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Lin Y, Li H, Li Z, Chen L, Xing W, Zhang X, Mu D. Pedicle Selection and Design in Reduction Mammaplasty: The Role of Preoperative Fluorescence Imaging. Aesthet Surg J 2024; 44:597-604. [PMID: 38271223 DOI: 10.1093/asj/sjae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Breast reduction has a wide selection of pedicles but often relies on the surgeon's preference and experience. Necrosis of the nipple-areola complex (NAC) is a catastrophic complication of breast reduction surgery. OBJECTIVES To solve the above problem objectively, we applied fluorescence imaging technology to the pedicle selection and design of breast reduction surgery for the first time, so that the dominant vessels of the NAC were included in the designed pedicle. METHODS We retrospectively enrolled 120 patients with breast reduction (a total of 239 breasts). We compared 60 patients who underwent breast reduction without fluorescence imaging for pedicle selection (Group A) with 60 patients who underwent pedicle selection with fluorescence imaging (Group B). The NAC blood supply was monitored after the operation. RESULTS In this study, 60 Group A cases (119 breasts) and 60 Group B cases (120 breasts) were analyzed. There were no statistically significant differences in patient demographic data or intraoperative resection weights. There were 7 cases of NAC necrosis in Group A (1 case of complete necrosis and 6 cases of partial necrosis), while no NAC necrosis occurred in Group B. There was a significant difference in the rate of NAC necrosis between the 2 groups. CONCLUSIONS Preoperative fluorescence imaging can guide the selection and design of breast reduction, significantly reducing postoperative NAC blood supply obstacles and necrosis. LEVEL OF EVIDENCE: 3
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Customizing Anterolateral Thigh Flap With Magnetic Resonance Angiography Differential Subsampling With Cartesian Ordering Imaging for Individualized Reconstruction of Extremity Defects. J Surg Res 2023; 283:733-742. [PMID: 36463812 DOI: 10.1016/j.jss.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 11/06/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Magnetic resonance angiography (MRA) with the differential subsampling with cartesian ordering (DISCO) imaging technique is rarely used in anterolateral thigh (ALT) flap. In our series, MRA DISCO imaging technique is used as a tool to customize ALT flaps. The aim of this study was to report the accuracy of cutaneous perforators identified by the MRA DISCO imaging. METHODS Nineteen patients underwent the MRA DISCO imaging for perforator mapping before the ALT flap transfer. A total of 38 ALT regions were studied on the MRA DISCO images. Flap thinning was performed under the guidance of MRA DISCO imaging. RESULTS The lateral circumflex femoral artery (LCFA) most commonly stems from the deep femoral artery (84.2%), followed by the common femoral artery (15.8%). The average number of perforator vessels per LCFA was 10.2 ± 1.7. The distinct oblique branch was observed in 16 out of the 38 ALT regions (42.1%). Among the 19 ALT flaps harvested, 5 were septocutaneous perforator flaps and 14 musculocutaneous perforator flaps. Ten were harvested based on the descending branch, and 3 used the oblique branch as the flap vascular pedicle. In addition, the displayed course and types of perforator vessels on the DISCO images of the 18 skin flaps were consistent with the intraoperative findings, with an accuracy of 94.7%. CONCLUSIONS The state of the cutaneous perforators of LCFA can be identified on the MRA DISCO images. The 3D-CE-MRA DISCO imaging is a practical method, which can ameliorate the design and customization of ALT flap for an individualized reconstruction.
