Perforator imaging and flap technology

Breast reconstruction has become an important consideration for women after mastectomy. The current American Society of Plastic Surgeons’ (ASPS) procedural statistics reveal that approximately 25% of reconstructions are performed using autologous tissue and 75% are performed using prosthetic devices. Although autologous breast reconstruction is less commonly performed than prosthetic-based reconstruction, there are many circumstances in which its use is preferred and indicated. The discrepancies between autologous and prosthetic reconstruction based on ASPS statistics are because of a variety of reasons. Arguments for prosthetic reconstruction include its ease relative to autologous reconstruction, patient factors that include shorter hospitalizations and less recovery time, as well as good to excellent aesthetic outcomes. Although, autologous reconstruction is considered by many surgeons as superior to prosthetic-based reconstruction in terms of overall aesthetics, some view it as too complicated, technically challenging, and more time consuming. Thus, the challenge has been to make autologous reconstruction more efficient, predictable, and reproducible.

From a historical perspective, autologous reconstruction has been limited by several factors, including selecting ideal patients, optimizing flap selection, length of surgery, and donor site morbidities. Donor site morbidities such as weakness, bulge, and hernia were occasionally observed after the use of traditional musculocutaneous flaps such as the pedicled transverse rectus abdominis musculocutaneous (TRAM). As free tissue transfer methods of breast reconstruction became popular, donor site issues became less frequent; however, other obstacles such as anastomotic patency, postoperative monitoring, and ensuring flap survival became relevant.

The evolution of free tissue transfer and perforator flaps can be chronicled to a period in which patients became increasingly concerned about the mentioned donor site morbidities that were related to complete harvest of the donor site muscles. Perforator flap surgery was the perfect solution to this issue because the muscles were completely preserved. However, performing perforator flap surgery has demanded an entirely new skill set that includes identification and selection of suitable perforator vessels, dissection of intramuscular perforators, assessment of flap perfusion based on one or several perforators, and reliable postoperative monitoring. As patient demand for perforator flaps increased, surgeons began searching for technologies and tools that would make these operations more predictable and reproducible as well as enable them to perform these flap surgeries more consistently.

Over the past decade, there have been a variety of technological advancements that have facilitated the ability to deliver reproducible and predictable outcomes with autologous breast reconstruction. Preoperative advancements have enabled surgeons to identify suitable perforators and to determine the patency of primary source vessels, namely the inferior epigastric and internal mammary vessels. Intraoperative advancements have enabled surgeons to assess anastomotic patency, vessel flow, and flap perfusion. Postoperative advancements have facilitated the ability of surgeons and nursing staff to monitor flaps based on tissue flow characteristics and discriminate between arterial and venous flow disturbances.

This article chronicles many of these advancements and reviews the current toolbox that surgeons now have at their disposal when performing autologous reconstruction. Some of the earlier tools include the acoustic Doppler ultrasonography and color duplex Doppler, whereas some of the newer tools include computed tomographic angiography (CTA), magnetic resonance angiography (MRA), dynamic infrared thermography (DIRT), fluorescent angiography and near-infrared spectroscopy (NIR). This article focuses on preoperative, intraoperative, and postoperative tools that have enabled the achievement of more reliable and predictable outcomes, especially in the setting of microvascular breast reconstruction.