Perforator flap magnetic resonance angiography for reconstructive breast surgery: A review of 25 deep inferior epigastric and gluteal perforator artery flap patients

Abstract

Purpose: To evaluate the accuracy of magnetic resonance angiography (MRA) for preoperative mapping of rectus and gluteal muscle perforating arteries prior to autologous flap breast reconstruction. Materials and Methods:Preoperative MRA on 25 consecutive patients undergoing perforator artery-based autologous breast reconstruction was performed at 1.5 T using 3D liver accelerate volume acquisition (LAVA) of abdominal or gluteal regions acquired during injection of 20 mL of gadobenate dimeglumine with bolus timing optimized using MR fluoroscopy or SmartPrep. Perforator artery size and coordinates relative to umbilicus or top of gluteal crease on 3D MRA were compared to findings at surgery. Reconstructed breast volume estimates from MRA were also compared to weights at harvesting.Results: In all, 132 perforator arteries were found at surgery to be located within 1 cm of the coordinates measured on MRA and were surgically verified to be suitable for flap perfusion. Surgery verified the arterial course and caliber through the rectus and gluteal muscles visualized on MRA in 48 of 49 arteries. Volume rendering of 3D MRA predicted a breast reconstruction volume with a mean difference of 47 g compared to measurements at harvesting.Conclusion: MRA accurately maps rectus and gluteal muscle perforator arteries for preoperative planning of autologous flaps for breast reconstruction.

Modern Perforator Flap Imaging with High-Resolution Blood Pool MR Angiography

“…As demonstrated by Ahmadzadeh et al (26), the majority of perforators are along the superior two-thirds of a line from the posterior superior iliac spine to the greater trochanter (16,27,28). The superior gluteal artery perforator pedicle length is usu- ally 5-7 cm and is measured from the point between the gluteus medius and piriformis muscles (16,28). This pedicle may course through or in between the gluteus maximus and gluteus medius muscles in a variety of orientations (9,27,28) (Fig 5).…”

“…The superior gluteal artery perforator flap is oriented transversely across the upper portion of the buttock, with the superior gluteal vessels oriented at the medial portion of the flap (Fig 4) (16). As demonstrated by Ahmadzadeh et al (26), the majority of perforators are along the superior two-thirds of a line from the posterior superior iliac spine to the greater trochanter (16,27,28). The superior gluteal artery perforator pedicle length is usu- ally 5-7 cm and is measured from the point between the gluteus medius and piriformis muscles (16,28).…”

Evolving options for breast reconstruction

“…As with abdominal flaps, this is typically performed via CTA, although magnetic resonance angiography has also been advocated for this purpose (Fig 12). 109 …”

Integrating Imaging Techniques in Deep Inferior Epigastric Perforator Breast Reconstruction.

“…[39][40][41][42] Contrast enhanced MRA delineates accurately the intramuscular trajectory of the perforators and can identify vessels >0.8mm in diameter. 11,[40][41][42] Rozen et al suggested that despite high sensitivity (100%) MRA was inferior to preoperative CTA due to low specificity (50%), 43 while Chernyak et al reported a 97% concordance of MRA imaging with intraoperative findings in DIEP flap breast reconstruction. 44 Despite its higher cost, MRA has certain advantages over CTA, namely elimination of exposure to ionizing radiation and safer required contrast medium.…”

“…Nevertheless, gadolinium may also be nephrotoxic for patients with renal insufficiency. 11,12,[40][41][42][43][44] Masia et al demonstrated that non-contrast magnetic resonance imaging was associated with high specificity and provided reliable information on the perforator branching within the subcutaneous abdominal tissue and the vascular connections between the superficial and the deep inferior epigastric vessels 45 Nevertheless, a serious limitation of MRA is possible patient discomfort, as it requires breath-hold for 10-20 seconds to avoid motion artifacts. Distress levels may increase in claustrophobic patients, while the technique is contraindicated in severely obese and patients with metallic implants.…”