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Singh N, Aghayev A, Ahmad S, Azene EM, Ferencik M, Hedgire SS, Kirsch DS, Lee YJ, Nagpal P, Pass HA, Pillai AK, Ripley B, Tannenbaum A, Thomas R, Steigner ML. ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery): 2022 Update. J Am Coll Radiol 2022; 19:S357-S363. [PMID: 36436962 DOI: 10.1016/j.jacr.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Ayaz Aghayev
- Panel Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Ahmad
- University of Toronto, Toronto, Ontario, Canada; American College of Physicians
| | - Ezana M Azene
- Director of PERT, Chair Cancer Advisory Council, Medical Governor, Gundersen Health System, La Crosse, Wisconsin
| | - Maros Ferencik
- Section Head of Cardiovascular Imaging, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Sandeep S Hedgire
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Yoo Jin Lee
- University of California San Francisco, San Francisco, California
| | - Prashant Nagpal
- Head, Cardiovascular Imaging, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Helen A Pass
- Chief of Breast Surgery and Co-Director of the Breast Center, Stamford Hospital, Stamford, Connecticut; American College of Surgeons
| | - Anil K Pillai
- Section Chief, Interventional Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | | | - Richard Thomas
- Section Chief of Thoracic Imaging and Cardiac CT and Associate Magnetic Resonance Medical Director, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Michael L Steigner
- Director, Vascular CT/MR, Medical Director 3D Lab, Specialty Chair, Brigham & Women's Hospital, Boston, Massachusetts
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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 2020; 74:945-956. [PMID: 33342741 DOI: 10.1016/j.bjps.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 10/21/2020] [Accepted: 12/02/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Perforator mapping may be performed prior to deep inferior epigastric perforator (DIEP) flap breast reconstruction to guide perforator selection. However, the accuracy of different imaging modalities remains unknown. This review aimed to evaluate the accuracy of different modalities for locating perforators for unipedicled DIEP flap breast reconstruction. METHODS MEDLINE and EMBASE were searched from inception to 24th September 2019 for studies concerning adult women undergoing DIEP flap breast reconstruction with preoperative perforator mapping. The index test was pre-operative imaging and the reference standard was intraoperative identification. RESULTS 21 articles with 1146 women were included. Six methods were described; handheld doppler, colour doppler (duplex) ultrasonography, computed tomography angiography, magnetic resonance angiography (MRA), direct infrared thermography with and without doppler. Meta-analysis revealed 94% (95% CI 88-99%) of DIEPs identified as the 'dominant perforator' on imaging were chosen as dominant perforators intraoperatively. Colour doppler (Duplex) ultrasonography had the lowest agreement (mean 74% [95% CI 67-81%]) whilst MRA had the highest agreement (mean 97% [95% CI 86-100%]). There was no statistically significant difference in the performance of different tests. All studies were subject to bias as the operators had knowledge of the index test prior to conducting the reference standard. CONCLUSIONS Based upon limited evidence, cross sectional (CT/MR) imaging modalities for preoperative DIEP mapping appear to have similar accuracy and perform better than ultrasound.
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Affiliation(s)
- John Kiely
- Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Trust, Bradford, UK.
| | - Mayank Kumar
- Department of Trauma & Orthopaedics, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK; Leeds Institute for Medical Research, The University of Leeds, Leeds, UK
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Preoperative Perforator Mapping in SGAP Flap: Does Magnetic Resonance Imaging Make the Difference? Plast Reconstr Surg 2019; 144:812-819. [PMID: 31568281 DOI: 10.1097/prs.0000000000006015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Preoperative vascular mapping has emerged as an excellent adjunct to perforator flap surgery, improving operative time while aiding the surgeon in the selection of the ideal perforator. This study evaluated the effect of preoperative vascular mapping by magnetic resonance imaging to identify tissue for a superior gluteal artery perforator (SGAP) flap on total operative time and compared radiologic mapping by magnetic resonance imaging with Doppler ultrasonography for perforator localization. The authors also investigated whether drawing the flap according to magnetic resonance imaging perforator localization or tissue availability affected the outcome of the donor site. METHODS A prospective study was performed on patients undergoing SGAP flap breast reconstruction. Patients were randomized into two groups. One group received preoperative magnetic resonance imaging for flap tissue planning based on localization of the perforator. The other group received flap planning