Optimising the preoperative planning of deep inferior epigastric perforator flaps for breast reconstruction

Santiago, M. Casares; García-Tutor, Emilio; Rodríguez-Caravaca, Gil; Gonzalez, Julian del Cerro; Klein, Lea; Alonso‐Burgos, Alberto

doi:10.1007/s00330-014-3243-5

Cited by 12 publications

(5 citation statements)

References 26 publications

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“…There are some discrepancies in literature concerning the agreement rate of CTA versus intraoperative perforator selection. Some authors report as high as 95.2% (Casares Santiago et al, 2014), 74% (Haddock et al, 2020), or 67.3% (Boer et al, 2017) while others revealed nearly half of DIEP flaps had been harvested with changes from the surgical planning due to insufficient information from preoperative CTA (Keys et al, 2013). Haddock et al (2020) found in their study that when used for preoperative planning, CTA reduced operative time by over 1 h. However their study only includes bilateral DIEP patients, which is relevant since there is no concern for fat necrosis of zone III.…”

Section: Discussionmentioning

confidence: 99%

Free‐style technique versus computed tomographic angiography‐guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study

et al. 2023

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BackgroundComputed tomographic angiography (CTA) is the preferred diagnostic tool in preoperative deep inferior epigastric perforator (DIEP) flap assessment, though some surgeons prefer approaching perforator selection with intraoperative findings alone.MethodsThis prospective observational study conducted between 2015 and 2020 assessed our intraoperative decision‐making “free‐style” technique for DIEP flap harvest. Any patient with indication for immediate or delayed breast reconstruction using abdominally based flaps and who received preoperative CTA was enrolled. Only unilateral cases performed by the same surgeon were considered. Allergy to iodine‐based contrast media, renal impairment and claustrophobia were other exclusion criteria. Primary endpoint consisted in comparing operative times and complication rates between free‐style technique and CTA‐guided approach. Secondary endpoints included evaluation of agreement rate between intraoperative findings and CTA, and identification of variables affecting operative time and complication rate. Demographics, surgical information, agreement versus non‐agreement and complications were collected.ResultsStarting from 206 patients, 100 were enrolled. Fifty were assigned to Group A, receiving DIEP flap with free‐style technique. The other 50 were assigned to Group B, receiving DIEP flap with CTA‐guided perforators selection. Study groups' demographics were homogenous. Operative time was statistically lower (p = .036) in free‐style group (252.4 ± 44.77 min vs. 265.6 ± 31.67 min). Complication rates were higher in CTA‐guided group (10% vs. 2%) though this was not significant (p = .092). Overall agreement rate in dominant perforator selection between intraoperatively and CTA‐based assessment was 81%. Multiple regression analysis showed no variable increased complication rate, though CTA‐guided approach, BMI > 30 and harvesting more than one perforator were respectively associated with B‐coefficient of 17.391 (2.430–32.351, 95% CI) [p = .023], 3.50 (0.640–6.379, 95% CI) [p = .017] and 18.887 (6.232–31.542, 95% CI) [p = .004], predicting increased operative time.ConclusionsThe free‐style technique proved to be a useful tool for guiding DIEP flap harvest with good sensibility in detecting the dominant perforator suggested by CTA without statistically increasing surgery duration and complications.

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Section: Discussionmentioning

confidence: 99%

Free‐style technique versus computed tomographic angiography‐guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study

et al. 2023

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“…The use of high-resolution vascular mapping preoperative tests on microsurgical flaps has been shown to decrease intraoperative complications in flap dissection [ 21 ], decrease overall surgical time and flap harvesting time [ 22 ], facilitate dissection and avoid serious vascular complications [ 23 ] in patients with vascular abnormalities that could not be diagnosed without such vascular tests or only with physical examination [ 22 , 23 , 24 ]. There is published evidence on the improvement of results when performing preoperative vascular mapping studies with MRA and CTA in several microsurgical flaps: fibula flap [ 24 , 25 , 26 , 27 ], deep inferior epigastric perforator flap [ 21 , 22 , 23 , 28 , 29 , 30 , 31 ] and other perforator flaps. The evidence for the use of preoperative vascular mapping tests in RFFF is scarce, with contradictory results.…”

Section: Discussionmentioning

confidence: 99%

Preoperative Doppler Ultrasonography Allen Test for Radial Forearm Free Flap in Oral Cancer Reconstruction: Implications in Clinical Practice

Tousidonis

Escobar

Caicoya

et al. 2021

JCM

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The Radial Forearm Free Flap (RFFF) is one of the most widely used microsurgical flaps for intraoral reconstruction. Although the Clinical Allen Test (CAT) is the most widely used preoperative diagnostic method with which to study the distal patency of the hand prior to the use of RFFF, several authors have reported potentially preventable serious vascular complications. This study included 87 consecutive patients with cancer of the oral cavity and RFFF as the flap of choice who were treated between 2010 and 2020, and compares the results of the Clinical Allen Test (CAT), the Doppler Allen Test (DAT) and the Surgical Allen Test (SAT). The preoperative vascular study found vascular abnormalities severe enough for the surgical team to change the preoperative flap of choice in 39% of patients. The Kappa index showed a weak concordance between the CAT and DAT. The study reflected a total concordance in the preoperative results of the Doppler study and the intraoperative results of the SAT. Due to its excellent agreement with SAT, the DAT would be the preoperative test of choice in patients who are candidates for RFFF. This study of vascular mapping tests with Doppler is intended to inform therapeutic decisions and present methods to gain information that cannot be obtained by physical examination alone.

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“…The deep inferior epigastric perforator (DIEP) flap is the most common flap used in breast reconstruction. Raising a DIEP flap requires meticulous dissection of the DIEP vessels; however, there is significant heterogeneity in their branching pattern and location [ 132 ]. CTA is the current ‘gold standard’ for pre-operative vascular mapping, reducing operative time and postoperative complications [ 133 – 135 ].…”

Section: Notes On Specific Protocolsmentioning

confidence: 99%

Vascular CT and MRI: a practical guide to imaging protocols

2018

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Non-invasive cross-sectional imaging techniques play a crucial role in the assessment of the varied manifestations of vascular disease. Vascular imaging encompasses a wide variety of pathology. Designing vascular imaging protocols can be challenging owing to the non-uniform velocity of blood in the aorta, differences in cardiac output between patients, and the effect of different disease states on blood flow. In this review, we provide the rationale behind—and a practical guide to—designing and implementing straightforward vascular computed tomography (CT) and magnetic resonance imaging (MRI) protocols.Teaching Points • There is a wide range of vascular pathologies requiring bespoke imaging protocols. • Variations in cardiac output and non-uniform blood velocity complicate vascular imaging. • Contrast media dose, injection rate and duration affect arterial enhancement in CTA. • Iterative CT reconstruction can improve image quality and reduce radiation dose. • MRA is of particular value when imaging small arteries and venous studies. Electronic supplementary materialThe online version of this article (10.1007/s13244-018-0597-2) contains supplementary material, which is available to authorised users.

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Optimising the preoperative planning of deep inferior epigastric perforator flaps for breast reconstruction

Cited by 12 publications

References 26 publications

Free‐style technique versus computed tomographic angiography‐guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study

Free‐style technique versus computed tomographic angiography‐guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study

Preoperative Doppler Ultrasonography Allen Test for Radial Forearm Free Flap in Oral Cancer Reconstruction: Implications in Clinical Practice

Vascular CT and MRI: a practical guide to imaging protocols

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