Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery

Abstract

Background The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature.

Methods An extensive literature review was performed to determine the most commonly used modalities, and their applicability, advantages and disadvantages.

Results The review demonstrated varioius findings including decreases in operative time and cost with the use of CT angiography to identification of perforators for inclusion in flap design with hand-held Doppler ultrasound. Modalities like MR angiography offer alternatives for patients with contrast allergies or renal dysfunction while maintaining a high level of clarity and fidelity. Although the use of conventional angiography has decreased due to the availability of less invasive alternatives, it continues to serve a role in the preoperative evaluation of patients for lower extremity reconstruction. Duplex ultrasonography has been of great interest recently as an inexpensive, risk free, and extraordinarily accurate diagnostic tool. Emerging technologies such as indocyanine green fluorescence angiography and dynamic infrared thermography provide real-time information about tissue vascularity and perfusion without requiring radiation exposure.

Conclusion This article presents an in-depth review of the various imaging modalities available to reconstructive surgeons and includes hand held Doppler ultrasound, CT angiography, MR angiography, conventional angiography, duplex ultrasonography, Indocyanine Green Fluorescence Angiography and Dynamic Infrared Thermography.

Keywords

ultrasound - imaging - angiography - microsurgery

Publikationsverlauf

Eingereicht: 17. Juni 2021

Angenommen: 27. August 2021

Artikel online veröffentlicht:
23. Oktober 2021

• References

• 1 Blondeel PN, Beyens G, Verhaeghe R. et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998; 51 (03) 202-209
• 2 Giunta RE, Geisweid A, Feller AM. The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 2000; 105 (07) 2381-2386
• 3 Rozen WM, Anavekar NS, Ashton MW. et al. Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?. Microsurgery 2008; 28 (07) 516-523
• 4 Rozen WM, Ashton MW, Stella DL. et al. Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT-guided stereotaxy. Microsurgery 2008; 28 (04) 227-232
• 5 Rozen WM, Ashton MW, Pan WR. et al. Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study. Microsurgery 2009; 29 (01) 16-23
• 6 Debelmas A, Camuzard O, Aguilar P, Qassemyar Q. Reliability of color Doppler ultrasound imaging for the assessment of anterolateral thigh flap perforators: a prospective study of 30 perforators. Plast Reconstr Surg 2018; 141 (03) 762-766
• 7 Feng S, Min P, Grassetti L. et al. A prospective head-to-head comparison of color Doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg 2016; 137 (01) 335-347
• 8 Mijuskovic B, Tremp M, Heimer MM. et al. Color Doppler ultrasound and computed tomographic angiography for perforator mapping in DIEP flap breast reconstruction revisited: a cohort study. J Plast Reconstr Aesthet Surg 2019; 72 (10) 1632-1639
• 9 González Martínez J, Torres Pérez A, Gijón Vega M, Nuñez-Villaveiran T. Preoperative vascular planning of free flaps: comparative study of computed tomographic angiography, color Doppler ultrasonography, and hand-held Doppler. Plast Reconstr Surg 2020; 146 (02) 227-237
• 10 Solomon GA, Yaremchuk MJ, Manson PN. Doppler ultrasound surface monitoring of both arterial and venous flow in clinical free tissue transfers. J Reconstr Microsurg 1986; 3 (01) 39-41
• 11 DellaCroce FJ, Sullivan SK. Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction. Plast Reconstr Surg 2005; 116 (01) 97-103 , discussion 104–105
• 12 Michelow BJ, Hartrampf Jr. CR, Bennett GK. TRAM flap safety optimized with intraoperative Doppler. Plast Reconstr Surg 1990; 86 (01) 143-146
• 13 Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg 2009; 124 (6, suppl): e295-e302