based on tissue availability and then underwent external Doppler ultrasonography to identify the dominant perforator. An ad hoc outcome scale was created to evaluate outcomes of the donor sites. RESULTS Preoperative vascular mapping by magnetic resonance imaging or external Doppler ultrasonography was performed the day of surgery on 35 and 27 patients, respectively. The mean flap elevation times of the imaging patients versus the ultrasonography patients were 252 and 228 minutes, respectively. The differences between flap elevation times and cosmetic outcomes for the two patient groups were not significant. CONCLUSION The authors' findings indicate that the use of magnetic resonance imaging for SGAP flap planning did not reduce operative time, and that donor-site outcomes were not affected by the modality used for preoperative perforator mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Rodkin B, Hunter-Smith DJ, Rozen WM. A review of visualized preoperative imaging with a focus on surgical procedures of the breast. Gland Surg 2019; 8:S301-S309. [PMID: 31709172 DOI: 10.21037/gs.2019.09.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Preoperative imaging has become a valuable tool in the planning of perforator flaps, and to date, computed tomographic angiography (CTA) has been shown to be the gold standard in this role. The evidence for this is a source of constant investigation, with advances in newer modalities coming to the fore. A literature review was undertaken to evaluate the current role of relevant imaging modalities in 'visualized surgery'-the ability to map anatomy prior to surgical incision. A focus is made on their accuracy in perforator mapping and correlation with improved clinical outcomes in the context of deep inferior epigastric artery perforator (DIEP) flap surgery. Other applications for preoperative imaging in breast surgery such as imaging of alternate donor sites or of the recipient site and imaging for volumetric assessment are also discussed. Preoperative imaging is integral to the planning of reconstructive breast surgery. This review has discussed the range of imaging techniques used to map and visualize perforator vasculature, and whilst there are varied clinical applications for the imaging modalities, CTA has been demonstrated to be the most precise and to confer the best clinical outcomes. Applications of the other imaging techniques are varied and these should remain as valid alternatives, particularly for patients where radiation or contrast exposure should be limited. Further studies could focus on the development of a more definitive protocol regarding the approach to preoperative imaging in breast surgery.
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Affiliation(s)
- Bridget Rodkin
- Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - David J Hunter-Smith
- Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Warren M Rozen
- Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
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Davis CR, Jones L, Tillett RL, Richards H, Wilson SM. Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging. Microsurgery 2018; 39:24-31. [PMID: 30182489 DOI: 10.1002/micr.30367] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/30/2018] [Accepted: 07/18/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion. METHODS All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed. RESULTS Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05). CONCLUSIONS Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.
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Affiliation(s)
- Christopher R Davis
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom.,Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Lyn Jones
- Department of Radiology, Southmead Hospital, Bristol, United Kingdom
| | - Rachel L Tillett
- Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Helen Richards
- Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Sherif M Wilson
- Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom
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Oliva IB, Day K, Dill KE, Hanley M, Ahmed O, Bennett SJ, Desjardins B, Gage KL, Ginsburg M, Hamawy AH, Steigner ML, Strax R, Verma N, Rybicki FJ. ACR Appropriateness Criteria ® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery). J Am Coll Radiol 2017; 14:S456-S461. [PMID: 29101984 DOI: 10.1016/j.jacr.2017.08.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 11/28/2022]
Abstract
Breast cancer is the most common malignancy in women in the United States. Breast reconstruction surgery is a commonly used therapy for patients with breast cancer. The technique for the deep inferior epigastric perforator flap uses a preserved rectus muscle, which decreases donor site morbidity. Accurate identification and measurement of the perforator branches of the deep inferior epigastric artery is pivotal during pre-operative planning so that the surgeon can prioritize the best vessel to use and ultimately improve clinical outcome. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Isabel B Oliva
- Principal Author, Yale University School of Medicine, New Haven, Connecticut.
