantages of each imaging modality were then classified according to clinically relevant utility.

Results

Overall, imaging technologies that produce 3-dimensional images were found to have greater resolution for identifying perforators and the pedicle network than 2- dimensional images.

Conclusions

This paper addresses the strengths and weaknesses of the currently used imaging modalities described and also discusses new technologies that may be helpful in the future for planning of ABBR.

[Breast Reconstruction: Impact of the Procedure on Quality of Life]

English Breast cancer and the surgical procedures associated with it have a major impact on the quality of life of affected patients. Research shows that the loss of the breast and the associated change in body image have a major impact on the female self-image for many women. This has a strong negative impact on the quality of life of those affected. With modern clinical outcome research including treatment results from the patient's perspective in the form of patient-reported outcome measures (PROMs), the satisfaction and quality of life of those affected can be measured, analysed and compared. This review examines the extent to which breast reconstruction improves the quality of life for many women and how the different reconstruction methods vary in their impact on quality of life and satisfaction. In addition, the review discusses the importance of standardised recording and analysis of PROMs in combination with objective clinical data and their integration into the treatment process, and it demonstrates implementation options. Such systematic recording of PROMs enables the creation of databases and registers, the evaluation of which provides information that can be used for scientific and clinical purposes. Based on these research results, prognostic models can be created and treatment results can be examined in comparative studies facilitating clinical decision-making and quality controls.

Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes

In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures.

Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations

Background and Objective

Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery.

Evidence

We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: “DIEP flap”, “Breast reconstruction”, “Patient management”, “Postoperative DIEP”, “Intraoperative anticoagulant therapy”, “Clinical recommendations”. A total of 106 research papers were retrieved pertaining to this systematic review.

Conclusion

A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.

Minimally invasive robotic breast reconstruction surgery

The rising popularity of robotic surgery has enabled surgeons to continue to expand the uses of robotic surgery. Robotic surgery offers minimally invasive approaches coupled with tremor elimination, up to seven degrees of freedom, ergonomic positioning, 3D magnified vision and improved resolution. We describe robotic surgery techniques for nipple-sparing mastectomies, latissimus dorsi muscle flap harvest, deep inferior epigastric perforator (DIEP) flap pedicle harvest, and robotic microsurgical anastomoses. By using a robotic system the surgeon is able to offer not only a minimally invasive approach to the patient but the surgeon's ability can be improved upon as well. This improved ability is best characterized in the robotic supermicrosurgical anastomosis where even the faintest surgeon's tremor is exploited. However, within the robotic system tremor is eliminated. We are now able to offer patients a completely minimally invasive approach to ablative breast surgery and breast reconstruction. A patient could have a robotic nipple-sparing mastectomy, followed by a robotic DIEP reconstruction with a robotic microsurgical anastomosis. The patient could even have robotic lymphovenous bypass to address lymphedema that could have arisen after an axillary dissection. A completely robotic surgical approach maximizes both utilization of the robotic system and patient benefit. By using robotic techniques in flap harvest the morbidity of traditional open surgeries is minimized and the use of robotic anastomoses expands the limits of human precision.

Noncontrast Magnetic Resonance Imaging of Perforators for Preoperative Evaluation of Anterolateral Thigh Flaps

The anterolateral thigh (ALT) flap is a commonly utilized perforator-based flap in reconstructive surgery. Although previous studies have used various angiographic techniques to preoperatively image ALT perforators, none have investigated the efficacy of noncontrast magnetic resonance imaging (MRI). Our study investigates the efficacy of our institutional fat suppression noncontrast MRI sequence to characterize the number, location, and course of dominant skin perforators in the ALT for preoperative planning.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction

BACKGROUND

Preoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan.

METHODS

We conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.

RESULTS

Two hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were "miscellaneous." In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation.

CONCLUSIONS

CTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Use of infrared thermography for the assessment of free flap perforators in autologous breast reconstruction: A systematic review

Perforator-based flaps have in recent years become the mainstay of autologous breast reconstruction practice. Imaging modalities ranging from Doppler ultrasound to CT angiography demonstrate varying utility in the preoperative identification and localisation of perforators. Despite these available radiological investigations, finding and quantitatively assessing perforators remain a time-consuming and tedious process that is often complicated by a number of factors including variable anatomy prior surgery and body habitus. Thermographic imaging shows promise as a novel modality for preoperative localisation of perforator vessels. This review summarises the currently available evidence for its application in perforator mapping for abdominal-based autologous breast reconstruction. We discuss the development of the technology over the years, its current use, its advantages and how it may impact on reconstructive breast surgery.

