How to assess a CTA of the abdomen to plan an autologous breast reconstruction

Free-style technique versus computed tomographic angiography-guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study

BACKGROUND

Computed tomographic angiography (CTA) is the preferred diagnostic tool in preoperative deep inferior epigastric perforator (DIEP) flap assessment, though some surgeons prefer approaching perforator selection with intraoperative findings alone.

METHODS

This prospective observational study conducted between 2015 and 2020 assessed our intraoperative decision-making "free-style" technique for DIEP flap harvest. Any patient with indication for immediate or delayed breast reconstruction using abdominally based flaps and who received preoperative CTA was enrolled. Only unilateral cases performed by the same surgeon were considered. Allergy to iodine-based contrast media, renal impairment and claustrophobia were other exclusion criteria. Primary endpoint consisted in comparing operative times and complication rates between free-style technique and CTA-guided approach. Secondary endpoints included evaluation of agreement rate between intraoperative findings and CTA, and identification of variables affecting operative time and complication rate. Demographics, surgical information, agreement versus non-agreement and complications were collected.

RESULTS

Starting from 206 patients, 100 were enrolled. Fifty were assigned to Group A, receiving DIEP flap with free-style technique. The other 50 were assigned to Group B, receiving DIEP flap with CTA-guided perforators selection. Study groups' demographics were homogenous. Operative time was statistically lower (p = .036) in free-style group (252.4 ± 44.77 min vs. 265.6 ± 31.67 min). Complication rates were higher in CTA-guided group (10% vs. 2%) though this was not significant (p = .092). Overall agreement rate in dominant perforator selection between intraoperatively and CTA-based assessment was 81%. Multiple regression analysis showed no variable increased complication rate, though CTA-guided approach, BMI > 30 and harvesting more than one perforator were respectively associated with B-coefficient of 17.391 (2.430-32.351, 95% CI) [p = .023], 3.50 (0.640-6.379, 95% CI) [p = .017] and 18.887 (6.232-31.542, 95% CI) [p = .004], predicting increased operative time.

CONCLUSIONS

The free-style technique proved to be a useful tool for guiding DIEP flap harvest with good sensibility in detecting the dominant perforator suggested by CTA without statistically increasing surgery duration and complications.

Transforming breast reconstruction: the pioneering role of artificial intelligence in preoperative planning

Autologous breast reconstruction surgery is a vital part of the recovery process for patients with breast cancer. While various reconstructive options exist, the deep inferior epigastric artery perforator (DIEP) flap is often favoured for its ability to closely mimic natural breast tissue. However, the complex vascular anatomy associated with the deep inferior epigastric artery (DIEA) presents challenges for surgeons during DIEP flap execution. Preoperative imaging, such as computed tomography angiography (CTA), is commonly used to understand vascular architecture and aid in selecting appropriate perforators. Conventional reporting of CTA scans is a labour-intensive process that can be challenging and requires specific expertise. The integration of artificial intelligence (AI) and machine learning (ML) algorithms in medical imaging has the potential to address these challenges. AI can enhance CTA through improved data acquisition, image post-processing, and potentially interpretation. By automating the perforator selection process, AI applications can significantly reduce the time spent on preoperative imaging analysis and potentially improve accuracy and reliability. While AI shows promise in optimizing efficiency, accuracy, and reliability in breast reconstruction planning, challenges and ethical considerations need to be addressed. This article explores the challenges, opportunities, and future directions of using AI in the preoperative planning of autologous breast reconstruction.

A History of Innovation: Tracing the Evolution of Imaging Modalities for the Preoperative Planning of Microsurgical Breast Reconstruction

Breast reconstruction is an essential component in the multidisciplinary management of breast cancer patients. Over the years, preoperative planning has played a pivotal role in assisting surgeons in planning operative decisions prior to the day of surgery. The evolution of preoperative planning can be traced back to the introduction of modalities such as ultrasound and colour duplex ultrasonography, enabling surgeons to evaluate the donor site's vasculature and thereby plan operations more accurately. However, the limitations of these techniques paved the way for the implementation of modern three-dimensional imaging technologies. With the advancements in 3D imaging, including computed tomography and magnetic resonance imaging, surgeons gained the ability to obtain detailed anatomical information. Moreover, numerous adjuncts have been developed to aid in the planning process. The integration of 3D-printing technologies has made significant contributions, enabling surgeons to create complex haptic models of the underlying anatomy. Direct infrared thermography provides a non-invasive, visual assessment of abdominal wall vascular physiology. Additionally, augmented reality technologies are poised to reshape surgical planning by providing an immersive and interactive environment for surgeons to visualize and manipulate 3D reconstructions. Still, the future of preoperative planning in breast reconstruction holds immense promise. Most recently, artificial intelligence algorithms, utilising machine learning and deep learning techniques, have the potential to automate and enhance preoperative planning processes. This review provides a comprehensive assessment of the history of innovation in preoperative planning for breast reconstruction, while also outlining key future directions, and the impact of artificial intelligence in this field.

Operative Efficiency in Deep Inferior Epigastric Perforator Flap Reconstruction: Key Concepts and Implementation

The deep inferior epigastric perforator flap has become one of the most popular approaches for autologous breast reconstruction after mastectomy. As much of health care has moved to a value-based approach, reducing complications, operative time, and length of stay in deep inferior flap reconstruction is becoming increasingly important. In this article, we discuss important preoperative, intraoperative, and postoperative considerations to maximize efficiency when performing autologous breast reconstruction and offer tips on how to handle certain challenges.

Preoperative Assessment of the Breast Reconstruction Patient

Through a multidisciplinary approach, as well as, a nuanced appreciation of patient goals and setting appropriate expectations, breast reconstruction can significantly improve the quality of life following mastectomy. A thorough review of the patient medical and surgical history in addition to oncologic treatments will facilitate discussion and recommendations for an individualized shared decision-making reconstructive process. Alloplastic reconstruction, although a highly popular modality, has important limitations. On the contrary, autologous reconstruction is more flexible but requires more thorough consideration.

[Breast Reconstruction Strategies in Case of Planned Radiotherapy]

INTRODUCTION

The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed.

METHODS

The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised.

RESULTS

An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients.

CONCLUSION

Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.

Necrosis or Flap Loss After Deep Inferior Epigastric Perforator Reconstruction: Impact of Perforators and Recipient Vessels

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.

Tracing: A Simple Interpretation Method for the DIEP Flap CT Angiography to Help Operative Decision-making

CT angiography (CTA) is an established technique that allows preoperative planning in DIEP flap reconstruction. However, innovative technological developments with extensive amounts of information require processing of data. It also requires user knowledge to interpret findings. Descriptions by radiologists are many times disappointingly limited to caliber and exit points of the perforator from the rectus fascia. Many DIEP flap surgeons similarly fail to utilize the CTA to its full extent. This is likely due to information overload. By tracing the DIEA on the CTA on a computer screen, using an ordinary ballpoint pen and a white sheet of paper, the surgeon can create a stylistic map of the dissectional-path of the DIEA. The map illustrates unusual branching patterns, perforator caliber and location, interconnections between individual perforators (or lack thereof), length of intramuscular dissection, and also rectus abdominis muscle intersections. The mapping can help in the choice of perforator(s) and may also speed up decision-making during surgical dissection. A penciled map also eases a round-table discussion, if multiple surgeons are involved in the operation. The map can also easily be brought to the operating room for guidance. Tracing is a user-friendly, time-efficient, intuitive, low-cost, and low-tech method that generates data that are easy to interpret, easy to share, and easy to discuss with other surgeons. The method is also not dependent on a radiologist for interpretation.