| | - Kevin Day
- Research Author, Stanford University, Stanford, California
| | - Karin E Dill
- Panel Chair, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Michael Hanley
- Panel Vice Chair, University of Virginia Health System, Charlottesville, Virginia
| | | | | | | | - Kenneth L Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | - Adam H Hamawy
- Princeton Plastic Surgeons, Princeton, New Jersey; American College of Surgeons
| | | | | | | | - Frank J Rybicki
- Specialty Chair, Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada
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Determining the Cost of Incidental Findings for Patients Undergoing Preoperative Planning for Abdominally Based Perforator Free Flap Breast Reconstruction with Computed Tomographic Angiography. Plast Reconstr Surg 2016; 138:804e-810e. [DOI: 10.1097/prs.0000000000002621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schrögendorfer KF, Nickl S, Keck M, Lumenta DB, Loewe C, Gschwandtner M, Haslik W, Nedomansky J. Viability of five different pre- and intraoperative imaging methods for autologous breast reconstruction. Eur Surg 2016; 48:326-333. [PMID: 29142584 PMCID: PMC5660891 DOI: 10.1007/s10353-016-0449-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 09/14/2016] [Indexed: 11/29/2022]
Abstract
Background Autologous breast reconstruction is an integral part in the treatment of breast cancer. While computed tomography angiography (CTA) is an established preoperative diagnostic tool for microsurgeons, no study has so far evaluated and compared five different imaging methods and their value for the reconstructive team. In order to determine the feasibility of each of the tools for routine or specialized diagnostic application, the methods' efficiency and informative value were analyzed. Methods We retrospectively analyzed imaging data of 41 patients used for perforator location and assessment for regional perfusion and vessel patency in patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flap (DIEP), transverse rectus abdominis muscle flap (TRAM), or transverse myocutaneous gracilis flap (TMG). Five different imaging techniques were used: hand held Doppler (HHD), CT angiography (CTA), macroscopic indocyanine green (ICG) video angiography, microscope-integrated ICG video angiography, and laser Doppler imaging (LDI). Results CTA proved to be the best tool for preoperative determination of the highly variable anatomy of the abdominal region, whereas HHD showed the same information on perforator localization with some false-positive results. Intraoperative HHD was an excellent tool for dissection and vessel patency judgment. Microscope-integrated ICG was an excellent tool to document the patency of microanastomoses. In our series, macroscopic perfusion measurement with ICG or LDI was only justified in special situations, where information on perfusion of abdominal or mastectomy flaps was required. LDI did not add any additional information. Conclusion Preoperative assessment should be performed by CTA with verification of the perforator location by HHD. Intraoperative HHD and microscope-integrated ICG contribute most toward the evaluation of vessel patency. ICG and LDI should only be used for special indications.
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Affiliation(s)
- K F Schrögendorfer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090 Vienna, Austria
| | - S Nickl
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090 Vienna, Austria
| | - M Keck
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090 Vienna, Austria
| | - D B Lumenta
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090 Vienna, Austria
| | - C Loewe
- Department of Radiology, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - M Gschwandtner
- Department of Angiology, Medical University of Vienna, Vienna, Austria
| | - W Haslik
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090 Vienna, Austria
| | - J Nedomansky
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Guertel 18-20, 1090 Vienna, Austria
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Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction. Gland Surg 2015; 4:164-78. [PMID: 26005648 DOI: 10.3978/j.issn.2227-684x.2015.03.06] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/18/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND The high incidence of breast cancer and growing number of breast cancer patients undergoing mastectomy has led to breast reconstruction becoming an important part of holistic treatment for these patients. In planning autologous reconstructions, preoperative assessment of donor site microvascular anatomy with advanced imaging modalities has assisted in the appropriate selection of flap donor site, individual perforators, and lead to an overall improvement in flap outcomes. In this review, we compare the accuracy of fluorescent angiography, computed tomographic angiography (CTA), and magnetic resonance angiography (MRA) and their impact on clinical outcomes. METHODS A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken. RESULTS Fluorescent angiography is technically limited by its inability to evaluate deep-lying perforators and hence, it has a minimal role in the preoperative setting. However, it may be useful intraoperatively in evaluating microvascular anastomotic patency and the mastectomy skin perfusion. CTA is currently widely considered the standard, due to its high accuracy and reliability. Multiple studies have demonstrated its ability to improve clinical outcomes, such as operative length and flap complications. However, concerns surrounding exposure to radiation and nephrotoxic contrast agents exist. MRA has been explored, however despite recent advances, the image quality of MRA is considered inferior to CTA. CONCLUSIONS Preoperative imaging is an essential component in planning autologous breast reconstruction. Fluorescent angiography presents minimal role as a preoperative imaging modality, but may be a useful intraoperative adjunct to assess the anastomosis and the mastectomy skin perfusion. Currently, CTA is the gold standard preoperatively. MRA has a role, particularly for women of younger age, iodine allergy, and renal impairment.
