Ultrasonographic Quantification of Blood Flow in Microsurgical Breast Reconstruction: Correlation with Indocyanine Green Angiography

Abstract

Background

Although autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap is a standard procedure, flap perfusion-associated complications remain a concern. This study aimed to investigate the correlation between blood flow information obtained through color Doppler ultrasonography (CDU) and flap perfusion assessed by indocyanine green (ICG) angiography.

Methods

This prospective study included 30 female patients who underwent DIEP flap breast reconstruction between August 2023 and June 2024. Preoperative flow parameters, including arterial peak velocity, arterial volume flow, and venous peak velocity, were measured using CDU. Flap perfusion was evaluated using ICG angiography.

Results

The study demonstrated a positive correlation between venous flow and overall flap blood flow. Arterial peak velocity (r = 0.368, p = 0.046), arterial volume flow (r = 0.455, p = 0.011), and venous peak velocity (r = 0.399, p = 0.029) all showed significant associations with ICG-stained area percentages. These findings suggest that venous flow data can provide valuable information for predicting flap viability.

Conclusion

This study demonstrates a significant correlation between flow information obtained through CDU and flap perfusion assessed via ICG angiography in patients undergoing DIEP flap breast reconstruction. Both arterial and venous flow data were shown to be crucial for predicting flap viability, with venous flow exhibiting a notable positive correlation with flap blood flow.

Keywords

microsurgical breast reconstruction - color doppler ultrasound - blood flow

Publication History

Received: 08 January 2025

Accepted: 12 May 2025

Accepted Manuscript online:
22 May 2025

Article published online:
13 June 2025

• References

• 1 Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110 (02) 466-475 , discussion 476–477
• 2 Hamnett KE, Subramanian A. Breast reconstruction in older patients: a literature review of the decision-making process. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1325-1334
• 3 Cai A, Suckau J, Arkudas A, Beier JP, Momeni A, Horch RE. Autologous breast reconstruction with transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps: an analysis of the 100 most cited articles. Med Sci Monit 2019; 25: 3520-3536
• 4 Chang DW. Breast reconstruction with microvascular MS-TRAM and DIEP Flaps. Arch Plast Surg 2012; 39 (01) 3-10
• 5 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124 (03) 752-764
• 6 Masterton G, Miller R, Patel J, Pratt P, Gosling N, Saour S. HoloLens in breast reconstruction: what is the future?. Plast Reconstr Surg 2023; 151 (06) 915e-917e
• 7 Scott JR, Liu D, Said H, Neligan PC, Mathes DW. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg 2010; 125 (02) 446-453
• 8 Hong JP, Hur J, Kim HB, Park CJ, Suh HP. The use of color duplex ultrasound for local perforator flaps in the extremity. J Reconstr Microsurg 2022; 38 (03) 233-237
• 9 Bajus A, Streit L, Kubek T. et al. Color Doppler ultrasound versus CT angiography for DIEP flap planning: a randomized controlled trial. J Plast Reconstr Aesthet Surg 2023; 86: 48-57
• 10 Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006; 117 (01) 37-43
• 11 Bajus A, Kubek T, Dražan L. et al. Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: a cohort study and learning curve assessment. J Plast Reconstr Aesthet Surg 2023; 76: 105-112
• 12 Cina A, Salgarello M, Barone-Adesi L, Rinaldi P, Bonomo L. Planning breast reconstruction with deep inferior epigastric artery perforating vessels: multidetector CT angiography versus color Doppler US. Radiology 2010; 255 (03) 979-987
• 13 Hong JP, Kim HB, Park CJ, Suh HP. Using duplex ultrasound for recipient vessel selection. J Reconstr Microsurg 2022; 38 (03) 200-205
• 14 Al Hindi A, Ozil C, Rem K. et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet 2019; 64 (03) 245-250
• 15 Zhu Y, Yoo H, Min S, Chang H. Efficacy of superficial inferior epigastric vein superdrainage in free TRAM and DIEP flap: an indocyanine green angiography study of 68 cases. J Plast Reconstr Aesthet Surg 2023; 84: 385-391
• 16 Kiely J, Kumar M, Wade RG. The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 74 (05) 945-956
• 17 Stekelenburg CM, Sonneveld PM, Bouman MB. et al. The hand held Doppler device for the detection of perforators in reconstructive surgery: what you hear is not always what you get. Burns 2014; 40 (08) 1702-1706