How to assess a CTA of the abdomen to plan an autologous breast reconstruction

The deep inferior epigastric perforator (DIEP) flap is recognised as the most popular option for autologous breast reconstruction. Planning of the DIEP flap involves pre-operative assessment of abdominal vascular anatomy with imaging, of which computed tomographic angiography (CTA) has become the mainstay. CTA enables detailed planning of a range of surgical steps, leading to reduced operative times and improved surgical outcomes. The value of CTA is only demonstrated when the relevant vascular anatomy is able to be demonstrated and appraised. For optimal analysis, a 64-slice multi-detector row CT scanner and imaging software including OsiriX™, Siemens InSpace™ or Horos™ are required. The seven major steps to consider include: (I) perforator size; (II) perforator angiosome; (III) intramuscular course; (IV) deep inferior epigastric artery (DIEA) pedicle; (V) venous anatomy; (VI) superficial inferior epigastric artery (SIEA) and superficial inferior epigastric vein (SIEV); and (VII) abdominal wall structure. These steps should also be reviewed when marking the patient and planning the flap intra-operatively. While CTA has superior sensitivity and specificity in mapping perforator anatomy it also faces challenges due to ionising radiation exposure, contrast-induced allergy and potential nephrotoxicity. Despite these challenges, the benefits of CTA to the individual patient has maintained its role in pre-operative planning of the DIEP flap.

Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases

Background

Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction.

Methods

Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed.

Results

Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612).

Conclusions

IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.

Preoperative cross-sectional mapping for deep inferior epigastric and profunda artery perforator flaps

Perforator flap-based breast reconstruction in a post mastectomy patient requires dissection of the artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap. Traditionally, these reconstructions were performed with the transverse rectus abdominis myocutaneous (TRAM) flap, but autologous breast reconstruction using muscle sparing free flaps has become steadily more popular in recent years. Preoperative imaging to locate and evaluate candidate perforators has become an essential step before patients undergo the microsurgical procedure. Preoperative mapping assists with operative planning, reduces operating times, and brings anatomical variations to their attention. Pre-operative imaging also assists in choosing the appropriate donor site for harvesting flaps. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been widely used for this type of preoperative imaging. Both MRA and CTA have their inherent advantages and disadvantages, and the preferred modality for this purpose varies by institution based on factors such as scanner availability, radiologist and surgeon experience, and comfort in interpreting the images. Concerns over excessive exposure to ionizing radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made MRA the first-choice imaging modality in many centers. The purpose of the article is to review technique and protocols for the pre-operative CTA/MRA in patients who are being considered for a deep inferior epigastric artery perforator (DIEP) or profunda artery perforator (PAP) flap and to familiarize the reader with the normal and variant anatomic features of the deep inferior epigastric and PAP vessels along with the anatomic and surgical considerations used in the selection of perforator flap donor site for breast reconstruction post mastectomy.

The effect of CT angiography and venous couplers on surgery duration in microvascular breast reconstruction: a single operator's experience

Background

The use of CT angiography (CTA) or venous couplers (VCs) has led to shorter operative times in free flap breast reconstruction (FFBR). However, there are no reports on the effect of these two interventions relative to each other or combined.

Methods

Abdominal based FFBRs performed by a single surgeon before introduction of either intervention were compared to those with VC only, and those after the addition of CTA to VCs (CT-VC). Operative time was defined as from "knife-to-skin" to insertion of the last stitch.

Results

One hundred and twenty patients; 40 without intervention (WI), 40 with VC, and 40 with CT-VC. Introduction of VCs did not significantly reduce operative time compared to WI (P=0.73). However, patients in the CT-VC group had significantly shorter operations vs. WI (472 vs. 586 min, P<0.00001) and vs. VC alone (472 vs. 572 min, P=0.0006). Similarly, introduction of each intervention showed a stepwise decrease in ischaemia time (WI vs. VC: 100 vs. 89 min, P=0.0106; VC vs. CT-VC: 89 vs. 80 min, P=0.0307; WI vs. CT-VC: 100 vs. 80 min, P<0.00001).

