Response to Letter to the Editor: Preoperative Imaging for Perforator Flaps—More Research Is Necessary

We thank Drs. Knobloch, Redeker, and Vogt for their interest in our special topic supplement issue, “Imaging Modalities in Perforator Flap Reconstruction.” It was our hope to stimulate a dialogue over best practices in reconstructive perforator flap surgery.

Although preoperative visualization of perforators may lead to many benefits, there are no adequate studies to date that can demonstrate the ideal technique. In fact, by showing the multitude of available techniques (handheld Doppler,[1] duplex ultrasound,[2] multidetector computed tomography,[2] [3] [4] magnetic resonance imaging,[5] [6] [7] near infrared imaging,[8] no imaging[9]), it becomes clear that there is no gold standard. As with many areas within plastic surgery, evidence-based medicine is difficult to design well, and we welcome any contributions to the literature from the authors.

The commentary on the use of Doppler ultrasound is insightful and deserves more attention. To date, we know of no studies within plastic surgery that show three- and four-dimensional ultrasound for vessel identification. We are aware of advances made within obstetric scanning; however, this technology has not been applied to our field. We once again welcome any literature looking specifically at this topic.

The current practice of perforator imaging in Germany is extremely interesting, and we thank the authors for highlighting this viewpoint in Plastic and Reconstructive Surgery.[10] It seems from the text that a majority of plastic surgeons (90.4%) use some form of imaging in Germany, with duplex ultrasound and color Doppler representing the majority. It would be helpful to see a study further elucidating these results and a full representation of the data gathered. For example, it would be interesting to see why these centers adapted similar practices. On a larger scale, it would be informative to understand what the pattern of usage is in the United States.

The potential quality improvements have not been properly studied as of yet. We are of similar opinion that the learning curve seen in novice surgeons may benefit from preoperative imaging, and early studies are showing benefits of reduced operative time. Large-scale cost-benefit analyses are necessary to ascertain true cost savings. In this era of cost cutting and rationing of health care, however, it can be difficult to justify the additional expense of an imaging study. Anecdotally, we have found it difficult with some insurance plans to justify the necessity for preoperative imaging, especially because the literature is not clear on the benefits (outcomes or cost). It would be a great contribution to the field if multiple, well-designed studies could validate the benefits of perforator flap imaging.

REFERENCES

• 1 Hallock G G. Attributes and shortcomings of acoustic Doppler sonography in identifying perforators for flaps from the lower extremity.  J Reconstr Microsurg. 2009;  25 377-381
• 2 Mathes D W, Neligan P C. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction.  J Reconstr Microsurg. 2010;  26 3-10
• 3 Hijjawi J B, Blondeel P N. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging.  J Reconstr Microsurg. 2010;  26 11-20
• 4 Masia J, Kosutic D, Clavero J A, Larranaga J, Vives L, Pons G. Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction.  J Reconstr Microsurg. 2010;  26 21-28
• 5 Masia J, Kosutic D, Cervelli D, Clavero J A, Monill J M, Pons G. In search of the ideal method in perforator mapping: noncontrast magnetic resonance imaging.  J Reconstr Microsurg. 2010;  26 29-35
• 6 Greenspun D, Vasile J V, Levine J L et al.. Anatomic imaging of abdominal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance imaging angiography.  J Reconstr Microsurg. 2010;  26 37-44
• 7 Vasile J V, Newman T, Rusch D G et al.. Anatomic imaging of gluteal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance angiography.  J Reconstr Microsurg. 2010;  26 45-57
• 8 Lee B T, Matsui A, Hutteman M et al.. Intraoperative near-infrared fluorescence imaging in perforator flap reconstruction: current research and early clinical experience.  J Reconstr Microsurg. 2010;  26 59-65
• 9 Lin S J, Rabie A, Yu P. Designing the anterolateral thigh flap without preoperative Doppler or imaging.  J Reconstr Microsurg. 2010;  26 67-72
• 10 Knobloch K, Gohritz A, Reuss E, Redeker J, Spies M, Vogt P M. Preoperative perforator imaging in reconstructive plastic surgery: current practice in Germany.  Plast Reconstr Surg. 2009;  124 183e-184e