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Preoperative imaging for deep inferior epigastric perforator flaps: a comparative study of computed tomographic angiography and magnetic resonance angiography

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European Journal of Plastic Surgery Aims and scope Submit manuscript

Abstract

Background

Breast reconstruction with transverse rectus abdominis myocutaneous flap has evolved towards the intramuscular dissection of perforators of the deep inferior epigastric pedicle to reduce abdominal wall morbidity. We aimed to compare magnetic resonance angiography (MRA) and computed tomography angiography (CTA) findings for the identification of deep inferior epigastric perforators (DIEP) flap and to compare the results with intraoperative findings.

Methods

This was a prospective comparative study that was approved by the local ethics committee, and written informed consent was obtained. Ten patients underwent both MRA and CTA scans prior to DIEP flap breast reconstruction. The perforators that were identified by MRA, CTA and surgery were projected on a scaled grid. The contrast ratios between the vessels and surrounding tissues were calculated and compared using a bilateral t test.

Results

Totals of 67 and 59 perforators were found with MRA mapping and CTA, respectively. Fifty-six perforators were found with both techniques. All 70 perforators identified (MRA and CTA) were found during surgery. The estimated sensitivities for CTA and MRA were 84 and 96 %, respectively. Both techniques showed specificities of 100 %. The contrast analysis showed a better contrast of the fat-surrounded vessels with CTA (p = 0.007) compared with MRA. However, a better contrast of the muscle-surrounded vessels was observed with MRA (p = 0.001) compared with CTA.

Conclusions

Our study found a higher sensitivity with MRA in identifying perforators compared with CTA. This difference can be explained by a higher contrast of vessels in muscles that facilitates identification, especially in cases in which perforators are within aponeuroses.

Level of Evidence

Level II: Diagnostic study

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References

  1. Hartrampf CR, Scheflan M, Black PW (1982) Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69:216–225

    Article  CAS  PubMed  Google Scholar 

  2. Blondeel N, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, Tonnard P, Lysens R, Boeckx WD, Matton G (1997) The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 50:322–330

    Article  CAS  PubMed  Google Scholar 

  3. Nahabedian MY, Momen B, Galdino G, Manson PN (2002) Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 110:466–475, discussion 476–467

    Article  PubMed  Google Scholar 

  4. Casey WJ 3rd, Chew RT, Rebecca AM, Smith AA, Collins JM, Pockaj BA (2009) Advantages of preoperative computed tomography in deep inferior epigastric artery perforator flap breast reconstruction. Plast Reconstr Surg 123:1148–1155

    Article  CAS  PubMed  Google Scholar 

  5. Ghattaura A, Henton J, Jallali N, Rajapakse Y, Savidge C, Allen S, Searle AE, Harris PA, James SE (2010) One hundred cases of abdominal-based free flaps in breast reconstruction. The impact of preoperative computed tomographic angiography. J Plast Reconstr Aesthet Surg 63:1597–1601

    Article  CAS  PubMed  Google Scholar 

  6. Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI (2008) The accuracy of computed tomographic angiography for mapping the perforators of the DIEA: a cadaveric study. Plast Reconstr Surg 122:363–369

    Article  CAS  PubMed  Google Scholar 

  7. Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Acosta R, Stillaert F, Zubieta JL, Hamdi M, Whitaker IS, Ashton MW (2010) Planning and optimising DIEP flaps with virtual surgery: the Navarra experience. J Plast Reconstr Aesthet Surg 63:289–297

    Article  PubMed  Google Scholar 

  8. Neil-Dwyer JG, Ludman CN, Schaverien M, McCulley SJ, Perks AG (2009) Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps. J Plast Reconstr Aesthet Surg 62:1661–1665

    Article  CAS  PubMed  Google Scholar 

  9. Rozen WM, Stella DL, Bowden J, Taylor GI, Ashton MW (2009) Advances in the pre-operative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery 29:119–123

    Article  PubMed  Google Scholar 

  10. Masia J, Clavero JA, Larranaga JR, Alomar X, Pons G, Serret P (2006) Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 59:594–599

    Article  CAS  PubMed  Google Scholar 

  11. Rozen WM, Ashton MW (2009) The “limited rectus sheath incisions” technique for DIEP flaps using preoperative CT angiography. Microsurgery 29:525–528

    Article  PubMed  Google Scholar 

  12. Rozen WM, Ashton MW, Kiil BJ, Grinsell D, Seneviratne S, Corlett RJ, Taylor GI (2008) Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 122:1321–1325

    Article  CAS  PubMed  Google Scholar 

  13. Gacto-Sanchez P, Sicilia-Castro D, Gomez-Cia T, Lagares A, Collell T, Suarez C, Parra C, Leal S, Infante-Cossio P, De la Higuera JM (2010) Computed tomographic angiography with VirSSPA three-dimensional software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg 125:24–31

    CAS  PubMed  Google Scholar 

  14. Vandevoort M, Vranckx JJ, Fabre G (2002) Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction. Plast Reconstr Surg 109:1912–1918