• 14 Burrill J, Dabbagh Z, Gollub F, Hamady M. Multidetector computed tomographic angiography of the cardiovascular system. Postgrad Med J 2007; 83 (985) 698-704
• 15 Boer VB, van Wingerden JJ, Wever CF, Beets MR, Verhaegen PD, Hamdi M. Perforator mapping practice for deep inferior epigastric artery perforator flap reconstructions: a survey of the Benelux Region. J Reconstr Microsurg 2021; 37 (02) 111-118
• 16 Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI. Magnetic resonance angiography and computed tomographic angiography for free fibular flap transfer. J Reconstr Microsurg 2008; 24 (06) 457-458
• 17 Fukaya E, Grossman RF, Saloner D, Leon P, Nozaki M, Mathes SJ. Magnetic resonance angiography for free fibula flap transfer. J Reconstr Microsurg 2007; 23 (04) 205-211
• 18 Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI. The accuracy of computed tomographic angiography for mapping the perforators of the DIEA: a cadaveric study. Plast Reconstr Surg 2008; 122 (02) 363-369
• 19 Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg 2010; 26 (01) 11-20
• 20 Smit JM, Dimopoulou A, Liss AG. et al. Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg 2009; 62 (09) 1112-1117
• 21 Haddock NT, Dumestre DO, Teotia SS. Efficiency in DIEP flap breast reconstruction: the real benefit of computed tomographic angiography imaging. Plast Reconstr Surg 2020; 146 (04) 719-723
• 22 Masia J, Kosutic D, Clavero JA, Larranaga J, Vives L, Pons G. Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg 2010; 26 (01) 21-28
• 23 Beckett KR, Moriarity AK, Langer JM. Safe use of contrast media: what the radiologist needs to know. Radiographics 2015; 35 (06) 1738-1750
• 24 van der Molen AJ, Reimer P, Dekkers IA. et al. Post-contrast acute kidney injury - Part 1: Definition, clinical features, incidence, role of contrast medium and risk factors : recommendations for updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 2018; 28 (07) 2845-2855
• 25 Rogers DC, Tadi P. Intravenous contrast. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021
• 26 Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63 (09) e674-e682
• 27 Klein S, Van Lienden KP, Van't Veer M, Smit JM, Werker PM. Evaluation of the lower limb vasculature before free fibula flap transfer. A prospective blinded comparison between magnetic resonance angiography and digital subtraction angiography. Microsurgery 2013; 33 (07) 539-544
• 28 Sheriff HO, Mahmood KA, Hamawandi N. et al. The supraclavicular artery perforator flap: a comparative study of imaging techniques used in preoperative mapping. J Reconstr Microsurg 2018; 34 (07) 499-508
• 29 Chen FR, Kerluku J, Mintz D. et al. Noncontrast magnetic resonance imaging of perforators for preoperative evaluation of anterolateral thigh flaps. Plast Reconstr Surg Glob Open 2020; 8 (10) e3174
• 30 Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol 2008; 36 (02) 69-74 , quiz 76–77
• 31 Vasile JV, Newman T, Rusch DG. et al. Anatomic imaging of gluteal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance angiography. J Reconstr Microsurg 2010; 26 (01) 45-57
• 32 Akashi M, Nomura T, Sakakibara S, Sakakibara A, Hashikawa K. Preoperative MR angiography for free fibula osteocutaneous flap transfer. Microsurgery 2013; 33 (06) 454-459
• 33 Kagen AC, Hossain R, Dayan E. et al. Modern perforator flap imaging with high-resolution blood pool MR angiography. Radiographics 2015; 35 (03) 901-915
• 34 Kelly AM, Cronin P, Hussain HK, Londy FJ, Chepeha DB, Carlos RC. Preoperative MR angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making. AJR Am J Roentgenol 2007; 188 (01) 268-274
• 35 Rozen WM, Stella DL, Bowden J, Taylor GI, Ashton MW. Advances in the pre-operative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery 2009; 29 (02) 119-123
• 36 Rodkin B, Hunter-Smith DJ, Rozen WM. A review of visualized preoperative imaging with a focus on surgical procedures of the breast. Gland Surg 2019; 8 (Suppl. 04) S301-S309
