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Meier EL, Ulrich DJO, Hummelink S. Projected augmented reality in DIEP flap breast reconstruction: Projecting perforators on the skin using dynamic infrared thermography. J Plast Reconstr Aesthet Surg 2024; 94:83-90. [PMID: 38763059 DOI: 10.1016/j.bjps.2024.05.001] [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: 12/13/2023] [Revised: 04/11/2024] [Accepted: 05/02/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Dynamic infrared thermography (DIRT) is a quick and non-invasive technique for perforator mapping in free flaps that provides real-time information. After a cold challenge, areas best supplied with blood become visible hotspots on color-coded maps, indicating perforators. This study presents a proof of principle for a new and innovative feature of DIRT, where projected augmented reality is used to directly display thermal images on the patient's abdomen prior to the deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS A self-aligning projection device prototype (Anatomy Projector) equipped with an integrated thermal camera was used to obtain thermal information and project the color-coded map directly on the patient's abdomen before DIEP flap breast reconstruction. Projected DIRT hotspots were verified using a hand-held Doppler, and compared to the vascularity on computed tomography angiography (CTA), and intraoperative perforator measurements following a Cartesian grid. RESULTS A total of 514 DIRT hotspots were projected in 50 patients, among them 97.3% could be verified using Doppler. The positive predictive value for CTA was 74.5%. Intraoperative measurements yielded 132 perforators in 71 flaps, among them 75 perforators (56.8%) correlated with projected DIRT hotspots, and half of them (54.7%) appeared within the first 5 emerging hotspots. CONCLUSION This study showed that real-time display of thermal data in DIEP flap breast reconstruction is feasible via projected augmented reality. Projection facilitates convenient marking of hotspots, and a high resemblance to Doppler and CTA data was observed. Further research should assess the added value of projecting thermal images intraoperatively and in other fields of plastic surgery.
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Affiliation(s)
- Eva L Meier
- Department of Plastic Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dietmar J O Ulrich
- Department of Plastic Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Stefan Hummelink
- Department of Plastic Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands.
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Minkhorst K, Castanov V, Li EA, Farrokhi K, Jaszkul KM, AlGhanim K, DeLyzer T, Simpson AM. Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction. Ann Plast Surg 2024; 92:703-710. [PMID: 38768024 DOI: 10.1097/sap.0000000000003916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. METHODS A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. RESULTS Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. CONCLUSIONS Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.
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Affiliation(s)
| | - Valera Castanov
- Division of Plastic and Reconstructive Surgery, Western University, London, Ontario, Canada
| | - Erica Ai Li
- From the Schulich School of Medicine, Western University, London
| | - Kaveh Farrokhi
- From the Schulich School of Medicine, Western University, London
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3
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Hansson E, Larsson C, Uusimäki A, Svensson K, Widmark Jensen E, Paganini A. A systematic review of randomised controlled trials in breast reconstruction. J Plast Surg Hand Surg 2024; 59:53-64. [PMID: 38751090 DOI: 10.2340/jphs.v59.40087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field. METHODS Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done. RESULTS A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction. CONCLUSIONS A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Camilla Larsson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Alexandra Uusimäki
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Karolina Svensson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Emmelie Widmark Jensen
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden; Department of Diagnostics, Acute and Critical Care, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Timóteo R, Pinto D, Martinho M, Gouveia P, Lopes DS, Mavioso C, Cardoso MJ. Skin deformation analysis for pre-operative planning of DIEAP flap reconstruction surgery. Med Eng Phys 2023; 119:104025. [PMID: 37634903 DOI: 10.1016/j.medengphy.2023.104025] [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: 01/20/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 08/29/2023]
Abstract
Deep inferior epigastric artery perforator (DIEAP) flap reconstruction surgeries can potentially benefit from augmented reality (AR) in the context of surgery planning and outcomes improvement. Although three-dimensional (3D) models help visualize and map the perforators, the anchorage of the models to the patient's body during surgery does not consider eventual skin deformation from the moment of computed tomography angiography (CTA) data acquisition until the position of the patient while in surgery. In this work, we compared the 3D deformation registration from supine arms down (CTA position) to supine with arms at 90° degrees (surgical position), estimating the patient's skin deformation. We processed the data sets of 20 volunteers with a 3D rigid registration tool and performed a descriptive statistical analysis and statistical inference. With 2.45 mm of root mean square and 2.89 mm of standard deviation, results include 30% cases of deformation above 3 mm and 15% above 4 mm. Pose transformation deformation indicates that 3D surface data from the CTA scan position differs from data acquired in loco at the surgical table. Such results indicate that research should be conducted to construct accurate 3D models using CTA data to display on the patient, while considering projection errors when using AR technology.