Conclusions

Combination of CTA and VC significantly reduced operative and ischaemic times for FFBR; this was predominantly due to use of CTA. CTA mitigates the surgical learning curve as demonstrated by shorter operating times via providing a vascular anatomy roadmap, thus facilitating flap harvest.

Combining Autologous Breast Reconstruction and Vascularized Lymph Node Transfer

Breast cancer patients are at risk for developing postmastectomy lymphedema syndrome of the ipsilateral upper extremity following treatment for breast cancer in the setting of an axillary dissection, postoperative radiation, and chemotherapy. For patients suffering from lymphedema who are also seeking breast reconstruction, combining an autologous abdominal free flap with a vascularized inguinal lymph node transfer provides patients the opportunity to have an aesthetic breast reconstruction as well as the potential to improve their lymphedema in a single operation. The present article aims to provide a description of the salient features of this approach including the preoperative preparation, the surgical technique, the postoperative management and complications, and a summary of the outcomes.

Concordance between preoperative computed tomography angiographic mapping and intraoperative perforator selection for deep inferior epigastric artery perforator flap breast reconstructions

Background

Preoperative imaging for perforator identification prior to a deep inferior epigastric artery perforator (DIEP) flap elevation for breast reconstruction has many advantages. Currently, computed tomography (CT) angiography provides good visualization of the perforators and their course, and is thus the imaging technique of choice. The primary aim of this study was to determine the concordance between the perforators identified preoperatively and the perforators ultimately selected intraoperatively, with a standardized protocol, in a single institution. Secondly, we wanted to compare our results with those of other, similar studies and, thirdly, to identify those factors that may lead to a higher concordance.

Methods

A retrospective review was undertaken of a case series of 49 consecutive patients undergoing unilateral autologous breast reconstruction with a DIEP flap at the Gelre Hospital, in the Netherlands, over a 4-year period from 2013 to 2017. The preoperative identification and selection of perforator number and location with the aid of CT angiography scanning were compared to the intraoperative findings and preference.

Results

Our study revealed a concordance of 67.3% between one or more perforators advised preoperatively by the radiologist and chosen intraoperatively by the surgeon. We identified significant differences in our protocol compared to others.

Conclusions

The study confirmed the benefit to both the patient and the surgeon when preoperative CT angiography is used. Scanning protocols may vary considerably and should thus be carefully scrutinized before future comparisons are made. Based on this study, the scanning range, method of selecting perforators and timing of image acquisition may have to be optimized for future prospective clinical trials.

Assessment of Free Flap Breast Reconstructions

Free flap breast reconstruction may be offered as a treatment option at federal facilities with appropriate patient selection and planning.

Viability of five different pre- and intraoperative imaging methods for autologous breast reconstruction

Background

Autologous breast reconstruction is an integral part in the treatment of breast cancer. While computed tomography angiography (CTA) is an established preoperative diagnostic tool for microsurgeons, no study has so far evaluated and compared five different imaging methods and their value for the reconstructive team. In order to determine the feasibility of each of the tools for routine or specialized diagnostic application, the methods' efficiency and informative value were analyzed.

Methods

We retrospectively analyzed imaging data of 41 patients used for perforator location and assessment for regional perfusion and vessel patency in patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flap (DIEP), transverse rectus abdominis muscle flap (TRAM), or transverse myocutaneous gracilis flap (TMG). Five different imaging techniques were used: hand held Doppler (HHD), CT angiography (CTA), macroscopic indocyanine green (ICG) video angiography, microscope-integrated ICG video angiography, and laser Doppler imaging (LDI).

Results

CTA proved to be the best tool for preoperative determination of the highly variable anatomy of the abdominal region, whereas HHD showed the same information on perforator localization with some false-positive results. Intraoperative HHD was an excellent tool for dissection and vessel patency judgment. Microscope-integrated ICG was an excellent tool to document the patency of microanastomoses. In our series, macroscopic perfusion measurement with ICG or LDI was only justified in special situations, where information on perfusion of abdominal or mastectomy flaps was required. LDI did not add any additional information.

Conclusion

Preoperative assessment should be performed by CTA with verification of the perforator location by HHD. Intraoperative HHD and microscope-integrated ICG contribute most toward the evaluation of vessel patency. ICG and LDI should only be used for special indications.