• 37 Newman TM, Vasile J, Levine JL. et al. Perforator flap magnetic resonance angiography for reconstructive breast surgery: a review of 25 deep inferior epigastric and gluteal perforator artery flap patients. J Magn Reson Imaging 2010; 31 (05) 1176-1184
• 38 Hölzle F, Ristow O, Rau A. et al. Evaluation of the vessels of the lower leg before microsurgical fibular transfer. Part II: magnetic resonance angiography for standard preoperative assessment. Br J Oral Maxillofac Surg 2011; 49 (04) 275-280
• 39 Mohan AT, Saint-Cyr M. Advances in imaging technologies for planning breast reconstruction. Gland Surg 2016; 5 (02) 242-254
• 40 May Jr. JW, Athanasoulis CA, Donelan MB. Preoperative magnification angiography of donor and recipient sites for clinical free transfer of flaps or digits. Plast Reconstr Surg 1979; 64 (04) 483-490
• 41 Ahmad N, Kordestani R, Panchal J, Lyles J. The role of donor site angiography before mandibular reconstruction utilizing free flap. J Reconstr Microsurg 2007; 23 (04) 199-204
• 42 Merritt CR. Doppler color flow imaging. J Clin Ultrasound 1987; 15 (09) 591-597
• 43 Bluemke DA, Chambers TP. Spiral CT angiography: an alternative to conventional angiography. Radiology 1995; 195 (02) 317-319
• 44 Weng C. Comparison of color flow Doppler, angiogram, CT angiogram and time resolved MR angiogram in the preoperative evaluation of lower extremity vascularity for fibular free flap reconstruction. Journal of Otolaryngology and Rhinology. 2016; 2 (01) 011
• 45 Gerlock Jr. AJ, Perry PE, Goncharenko V, Franklin JD. Evaluation of the dorsalis pedis free flap donor site by angiography. Radiology 1979; 130 (02) 341-343
• 46 Smith RB, Thomas RD, Funk GF. Fibula free flaps: the role of angiography in patients with abnormal results on preoperative color flow Doppler studies. Arch Otolaryngol Head Neck Surg 2003; 129 (07) 712-715
• 47 Cho KJ. Carbon dioxide angiography: scientific principles and practice. Vasc Spec Int 2015; 31 (03) 67-80
• 48 Cho MJ, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36 (07) 514-521
• 49 Oni G, Chow W, Ramakrishnan V, Griffiths M. Plastic surgeon-led ultrasound. Plast Reconstr Surg 2018; 141 (02) 300e-309e
• 50 Cheung ME, Singh V, Firstenberg MS. Duplex ultrasound. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2020
• 51 Grant EG, White EM. eds. Duplex Sonography. New York, NY: Springer-Verlag; 1988
• 52 Mathes DW, Neligan PC. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr Microsurg 2010; 26 (01) 3-10
• 53 Seidenstucker K, Munder B, Richrath P. et al. A prospective study using color flow duplex ultrasonography for abdominal perforator mapping in microvascular breast reconstruction. Med Sci Monit 2010; 16 (08) MT65-MT70
• 54 Tashiro K, Harima M, Kato M. et al. Preoperative color Doppler ultrasound assessment in planning of SCIP flaps. J Plast Reconstr Aesthet Surg 2015; 68 (07) 979-983
• 55 Figus A, Wade RG, Gorton L, Rubino C, Griffiths MG, Ramakrishnan VV. Venous perforators in DIEAP flaps: an observational anatomical study using duplex ultrasonography. J Plast Reconstr Aesthet Surg 2012; 65 (08) 1051-1059
• 56 Gao Y, Yuan Y, Li H. et al. Preoperative imaging for thoracic branch of supraclavicular artery flap: a comparative study of contrast-enhanced ultrasound with three-dimensional reconstruction and color duplex ultrasound. Ann Plast Surg 2016; 77 (02) 201-205
• 57 Dorfman D, Pu LL. The value of color duplex imaging for planning and performing a free anterolateral thigh perforator flap. Ann Plast Surg 2014; 72 (Suppl. 01) S6-S8
• 58 Lichte J, Teichmann J, Loberg C. et al. Routine preoperative colour Doppler duplex ultrasound scanning in anterolateral thigh flaps. Br J Oral Maxillofac Surg 2016; 54 (08) 909-913
• 59 Miller JP, Carney MJ, Lim S, Lindsey JT. Ultrasound and plastic surgery: clinical applications of the newest technology. Ann Plast Surg 2018; 80 (6S, suppl 6): S356-S361