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Affiliation(s)
- Rafaela Timóteo
- Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - David Pinto
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - Marta Martinho
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - Pedro Gouveia
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal; Faculdade de Medicina de Lisboa, Av. Prof. Egas Moniz MB, 1649-028 Lisboa, Portugal.
| | - Daniel Simões Lopes
- Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; INESC ID, Rua Alves Redol 9, 1000-029 Lisboa, Portugal; ITI/LARSyS, Hub Criativo do Beato, Factory Lisbon, Rua da Manutenção 71, Building F S05, 1900-500 Lisboa, Portugal.
| | - Carlos Mavioso
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - Maria João Cardoso
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
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Groenier M, Spijkerboer K, Venix L, Bannink L, Yperlaan S, Eyck Q, van Manen JG, Miedema HAT. Evaluation of the impact of technical physicians on improving individual patient care with technology. BMC MEDICAL EDUCATION 2023; 23:181. [PMID: 36959581 PMCID: PMC10037766 DOI: 10.1186/s12909-023-04137-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The rapid introduction of technical innovations in healthcare requires that professionals are adequately prepared for correct clinical use of medical technology. In response to the technological transformation of healthcare, a new type of professional, the Technical Physician (TP), was created and is trained to improve individual patient care using technology tailored to the needs of individual patients. This study investigates the TPs' impact on patient care in terms of innovation, effectiveness, efficiency, and patient safety. METHOD Semi-structured, in-depth interviews were conducted with 30 TPs and 17 medical specialists (MSs) working in academic or teaching hospitals in the Netherlands. The pre-structured and open-ended interview questions focused on: 1) the perceived impact on innovation, effectiveness, efficiency, and safety, and 2) opportunities and challenges in daily work. RESULTS TPs and MSs unanimously experienced that TPs contributed to innovation. A majority indicated that effectiveness (TP 57%; MS 71%) and efficiency (TP 67%; MS 65%) of clinical practice had increased. For safety, 87% of TPs but only 47% of MSs reported an increase. The main explanation given for TPs positive impact was combining medical and technical knowledge. Mainly organizational barriers were mentioned as a potential cause for a less visible contribution of TPs. CONCLUSION AND DISCUSSION TPs and MSs unanimously agreed that TPs contributed to innovating patient care through their integrative medical and technical competencies. Most TPs and MSs also reported increased effectiveness, efficiency, and safety of patient care due to the TPs' work. TPs and MSs expected that the TPs' impact on direct and indirect patient care will be enhanced once organizational barriers are removed.