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Affiliation(s)
- Michael P Chae
- 1 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia ; 2 Monash University Plastic and Reconstructive Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia
| | - David J Hunter-Smith
- 1 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia ; 2 Monash University Plastic and Reconstructive Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia
| | - Warren Matthew Rozen
- 1 Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria 3168, Australia ; 2 Monash University Plastic and Reconstructive Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia
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Kubota Y, Mitsukawa N, Akita S, Hasegawa M, Satoh K. Postoperative patency of the retrograde internal mammary vein anastomosis in free flap transfer. J Plast Reconstr Aesthet Surg 2014; 67:205-11. [DOI: 10.1016/j.bjps.2013.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 09/02/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022]
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Boucher F, Moutran M, Boutier R, Papillard M, Rouviere O, Braye F, Mojallal A. Angiotomodensitométrie préopératoire dans les lambeaux perforants : standardisation du protocole. ANN CHIR PLAST ESTH 2013; 58:290-309. [DOI: 10.1016/j.anplas.2012.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
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Abstract
OBJECTIVE The purpose of this review is to illustrate various applications of gadofosveset trisodium in evaluating abdominal and peripheral vascular disease. The basic properties, technical considerations, and clinical and potential future applications of gadofosveset are described. CONCLUSION Gadofosveset trisodium facilitates comprehensive high-resolution arterial and venous MR angiography. Because of its prolonged intravascular residence time, gadofosveset trisodium is particularly useful for evaluating venous, dynamic, and functional vascular disease with a single low-dose contrast injection.
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Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol 2013; 23:2333-43. [DOI: 10.1007/s00330-013-2834-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 02/08/2013] [Accepted: 02/14/2013] [Indexed: 10/27/2022]
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Decision-making in DIEP and ms-TRAM flaps: The potential role for a combined laser Doppler spectrophotometry system. J Plast Reconstr Aesthet Surg 2013; 66:73-9. [DOI: 10.1016/j.bjps.2012.08.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 08/27/2012] [Indexed: 11/21/2022]
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Kocak E, Carruthers KH, Knopp MV, Carkaci S, Martin EW, Povoski SP. Image-guided technologies to facilitate the dissection of microsurgical autologous tissue-free flaps. Expert Rev Med Devices 2012; 9:547-9. [PMID: 23249148 DOI: 10.1586/erd.12.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Contrast-Enhanced Magnetic Resonance Angiography for Preoperative Imaging of Deep Inferior Epigastric Artery Perforator Flaps. Ann Plast Surg 2011; 67:671-4. [DOI: 10.1097/sap.0b013e3181fab9ea] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Masia J, Navarro C, Clavero JA, Alomar X. Noncontrast magnetic resonance imaging for preoperative perforator mapping. Clin Plast Surg 2011; 38:253-61. [PMID: 21620150 DOI: 10.1016/j.cps.2011.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Identifying the position, course, and caliber of the dominant perforator is extremely valuable in the preoperative study for perforator surgery. Besides reliability, the ideal technique should offer low cost and high availability and reproducibility. It should be fast, easy to interpret, and free of morbidity. Multidetector-row computed tomography (MDTC) and magnetic resonance imaging (MRI) provide images that are easy to interpret, and assess the perforator's caliber and localization and its intramuscular course and anatomic relationships. Noncontrast MRI avoids radiation to the patient and eliminates the need for intravenous contrast medium. This article discusses this method and presents our experience.
