Preoperative Imaging Techniques for Perforator Selection in Abdomen-Based Microsurgical Breast Reconstruction

The clinical application of perforator-based flaps for microsurgical breast reconstruction has increased exponentially over the past 10 years. The benefits of the procedure are thought to be that it produces less postoperative pain, lowers abdominal morbidity, and allows for better preservation of muscles at the donor site compared with conventional musculocutaneous flaps. The disadvantages of perforator flaps are that they are more difficult to harvest, which can result in a longer operative time and higher costs. The vascular anatomy of the deep inferior epigastric artery and its perforating branches in the abdominal wall varies greatly not only among individuals but also from one side of the abdomen to the other. Perforator location, number, caliber, and the intramuscular trajectory of the branches all impact the design and harvest of the flap. The creation of a presurgical map of the vessels on the abdomen can facilitate surgical planning and could decrease operating room time, reduce intraoperative complications, and lead to improved outcomes. This article reviews the available techniques for preoperative planning with the currently available imaging modalities: hand-held Doppler, color Doppler (duplex) ultrasound, CT angiography, and MR angiography.

The vascular anatomy of the deep inferior epigastric artery and its perforating branches in the abdominal wall varies greatly not only among individuals but also from one side of the abdomen to the other. Perforator location, number, caliber, and the intramuscular trajectory of the branches all impact the design and harvest of the flap. The creation of a presurgical map of the vessels on the abdomen can facilitate surgical planning and could decrease operating room time, reduce intraoperative complications, and lead to improve outcomes.

This article reviews the available techniques for preoperative planning with the currently available imaging modalities: hand-held Doppler, color Doppler (duplex) ultrasound, CT angiography (CTA), and MR angiography (MRA).

Doppler ultrasound

One of the most inexpensive and common techniques for locating perforators is the use of the unidirectional Doppler probe. The Doppler probe can be used by the surgeon in both the pre- and postoperative settings and a comparison made between pre- and postoperative signals. The hand-held Doppler is available in all surgical operating suites and can be used to mark the relative location of perforators. The downside of this device is that it may be too highly sensitive, and thereby often locates not only clinically significant perforators but also very small perforators that are insufficient to support the flap. This lack of specificity has been well documented in its use for locating perforators in the anterior lateral thigh flap. Because of this lack of specificity, use of the hand-held Doppler alone has not been considered reliable for perforator mapping; it does not achieve the sensitivity and breadth of information available with the other imaging technologies. In addition, because of the significant time, low accuracy, and high interobserver variability associated with perforator mapping, unidirectional Doppler is not currently embraced as a suitable preoperative imaging modality. It remains a useful tool for intraoperative evaluation to document and follow the flow of a chosen perforator during dissection.

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