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Affiliation(s)
- Marleen Groenier
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
| | - Koen Spijkerboer
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
| | - Lisanne Venix
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
| | - Lars Bannink
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
| | - Saskia Yperlaan
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
| | - Quinten Eyck
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
| | - Jeannette G. van Manen
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Heleen A. Th. Miedema
- Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands
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Tang Y, Guo Q, Li X, Huang Y, Kuang W, Luo L. Augmented reality-assisted systematic mapping of anterolateral thigh perforators. BMC Musculoskelet Disord 2022; 23:1047. [PMID: 36457082 PMCID: PMC9716696 DOI: 10.1186/s12891-022-06013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE In soft tissue reconstructive surgery, perforator localization and flap harvesting have always been critical challenges, but augmented reality (AR) has become a dominant technology to help map perforators. METHODS The lateral circumflex femoral artery (LCFA) and its perforators were reconstructed by CTA in consecutive patients (N = 14). Then, the anterolateral thigh perforators and the points from which the perforators emerged from the deep fascia were marked and projected onto the skin surface. As the virtual images were projected onto patients according to bony markers, the courses of the LCFA and its perforators were depicted on the skin surface for intraoperative guidance. Finally, the locations of the emergence points were verified by intraoperative findings and compared to those determined by handheld Doppler ultrasound. RESULTS The sources, locations, and numbers of perforators were determined by CTA. The perforators and their emergence points were accurately mapped on the skin surface by a portable projector to harvest the anterolateral thigh perforator flap. During the operation, the accuracy of the CTA & AR method was 90.2% (37/41), and the sensitivity reached 97.4% (37/38), which were much higher than the corresponding values of Doppler ultrasound. Additionally, the differences between the AR-marked points and the intraoperative findings were much smaller than those seen with Doppler ultrasound (P < 0.001). Consequently, all of the flaps were well designed and survived, and only one complication occurred. CONCLUSION Augmented reality, namely, CTA combined with projection in this study, plays a vital and reliable role in locating the perforator emergence points and guiding the procedure to harvest flaps and has fewer potential risks.
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Affiliation(s)
- Yifu Tang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Qiang Guo
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Xiaoning Li
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Yuzhao Huang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Wei Kuang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Ling Luo
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
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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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FlapMap Visual Language System for Vascular Imaging Prior to Microvascular Free Tissue Transfer. Plast Reconstr Surg Glob Open 2022; 10:e4351. [PMID: 35673551 PMCID: PMC9162446 DOI: 10.1097/gox.0000000000004351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
Preoperative vascular imaging has been shown to be beneficial before free tissue transfer procedures, especially for deep inferior epigastric perforator flap breast reconstruction. Although computerized tomography angiography and magnetic resonance angiogram are increasingly frequently performed, there is no standardized method for recording, analyzing, and communicating the vast amount of clinically relevant information that is obtained from these tomographic imaging studies. Herein, the authors propose a new visual language system for preoperative imaging called “FlapMap,” which allows for the creation of a clinically actionable, easily understood, and easily communicated single image that aids in preoperative planning before microvascular free tissue transfer.
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Steenbeek LM, Peperkamp K, Ulrich DJ, Stefan H. Alternative imaging technologies for perforator mapping in free flap breast reconstructive surgery – a comprehensive overview of the current literature. J Plast Reconstr Aesthet Surg 2022; 75:4074-4084. [DOI: 10.1016/j.bjps.2022.06.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/29/2022] [Accepted: 06/21/2022] [Indexed: 10/31/2022]
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Winters H, Tielemans H, Hummelink S, Slater N, Ulrich D. DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1718-1722. [DOI: 10.1016/j.ejso.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
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Phan R, Chae MP, Hunter-Smith DJ, Rozen WM. Advances in perforator imaging through holographic CTA and augmented reality: a systematic review. AUSTRALASIAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.34239/ajops.v5n1.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Free tissue transfer has become a mainstay in reconstructive plastic surgery, and techniques to plan such surgery continue to evolve. Novel technologies and increases in computational power have enabled computed tomographic angiography (CTA)data augmentation onto patients to assist in pedicle identification and dissection. Given the rapidly evolving field and research in this domain, a systematic re-view was undertaken to establish the evidence for its usefulness in pedicle identification and dissection.
Methods: An extensive search using keywords in EMBASE and PubMed with bibliographic linkage following PRISMA guidelines was performed. 107 articles were identified. Duplicate articles were removed prior to review. Two reviewers independently screened the titles for appropriate topic relevance. Full articles were then screened for review.