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Affiliation(s)
- Jaume Masia
- Plastic Surgery Department, Hospital de la Santa Creu i Sant Pau (Universidad Autónoma de Barcelona), Sant Antoni Maria Claret 167, Barcelona, Spain.
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Contrast-enhanced magnetic resonance angiography for preoperative imaging in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; 128:56-62. [PMID: 21701321 DOI: 10.1097/prs.0b013e31821740b1] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Contrast-enhanced magnetic resonance angiography has been shown to be very accurate for identifying the perforator size, location, and intramuscular course, and the associated venous system, without exposing the patient to ionizing radiation. This study reports the authors' experience using this imaging modality in a large patient series. METHODS A retrospective review of patients who had undergone preoperative contrast-enhanced magnetic resonance angiography followed by free abdominal flap breast reconstruction was conducted. The results of imaging were compared with intraoperative findings, and surgical outcomes were compared with scan data. The results were compared with control data in patients who did not undergo presurgical imaging. RESULTS One hundred thirty-two patients underwent contrast-enhanced magnetic resonance angiography presurgical imaging, and the results were compared with 84 controls. The imaging was found to be accurate for evaluating the perforator anatomy for free abdominal flap planning, with a high concordance between imaging and intraoperative findings. Without presurgical angiography, the ratio of deep inferior epigastric perforator (DIEP) flap-to-free transverse rectus abdominis musculocutaneous flap harvest was 0.9:1; with presurgical imaging, the ratio was 1.6:1 (p < 0.05). With presurgical angiography, there was a mean reduction in operating time of 26 minutes for unilateral DIEP flap harvest and 40 minutes for bilateral harvest, although these values were not significant. There was a significant reduction in the partial flap failure rate with preoperative imaging. CONCLUSIONS Presurgical imaging using contrast-enhanced magnetic resonance angiography demonstrates a high concordance with intraoperative findings. In this series, the percentage of flaps that were raised as DIEP flaps was significantly increased in patients who underwent preoperative imaging, and the partial flap failure rate was significantly reduced. CLINICAL QUESTION/LEVEL OF EVIDENCE : Therapeutic, III.(Figure is included in full-text article.).
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Casey WJ, Rebecca AM, Kreymerman PA, Macias LH. Computed tomographic angiography: assessing outcomes. Clin Plast Surg 2011; 38:241-52. [PMID: 21620149 DOI: 10.1016/j.cps.2011.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Perforator flaps are preferable for breast reconstruction after mastectomy in many patients. Preoperative imaging of the perforators and source vessels is desirable to reduce surgeon stress, limit donor and recipient site complications, and minimize operative time and associated costs. Computed tomographic angiography (CTA) has been shown to provide highly accurate representations of vascular anatomy with excellent spatial resolution. A critical review of the currently available literature was performed to identify the benefits of preoperative imaging (specifically CTA) in perforator flap reconstruction.
