Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery

Abstract

Breast reconstruction with adipocutaneous free flap from the abdominal wall combines the benefits of abdominoplasty to those of a prosthesis-free breast reconstruction. The deep inferior epigastric artery perforator (DIEP) flap is supplied by intramuscular perforators from the deep inferior epigastric artery (DIEA). It consists of the dissection of perforating branches of the DIEA within the rectus abdominis muscle, thus sparing both muscle and fascia. Preoperative imaging in the planning of DIEP flap surgery has been shown to facilitate faster and safer surgery. This review article aims to discuss advantages and drawbacks of current imaging modalities for mapping the course of perforating vessels in the planning of DIEP flap surgery, and to present state-of-the-art imaging techniques.

Integrating Imaging Techniques in Deep Inferior Epigastric Perforator Breast Reconstruction.

“…Expertise is required while there is interobserver variability. 11,12 Subcutaneous vessels that are not perforators may be visualized resulting in false positives, while in overweight patients sensitivity further decreases. Moreover, the duration of the examination is 45-60 minutes, rendering the technique uncomfortable for the patient, who has to remain in the same position during the procedure.…”

“…Moreover, the duration of the examination is 45-60 minutes, rendering the technique uncomfortable for the patient, who has to remain in the same position during the procedure. 11,12 It is noteworthy that CDU does not provide information on the anatomic relationship between the deep inferior epigastric system and other structures, such as the superior inferior epigastric (SIE) system. In addition, as CDU is a real-time technique, further post examination analysis of data is not possible.…”

“…5(1), 2380-2387 2381 mapping of the vessels facilitates precise flap design and harvest, reduces operative time and intraoperative complications while it improves outcomes and efficiency. 4,[9][10][11] The selected dominant perforator is usually medially located, bares a short intramuscular course and a diameter >1 mm, with an extended vascular distribution within the flap adipose tissue to match the flap and to allow preservation of muscle innervation. 2,12 The pre-operative vascular mapping includes imaging modalities ranging from Color Doppler 13 to sophisticated stereotactic vascular representation systems.…”

“…2,12 The pre-operative vascular mapping includes imaging modalities ranging from Color Doppler 13 to sophisticated stereotactic vascular representation systems. 11,14 The ideal imaging technique should have no risk to the patient, attain exceptional quality and highly informative images, and be fast and comfortable to the patient. 11,12 Prerequirement for the reliability of each of the imaging techniques is a standardized protocol for accurate identification of DIEA perforators.…”

“…11,14 The ideal imaging technique should have no risk to the patient, attain exceptional quality and highly informative images, and be fast and comfortable to the patient. 11,12 Prerequirement for the reliability of each of the imaging techniques is a standardized protocol for accurate identification of DIEA perforators. 13 This review presents current imaging methods integrated in DIEP mapping for breast reconstruction, emphasizing on ultrasonography and computed tomographic angiography.…”