Results: Eleven articles were appropriate for review. Two articles analysed the time taken to identify perfo-rators using augmented reality (AR) compared to Doppler ultrasound. The remainder of the articles ana-lysed time to perforator identification, differences between projected location and dissected perforator location, qualitative feedback from surgeons on the use of AR systems for perforator identification and proof of concept and the usefulness of AR in perforator flap surgery.
Conclusion: This review demonstrates that while established methods of data rendering and projection can achieve holographic projection and AR, there is a lack of objective outcome data to demonstrate its usefulness. This, combined with a cost analysis, are the main obstructions to this technology being more widely adopted.
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Accuracy and precision of the CTA perforator localization technique for virtual surgical planning of composite osteocutaneous fibular free flaps in head and neck reconstruction. J Oral Maxillofac Surg 2022; 80:1434-1444. [DOI: 10.1016/j.joms.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/19/2022] [Accepted: 03/22/2022] [Indexed: 11/22/2022]
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Perez-Iglesias CT, Laikhter E, Kang CO, Nassar AH, Maselli AM, Cauley R, Lee BT. Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps. J Reconstr Microsurg 2022; 38:221-227. [DOI: 10.1055/s-0041-1740955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Background The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative.
Methods An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps.
Results This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications.
Conclusion This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.
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Affiliation(s)
- Carolina Torres Perez-Iglesias
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Laikhter
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine O. Kang
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amer H. Nassar
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy M. Maselli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T. Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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14
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Fitoussi A, Tacher V, Pigneur F, Heranney J, Sawan D, Dao TH, Hersant B, Meningaud JP, Bosc R. Augmented reality-assisted deep inferior epigastric artery perforator flap harvesting. J Plast Reconstr Aesthet Surg 2021; 74:1931-1971. [PMID: 33985928 DOI: 10.1016/j.bjps.2021.03.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/10/2021] [Accepted: 03/25/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Alexandre Fitoussi
- Medical Imaging department, Henri Mondor Hospital, 51, Avenue du Marechal Lattre de Tassigny, 94000 Creteil, France.
| | - Vania Tacher
- Medical Imaging department, Henri Mondor Hospital, 51, Avenue du Marechal Lattre de Tassigny, 94000 Creteil, France
| | - Frederic Pigneur
- Medical Imaging department, Henri Mondor Hospital, 51, Avenue du Marechal Lattre de Tassigny, 94000 Creteil, France
| | - Julie Heranney
- Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery Department, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Dana Sawan
- Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery Department, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Thu Ha Dao
- Medical Imaging department, Henri Mondor Hospital, 51, Avenue du Marechal Lattre de Tassigny, 94000 Creteil, France; Henri Mondor Breast Center, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Barbara Hersant
- Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery Department, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France; Henri Mondor Breast Center, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Jean-Paul Meningaud
- Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery Department, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Romain Bosc
- Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery Department, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France; Henri Mondor Breast Center, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France; INSERM Team U955-E10, Biology of the NeuroMuscular System, Paris East University, 94000 Créteil, France
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15
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Palve JS, Luukkaala TH, Kääriäinen MT. Necrosis or Flap Loss After Deep Inferior Epigastric Perforator Reconstruction: Impact of Perforators and Recipient Vessels. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2021. [DOI: 10.1055/s-0041-1729638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Background The aim of this study is to analyze the impact of the number and location of perforators harvested and the recipient vessels used on deep inferior epigastric perforator (DIEP) flap survival and the occurrence of flap necrosis requiring re-operation.
Patients and Methods Four hundred and seventy-one DIEP flap reconstructions, performed between January 2008 and December 2019, were retrospectively analyzed.