• 60 Safran T, Gorsky K, Viezel-Mathieu A, Kanevsky J, Gilardino MS. The role of ultrasound technology in plastic surgery. J Plast Reconstr Aesthet Surg 2018; 71 (03) 416-424
• 61 Patel KM, Chu SY, Huang JJ, Wu CW, Lin CY, Cheng MH. Preplanning vascularized lymph node transfer with duplex ultrasonography: an evaluation of 3 donor sites. Plast Reconstr Surg Glob Open 2014; 2 (08) e193
• 62 Arya R, Griffiths L, Figus A, King D, Ramakrishnan V, Griffiths M. Post-operative assessment of perfusion of deep inferior epigastric perforator (DIEP) free flaps via pulsatility index (PI) using a portable colour Doppler sonogram device. J Plast Reconstr Aesthet Surg 2013; 66 (07) 931-936
• 63 Başaran K, Ucar A, Guven E, Arinci A, Yazar M, Kuvat SV. Ultrasonographically determined pedicled breast reduction in severe gigantomastia. Plast Reconstr Surg 2011; 128 (04) 252e-259e
• 64 Jacob DD, Kwiecien GJ, Cakmakoglu C, Moreira A. Color duplex ultrasound for localization of vascular compromise in microsurgical breast reconstruction. Plast Reconstr Surg 2020; 145 (03) 666e-667e
• 65 Swanson E. The expanding role of diagnostic ultrasound in plastic surgery. Plast Reconstr Surg Glob Open 2018; 6 (09) e1911
• 66 Kehrer A, Heidekrueger PI, Lonic D. et al. High-resolution ultrasound-guided perforator mapping and characterization by the microsurgeon in lower limb reconstruction. J Reconstr Microsurg 2021; 37 (01) 75-82
• 67 Alander JT, Kaartinen I, Laakso A. et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging 2012; 2012: 940585
• 68 Benya R, Quintana J, Brundage B. Adverse reactions to indocyanine green: a case report and a review of the literature. Cathet Cardiovasc Diagn 1989; 17 (04) 231-233
• 69 Georgiou AK, Singh P, Hever P, Arize C, Mosahebi A. The use of indocyanine green in plastic surgery. J Plast Reconstr Aesthet Surg 2020; 73 (09) e8-e9
• 70 Ott P. Hepatic elimination of indocyanine green with special reference to distribution kinetics and the influence of plasma protein binding. Pharmacol Toxicol 1998; 83 (Suppl. 02) 1-48
• 71 Li K, Zhang Z, Nicoli F. et al. Application of indocyanine green in flap surgery: a systematic review. J Reconstr Microsurg 2018; 34 (02) 77-86
• 72 Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction. Gland Surg 2015; 4 (02) 164-178
• 73 Christensen JM, Baumann DP, Myers JN, Buretta K, Sacks JM. Indocyanine green near-infrared laser angiography predicts timing for the division of a forehead flap. Eplasty 2012; 12: e41
• 74 Lee LN, Smith DF, Boahene KD, Byrne PJ. Intraoperative laser-assisted indocyanine green imaging for objective measurement of the vascular delay technique in locoregional head and neck flaps. JAMA Facial Plast Surg 2014; 16 (05) 343-347
• 75 Lohman RF, Ozturk CN, Ozturk C, Jayaprakash V, Djohan R. An analysis of current techniques used for intraoperative flap evaluation. Ann Plast Surg 2015; 75 (06) 679-685
• 76 Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J 2014; 34 (01) 61-65
• 77 Miland Å, Weerd L, Mercer J. Intraoperative use of dynamic infrared thermography and indocyanine green fluorescence video angiography to predict partial skin flap loss. Eur J Plast Surg 2008; 30: 269-276
• 78 Hagopian TM, Ghareeb PA, Arslanian BH, Moosavi BL, Carlson GW. Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure. Breast J 2015; 21 (02) 185-188
• 79 Krishnan KG, Schackert G, Steinmeier R. Near-infrared angiography and prediction of postoperative complications in various types of integumentary flaps. Plast Reconstr Surg 2004; 114 (05) 1361-1362
• 80 Ritschl LM, Fichter AM, Bomhard AV. et al. Comparison between different perforator imaging modalities for the anterolateral thigh perforator flap transfer: a prospective study. J Reconstr Microsurg 2020; 36 (09) 686-693
• 81 Burnier P, Niddam J, Bosc R, Hersant B, Meningaud JP. Indocyanine green applications in plastic surgery: a review of the literature. J Plast Reconstr Aesthet Surg 2017; 70 (06) 814-827
