Preoperative Computed Tomography Angiogram to Predict Patients With Favorable Anatomy for Superficial Inferior Epigastric Artery Flap Breast Reconstruction

Abstract

Superficial inferior epigastric artery (SIEA) flap breast reconstruction has advantages over deep inferior epigastric perforator flap (DIEP) and muscle sparing transverse rectus abdominus myocutaneous flap (TRAM) reconstructions with less donor site morbidity and less complicated flap dissection. Not all patients have an adequate SIEA and superficial inferior epigastric vein (SIEV) to support free tissue breast reconstruction, and dissection of the SIEA in all patients can be time consuming. Preoperative computed tomography (CT) angiograms can be used to identify the SIEA and SIEV in patients planning to undergo free abdominal tissue breast reconstruction and direct more efficient dissection in patients with a large SIEA. Retrospective analysis of free abdominal tissue flap breast reconstruction from a single plastic surgeon was performed. All patients undergoing free abdominal tissue breast reconstruction had a preoperative CT angiogram using a protocol for the evaluation of the abdominal wall perforating arteries. CT scans were reviewed by the surgeon preoperatively and evaluated for the presence, caliber, and image quality of the SIEA and SIEV. All patients, regardless of CT angiogram findings, had operative dissection and evaluation of the SIEA and SIEV. A total of 177 free flaps were performed on 113 patients who underwent preoperative CT angiogram and free abdominal tissue breast reconstruction. Of them, 64 patients had bilateral breast reconstruction. Twelve SIEA flaps (10.6%) were performed on 12 patients. During preoperative CT angiographic evaluation, 49 patients (43%) were noted to have at least one visible SIEA, whereas only 24 of those patients (21%) were felt to have an SIEA of adequate caliber. No flaps were lost during the postoperative period. All 12 SIEA flaps performed had an adequate SIEA when observed on preoperative CT angiogram. Overall, 50% of patients found to have at least one adequate SIEA on CT angiogram had a single breast reconstructed with an SIEA flap. If the SIEA was not visualized on CT angiogram, no usable SIEA was found during surgery. Preoperative CT angiogram of the abdominal wall perforating arteries can help predict which patients may have adequate anatomy for an SIEA-based free flap. This information may help direct more efficient dissection of the abdominal flaps by selecting out patients who do not have an adequate SIEA.

Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging

“…(Sadik, Pasko, Cohen, & Cacioppo, 2013) Despite this, preoperative CTA improves outcomes when raising SIEV flaps. (Piorkowski, DeRosier, Nickerson, & Fix, 2011) Evidence also supports MRA. (Greenspun et al, 2010;Masia et al, 2010;Schaverien et al, 2010;Schaverien, Ludman, Neil-Dwyer, Perks, et al, 2011) CTA is our preferred imaging modality due to radiological expertise, hospital set-up, and reduced cost from combined scans for both oncological staging and reconstructive planning.…”

SIEA versus DIEP Arterial Complications

“…Preoperative computed tomographic angiography can characterize SIEA caliber and course, 26 SIEV drainage and branching, 22 and prediction of adequate anatomy for flap success. 27 Experts cite that the current utility of SIEA flaps is limited to select cases with favorable anatomy. 17 Although preoperative computed tomographic angiography is useful, intraoperative decision-making remains principal.…”

The Impact of Preoperative CT Angiography on Breast Reconstruction With Abdominal Perforator Flaps

“…11 Furthermore, Piorkowski et al evaluated SIEA adequacy of 113 patients based on pCTA and compared the results to operative dissection and determined that 50% of patients who were found to have at least one adequate SIEA on pCTA had a single breast reconstructed with an SIEA flap. 12 The differences in accuracy of pCTA between studies available in the literature can be attributed to variations in patient population, surgeons' preference, and interpretation of operative or CT findings. We believe that pCTA is extremely accurate in identifying and mapping the perforators for abdominal free flap breast reconstruction and is superior to that of the previous modalities used in this role.…”