Results Flap necrosis requiring re-operation was observed in 40 (9%) of flaps and total flap loss rate was 1% (n = 6). No significant differences were observed between internal mammary vessels (IMV, n = 287, 61%) and thoracodorsal vessels (TDV, n = 184, 39%) regarding postoperative re-anastomosis (p = 0.529) or flap survival (p = 0.646). Intraoperative conversion from IMV to TDV was performed on 64 (14%) patients. TDV were more commonly associated with problems in preparation of the vessels than IMV (p < 0.001). Second vein anastomosis was performed on 18 (4%) patients. In total, 81 flaps (17%) had one perforator, 165 (35%) had two, 218 (46%) had three to five, and 7 (2%) had more than five perforators. Flaps with three to five perforators were more commonly associated with flap necrosis (p < 0.001) than flaps with one or two perforators. Independent factors associated with necrosis were body mass index (BMI) > 30 (odds ratio [OR]: 2.28; 95% confidence interval: 1.06–4.91, p = 0.035) and perforator/s located on the lateral row (OR: 3.08, 95% CI 1.29–7.33, p = 0.011).
Conclusion We conclude that the occurrence of flap necrosis requiring re-operation may be higher in DIEP flaps with more than two perforators or perforator/s located on the lateral row and in obese patients. Neither the recipient vessels used nor the number of perforators harvested had any impact on the flap survival rate.
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Affiliation(s)
- Johanna S. Palve
- Department of Plastic Surgery, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Tiina H. Luukkaala
- Research, Development and Innovation Center, Tampere University Hospital and Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Minna T. Kääriäinen
- Department of Plastic Surgery, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
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16
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Abstract
BACKGROUND During a deep inferior epigastric perforator (DIEP) flap harvest, the identification and localization of the epigastric arteries and its perforators are crucial. Holographic augmented reality is an innovative technique that can be used to visualize this patient-specific anatomy extracted from a computed tomographic scan directly on the patient. This study describes an innovative workflow to achieve this. METHODS A software application for the Microsoft HoloLens was developed to visualize the anatomy as a hologram. By using abdominal nevi as natural landmarks, the anatomy hologram is registered to the patient. To ensure that the anatomy hologram remains correctly positioned when the patient or the user moves, real-time patient tracking is obtained with a quick response marker attached to the patient. RESULTS Holographic augmented reality can be used to visualize the epigastric arteries and its perforators in preparation for a deep inferior epigastric perforator flap harvest. CONCLUSIONS Potentially, this workflow can be used visualize the vessels intraoperatively. Furthermore, this workflow is intuitive to use and could be applied for other flaps or other types of surgery.
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Zhang Y, Xiao W, Ng S, Zhou H, Min P, Xi W, Masia J, Blondeel P, Feng S. Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2021; 74:2068-2075. [PMID: 33551358 DOI: 10.1016/j.bjps.2020.12.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/14/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pre-expanded pedicled flaps possess a more flexible transfer pattern and higher tissue utilization than random flaps, but the perfusion is fully dependent on the chosen axial vessels. A precise mapping of the vessels would assist the surgical design and increase the likelihood of success. The application of Infrared thermography (IRT) has been previously reported for perforator location. The aim of this study is to report the use of IRT in mapping the course and distribution of axial vessels in the pre-expanded flap to guide the designing and harvesting. METHODS Patients who underwent head and neck reconstruction using pre-expanded flaps were included. After tissue expansion, IRT was used to mark the vessel distribution along the expanded flap. The results were compared with color Doppler ultrasound (CDU) and/or computed tomographic angiography (CTA). The flap was designed and raised based on the pre-operative marking by IRT. The mark was verified intraoperatively. RESULTS A total of 26 expanded flaps were performed, including 20 pedicled flaps and 6 free flaps. IRT succeeded to map the vessel distribution in all cases. All marked results were verified by CDU, CTA, and intraoperative dissection (26/26, 100%). IRT showed more comprehensive distribution of vascular branches than CDU or CTA, and could be utilized intraoperatively to identify the arteries. CONCLUSION IRT provides accurate and comprehensive mapping of the axial vessel distribution in the pre-expanded flaps, assisting with flap design and harvest. It is easy to use and non-invasive as an important tool pre- or intraoperatively to ensure the safe elevation.