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Affiliation(s)
- William J Casey
- Division of Plastic and Reconstructive Surgery, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
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Lee JS, Patel KM, Zou Z, Prince MR, Cohen EI. Computerized Tomographic and Magnetic Resonance Angiography for Perforator-Based Free Flaps: Technical Considerations. Clin Plast Surg 2011; 38:219-28. [PMID: 21620147 DOI: 10.1016/j.cps.2011.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Katz RD, Manahan MA, Rad AN, Flores JI, Singh NK, Rosson GD. Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction. Microsurgery 2011; 30:593-602. [PMID: 20853328 DOI: 10.1002/micr.20794] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Many studies demonstrate direct patient benefits from use of preoperative computed tomography angiograms (CTA) for abdominal tissue-based breast reconstruction. We present a novel classification schema to translate imaging results into further clinical relevance. METHODS Each hemiabdomen CTA was classified into a schema that addressed findings of expected anatomy, anatomy that necessitates a change in operative technique and anatomy that suggests less morbid procedures may be considered. RESULTS Eighty-six patients (172 hemiabdomens) were available for study. Of the reconstructions performed in this time period, 40 (47%) were bilateral and 46 (53%) unilateral. Based on perforator size and location, relative perimuscular anatomy, and continuity of vessels, five categories were defined: type I "Traditional" anatomy (n = 150, 87%), type II "Highly Favorable" anatomy (n = 11, 6.4%), type III "Altered-Superiorly Translocated" anatomy (n = 9, 5.2%), type IV "Superficial Dominant" anatomy (n = 26, 15%), and type V "Hostile" anatomy (n = 4, 2.3%). The additive total is greater than 100%, because vessels may fall into more than one category. DISCUSSION In providing the microsurgeon with a preoperative vascular map that has the potential to influence the preoperative, operative, and postoperative course, abdominal CTAs should be considered a worthy adjunct to the diagnostic armamentarium of the reconstructive surgeon. These classifications and their clinical impacts become even more important in centers performing increasing numbers of bilateral reconstructions. We believe that our simple schema can facilitate effective use of this powerful tool, aiding in overall care of the breast reconstruction patient.
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Affiliation(s)
- Ryan D Katz
- Division of Plastic, Reconstructive and Maxillofacial Surgery, the Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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The future in perforator flap imaging: a new technique to substantially reduce radiation dose with computed tomographic angiography. Plast Reconstr Surg 2010; 126:98e-100e. [PMID: 20679807 DOI: 10.1097/prs.0b013e3181de25f9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63:e674-82. [DOI: 10.1016/j.bjps.2010.06.013] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 06/07/2010] [Accepted: 06/09/2010] [Indexed: 11/30/2022]
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Pratt GF, Rozen WM, Chubb D, Whitaker IS, Grinsell D, Ashton MW, Acosta R. Modern adjuncts and technologies in microsurgery: An historical and evidence-based review. Microsurgery 2010; 30:657-66. [DOI: 10.1002/micr.20809] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 05/13/2010] [Indexed: 11/11/2022]
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Dancey A, Blondeel PN. Technical tips for safe perforator vessel dissection applicable to all perforator flaps. Clin Plast Surg 2010; 37:593-606, xi-vi. [PMID: 20816515 DOI: 10.1016/j.cps.2010.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The introduction of perforator flaps by Koshima and Soeda in 1989 was met with much animosity in the surgical community. The flaps challenged conventional teaching and were often branded as being unsafe. Surgeries using perforator flaps are now routinely practiced all over the world, with increasing emphasis on minimizing donor site morbidity, and perforator flaps are becoming the current gold standard. The simple principles and techniques of perforator dissection can be applied to all perforator flaps, provided the surgeon has an intimate knowledge of the regional anatomy. Thus, virtually any piece of skin can be harvested as long as it incorporates a feeding vessel. This article highlights the essential techniques in planning and raising perforator flaps and the common pitfalls to be avoided.
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Affiliation(s)
- Anne Dancey
- Department of Plastic and Reconstructive Surgery, University Hospital Gent, De Pintelaan 185, Gent B-9000, Belgium
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Chiribiri A, Morton G, Nagel E. Gadofosveset injection for magnetic resonance angiography. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/iim.10.39] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography. Plast Reconstr Surg 2010; 126:385-392. [DOI: 10.1097/prs.0b013e3181de2313] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mathes DW, Neligan PC. Preoperative imaging techniques for perforator selection in abdomen-based microsurgical breast reconstruction. Clin Plast Surg 2010; 37:581-91, xi. [PMID: 20816514 DOI: 10.1016/j.cps.2010.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- David W Mathes
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific, Box 35640, Seattle, WA 98195, USA.
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