Determining the Cost of Incidental Findings for Patients Undergoing Preoperative Planning for Abdominally Based Perforator Free Flap Breast Reconstruction with Computed Tomographic Angiography:

Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome

Implant-based reconstruction is the most common method of breast reconstruction. Autologous breast reconstruction is an indispensable option for breast reconstruction demanding keen microsurgical skills and robust anatomical understanding. The reconstructive choice is made by the patient after a discussion with the plastic surgeon covering all the available options. Advantages and disadvantages of each technique along with long-term oncologic outcome are reviewed.

The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis

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.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction

BACKGROUND

Preoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan.

METHODS

We conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.

RESULTS

Two hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were "miscellaneous." In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation.

CONCLUSIONS

CTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

A review of visualized preoperative imaging with a focus on surgical procedures of the breast

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.