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Affiliation(s)
- Yixin Zhang
- Department of Plastic Surgery, Shanghai 9th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China.
| | - Wentian Xiao
- Department of Plastic Surgery, Shanghai 9th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Sally Ng
- Department of Plastic Surgery, The Austin Hospital, Melbourne, Australia
| | - Huihong Zhou
- Department of Plastic Surgery, Shanghai 9th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Peiru Min
- Department of Plastic Surgery, Shanghai 9th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Wenjing Xi
- Department of Plastic Surgery, Shanghai 9th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Jaume Masia
- Department of Plastic Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Phillip Blondeel
- Department of Plastic and Reconstructive Surgery, Gent University Hospital, Gent, Belgium
| | - Shaoqing Feng
- Department of Plastic Surgery, Shanghai 9th Peoples Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, PR China
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18
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Vles MD, Terng NCO, Zijlstra K, Mureau MAM, Corten EML. Virtual and augmented reality for preoperative planning in plastic surgical procedures: A systematic review. J Plast Reconstr Aesthet Surg 2020; 73:1951-1959. [PMID: 32622713 DOI: 10.1016/j.bjps.2020.05.081] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Virtual and augmented reality (VR and AR) are fast-developing technologies that allow the three-dimensional visualization of digital information. OBJECTIVE This systematic review aimed to compare the application of VR and AR to conventional methods in preoperative planning of plastic surgical procedures. METHOD A systematic literature search was conducted in Embase, Medline (Ovid), Web-of-Science, Cochrane, and Google Scholar databases on October 11, 2019. All literature comparing AR and/or VR with conventional methods for preoperative planning was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy of the procedure, operative time, complications, and costs of total intervention. RESULTS No articles on VR were found. Six articles were found on interventions performed with AR assistance. AR showed to be significantly better for the accuracy of osteotomies in mandibular angle osteotomies and intraoral mandible distraction compared to conventional methods. For synostotic plagiocephaly and orbital hypertelorism correction, the use of AR demonstrated a precise osteotomy. Intraoperative perforator identification in DIEP flap procedures was more accurate with AR compared to Doppler ultrasound. Harvesting time (p < 0.012) and operative time (p < 0.01) in DIEP-flap procedures and mandibular angle osteotomies, respectively, were significantly reduced if AR was used. No articles were found regarding the costs of using AR for preoperative planning. CONCLUSION AR technology has the potential to assist the plastic surgeon in operating more accurately, safely, and fast. Studies on VR technology for preoperative planning in plastic surgery are lacking. More comparative studies are necessary, including data on clinical outcomes and cost-effectiveness.
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Affiliation(s)
- M D Vles
- Erasmus Medical Center, Rotterdam, the Netherlands
| | - N C O Terng
- Leiden University Medical Center, Leiden, the Netherlands
| | - K Zijlstra
- Delft University of Technology, Delft, the Netherlands
| | - M A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Office NA-2214, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - E M L Corten
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Office NA-2214, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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19
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Homsy C, McCarthy ME, Lim S, Lindsey JT, Sands TT, Lindsey JT. Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery. Ann Plast Surg 2020; 84:S424-S430. [DOI: 10.1097/sap.0000000000002203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Hummelink S, Ulrich DJO. Response: Augmented reality microsurgical planning with a smartphone (ARM-PS): A dissection route map in your pocket. J Plast Reconstr Aesthet Surg 2019; 72:1700-1738. [PMID: 31296443 DOI: 10.1016/j.bjps.2019.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Stefan Hummelink
- Department of Plastic Surgery, Radboudumc, Nijmegen, the Netherlands.
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