• 82 Pruimboom T, van Kuijk SMJ, Qiu SS. et al. Optimizing indocyanine green fluorescence angiography in reconstructive flap surgery: a systematic review and ex vivo experiments. Surg Innov 2020; 27 (01) 103-119
• 83 Bigdeli AK, Thomas B, Falkner F, Gazyakan E, Hirche C, Kneser U. The impact of indocyanine-green fluorescence angiography on intraoperative decision-making and postoperative outcome in free flap surgery. J Reconstr Microsurg 2020; 36 (08) 556-566
• 84 Ludolph I, Horch RE, Arkudas A, Schmitz M. Enhancing safety in reconstructive microsurgery using intraoperative indocyanine green angiography. Front Surg 2019; 6 (39) 39
• 85 Weum S, Mercer JB, de Weerd L. Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study. BMC Med Imaging 2016; 16 (01) 43-43
• 86 Tenorio X, Mahajan AL, Wettstein R, Harder Y, Pawlovski M, Pittet B. Early detection of flap failure using a new thermographic device. J Surg Res 2009; 151 (01) 15-21
• 87 de Weerd L, Mercer JB, Weum S. Dynamic infrared thermography. Clin Plast Surg 2011; 38 (02) 277-292
• 88 Hardwicke JT, Osmani O, Skillman JM. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg 2016; 137 (01) 39-41
• 89 Illg C, Krauss S, Rothenberger J, Kolbenschlag J, Daigeler A, Schäfer RC. Air flow cooling improves anterolateral thigh perforator mapping using the FLIR ONE thermal camera. J Reconstr Microsurg 2022; 38 (02) 144-150
• 90 Pereira N, Hallock GG. Smartphone thermography for lower extremity local flap perforator mapping. J Reconstr Microsurg 2021; 37 (01) 59-66
• 91 Stocco C, Papa G, Ramella V, Arnež ZM. Early detection of vascular obstruction in microvascular flaps using a thermographic camera. J Reconstr Microsurg 2019; 35 (07) e5
• 92 John HE, Niumsawatt V, Rozen WM, Whitaker IS. Clinical applications of dynamic infrared thermography in plastic surgery: a systematic review. Gland Surg 2016; 5 (02) 122-132
• 93 Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg 2010; 52 (3, suppl): 81S-91S
• 94 Vargas CR, Koolen PG, Ho OA, Tobias AM, Lin SJ, Lee BT. Preoperative CT-angiography in autologous breast reconstruction. Microsurgery 2016; 36 (08) 623-627
• 95 Zhang X, Mu D, Yang Y. et al. Predicting the feasibility of utilizing SIEA flap for breast reconstruction with preoperative BMI and computed tomography angiography (CTA) data. Aesthetic Plast Surg 2021; 45 (01) 100-107
• 96 Zhang Y, Pan X, Yang H, Yang Y, Huang H, Rui Y. Computed tomography angiography for the chimeric anterolateral thigh flap in the reconstruction of the upper extremity. J Reconstr Microsurg 2017; 33 (03) 211-217
• 97 Haddock N, Garfein ES, Reformat D, Hecht E, Levine J, Saadeh P. Perforator vessel recipient options in the lower extremity: an anatomically based approach to safer limb salvage. J Reconstr Microsurg 2010; 26 (07) 461-469
• 98 Rozen WM, Ashton MW, Grinsell D, Stella DL, Phillips TJ, Taylor GI. Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators. Microsurgery 2008; 28 (05) 306-313
• 99 Midgley SM, Einsiedel PF, Phillips TJ, Stella DL. Justifying the use of abdominal wall computed tomographic angiography in deep inferior epigastric artery perforator flap planning. Ann Plast Surg 2011; 67 (05) 457-459
• 100 Froelich MF, Kunz WG, Kim SH, Sommer WH, Clevert DA, Rübenthaler J. Cost-effectiveness of contrast-enhanced ultrasound for the detection of endovascular aneurysm repair-related endoleaks requiring treatment. J Vasc Surg 2021; 73 (01) 232-239.e2
• 101 Collins R, Cranny G, Burch J. et al. A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease. Health Technol Assess 2007; 11 (20) iii-iv , xi–xiii, 1–184
• 102 Kehrer A, Lonic D, Heidekrueger P. et al. Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS). Microsurgery 2020; 40 (07) 750-759
• 103 Homsy C, McCarthy ME, Lim S, Lindsey Jr. JT, Sands TT, Lindsey Sr JT. Portable color-flow ultrasound facilitates precision flap planning and perforator selection in reconstructive plastic surgery. Ann Plast Surg 2020; 84 (6S, suppl 5): S424-S430