J Reconstr Microsurg 2010; 26(01): 003-010
DOI: 10.1055/s-0029-1244806
Original Article

Current Techniques in Preoperative Imaging for Abdomen-based Perforator Flap Microsurgical Breast Reconstruction

David W Mathes
1   Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Washington School of Medicine, Seattle, Washington
,
Peter C Neligan
1   Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Washington School of Medicine, Seattle, Washington
› Author Affiliations

Abstract

Perforator-based microsurgical reconstruction of the breast has steadily increased since the introduction of the technique in the 1990s. The procedure appears to offer less postoperative pain, lower abdominal morbidity, and better preservation of the rectus muscles than the more conventional flaps. However, the major disadvantage of these flaps that they can be difficult to harvest, resulting in a longer operative times. The challenges in flap dissection are a result of the variability in the vascular anatomy of the deep inferior epigastric artery (DIEA) and its perforating branches through the rectus muscle. The location, number, and caliber of the perforators and the intramuscular trajectory of the DIEA branches vary greatly not only from individual to individual, but from one hemiabdomen to the other. The establishment of a presurgical map of the vessels on the abdomen facilitates surgical planning and may decrease operating room time, reduce intraoperative complications, and possibly improve outcomes. This article reviews the available techniques for preoperative planning with the currently available imaging modalities of handheld Doppler, color Doppler (duplex) ultrasound, computed tomography angiography, and magnetic resonance angiography.



Publication History

Publication Date:
18 December 2009 (online)

© 2010. Thieme Medical Publishers

Thieme Medical Publishers

 
  • REFERENCES

  • 1 Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg 1994; 47: 495-501
  • 2 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32: 32-38
  • 3 Allen RJ. DIEP versus TRAM for breast reconstruction. Plast Reconstr Surg 2003; 111: 2478
  • 4 Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006; 117: 737-746 discussion 747-750
  • 5 Blondeel N, Vanderstraeten GG, Monstrey SJ. et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50: 322-330
  • 6 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: 363-369
  • 7 Taylor GI, Doyle M, McCarten G. The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg 1990; 43: 1-16
  • 8 Hallock GG. Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 2003; 30: 347-357 v–vi
  • 9 Rand RP, Cramer MM, Strandness Jr DE. Color-flow duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients. Plast Reconstr Surg 1994; 93: 453-459
  • 10 Giunta RE, Geisweid A, Feller AM. The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 2000; 105: 2381-2386
  • 11 Blondeel PN, Beyens G, Verhaeghe R. et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998; 51: 202-209
  • 12 Masia J, Clavero JA, Larrañaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59: 594-599
  • 13 Clavero JA, Masia J, Larrañaga J. et al. MDCT in the preoperative planning of abdominal perforator surgery for postmastectomy breast reconstruction. AJR Am J Roentgenol 2008; 191: 670-676
  • 14 Masia J, Clavero JA, Larrañaga J, Vives L, Pons G. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg 2008; 122: 80e-81e
  • 15 Masia J, Larrañaga J, Clavero JA, Vives L, Pons G, Pons JM. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg 2008; 60: 29-36
  • 16 Rosson GD, Williams CG, Fishman EK, Singh NK. 3D CT angiography of abdominal wall vascular perforators to plan DIEAP flaps. Microsurgery 2007; 27: 641-646
  • 17 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: 306-313
  • 18 Rozen WM, Ashton MW, Stella DL, Phillips TJ, Grinsell D, Taylor GI. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg 2008; 122: 1003-1009
  • 19 Rozen WM, Phillips TJ, Ashton MW, Stella DL, Taylor GI. A new preoperative imaging modality for free flaps in breast reconstruction: computed tomographic angiography. Plast Reconstr Surg 2008; 122: 38e-40e
  • 20 Tregaskiss AP, Goodwin AN, Bright LD, Ziegler CH, Acland RD. Three-dimensional CT angiography: a new technique for imaging microvascular anatomy. Clin Anat 2007; 20: 116-123
  • 21 Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 2008; 121 (01) Suppl 1-8
  • 22 Rozen WM, Garcia-Tutor E, Alonso-Burgos A. et al. Planning and optimising DIEP flaps with virtual surgery: the Navarra experience. J Plast Reconstr Aesthet Surg 2008. November 28 (Epub ahead of print).
  • 23 Casey III WJ, Chew RT, Rebecca AM, Smith AA, Collins JM, Pockaj BA. Advantages of preoperative computed tomography in deep inferior epigastric artery perforator flap breast reconstruction. Plast Reconstr Surg 2009; 123: 1148-1155
  • 24 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: 1112-1117
  • 25 Scott JR, Liu D, Said H, Neligan PC, Mathes DW. CT angiography in planning abdomen-based microsurgical breast reconstruction: a comparison to color duplex ultrasound. Plast Reconstr Surg, 2009 Accepted for publication
  • 26 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: 205-211
  • 27 Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Benito A, Dominguez PD, Zubieta JL. Preoperative planning of DIEP and SGAP flaps: preliminary experience with magnetic resonance angiography using 3-tesla equipment and blood-pool contrast medium. J Plast Reconstr Aesthet Surg. 2009 January 2 (Epub ahead of print)
  • 28 Chernyak V, Rozenblit AM, Greenspun DT. et al. Breast reconstruction with deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators. Radiology 2009; 250: 417-424
  • 29 Rozen WM, Stella DL, Phillips TJ, Ashton MW, Corlett RJ, Taylor GI. Magnetic resonance angiography in the preoperative planning of DIEA perforator flaps. Plast Reconstr Surg 2008; 122: 222e-223e