    Article  PubMed  Google Scholar 

  15. Holm C, Mayr M, Hofter E, Ninkovic M (2006) Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 117:37–43

    Article  CAS  PubMed  Google Scholar 

  16. Bailey SH, Saint-Cyr M, Wong C, Mojallal A, Zhang K, Ouyang D, Arbique G, Trussler A, Rohrich RJ (2010) The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results. Plast Reconstr Surg 126:739–751

    Article  CAS  PubMed  Google Scholar 

  17. Wong C, Saint-Cyr M, Mojallal A, Schaub T, Bailey SH, Myers S, Brown S, Rohrich RJ (2010) Perforasomes of the DIEP flap: vascular anatomy of the lateral versus medial row perforators and clinical implications. Plast Reconstr Surg 125:772–782

    Article  CAS  PubMed  Google Scholar 

  18. Rozen WM, Ashton MW, Murray AC, Taylor GI (2008) Avoiding denervation of rectus abdominis in DIEP flap harvest: the importance of medial row perforators. Plast Reconstr Surg 122:710–716

    Article  CAS  PubMed  Google Scholar 

  19. Baumann DP, Lin HY, Chevray PM (2010) Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 125:1335–1341

    Article  CAS  PubMed  Google Scholar 

  20. Rozen WM, Whitaker IS, Chubb D, Ashton MW (2010) Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 126:2286–2288, author reply 2288–2289

    Article  CAS  PubMed  Google Scholar 

  21. Taylor GI, Doyle M, McCarten G (1990) The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg 43:1–16

    Article  CAS  PubMed  Google Scholar 

  22. Blondeel PN, Beyens G, Verhaeghe R, Van Landuyt K, Tonnard P, Monstrey SJ, Matton G (1998) Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 51:202–209

    Article  CAS  PubMed  Google Scholar 

  23. Hallock GG (2003) Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 30:347–357, v–vi

    Article  PubMed  Google Scholar 

  24. Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI (2008) Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 121:9–16

    Article  CAS  PubMed  Google Scholar 

  25. Giunta RE, Geisweid A, Feller AM (2000) The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 105:2381–2386

    Article  CAS  PubMed  Google Scholar 

  26. Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Cano D, Martinez-Cuesta A, Pina LJ (2006) Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience. J Plast Reconstr Aesthet Surg 59:585–593

    Article  CAS  PubMed  Google Scholar 

  27. Rozen WM, Whitaker IS, Stella DL, Phillips TJ, Einsiedel PF, Acosta R, Ashton MW (2009) The radiation exposure of computed tomographic angiography (CTA) in DIEP flap planning: low dose but high impact. J Plast Reconstr Aesthet Surg 62:e654–e655

    Article  PubMed  Google Scholar 

  28. Brenner DJ, Hall EJ (2007) Computed tomography—an increasing source of radiation exposure. N Engl J Med 357:2277–2284

    Article  CAS  PubMed  Google Scholar 

  29. Chernyak V, Rozenblit AM, Greenspun DT, Levine JL, Milikow DL, Chia FA, Erhard HA (2009) Breast reconstruction with deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators. Radiology 250:417–424

    Article  PubMed  Google Scholar 

  30. Hedley AJ, Molan MP, Hare DL, Anavekar NS, Lerino FL (2007) Nephrogenic systemic fibrosis associated with gadolinium-containing contrast media administration in patients with reduced glomerular filtration rate. Nephrology (Carlton) 12:111

    Article  Google Scholar 

  31. Goksel O, Aydin O, Atasoy C, Akyar S, Demirel YS, Misirligil Z, Bavbek S (2011) Hypersensitivity reactions to contrast media: prevalence, risk factors and the role of skin tests in diagnosis—a cross-sectional survey. Int Arch Allergy Immunol 155:297–305

    Article  PubMed  Google Scholar 

  32. Rozen WM, Ashton MW, Whitaker IS, Wagstaff MJ, Acosta R (2009) The financial implications of computed tomographic angiography in DIEP flap surgery: a cost analysis. Microsurgery 29:168–169

    Article  PubMed  Google Scholar 

  33. Rozen WM, Palmer KP, Suami H, Pan WR, Ashton MW, Corlett RJ, Taylor GI (2008) The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg 121:367–373

    Article  CAS  PubMed  Google Scholar 

  34. Rozen WM, Phillips TJ, Stella DL, Ashton MW (2009) Preoperative CT angiography for DIEP flaps: ‘must-have’ lessons for the radiologist. J Plast Reconstr Aesthet Surg 62:e650–e651

    Article  CAS  PubMed  Google Scholar 

  35. Rozen WM, Anavekar NS, Ashton MW (2010) Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps. J Plast Reconstr Aesthet Surg 63:e120–e121

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Orthopedic, Traumatology, Plastic Reconstructive and Hand Surgery Unit, University Hospital of Besançon, place Saint Jacques, 25030, Besançon, France

    Julien Pauchot & Yves Tropet

  2. Research Unit: EA 4268 I4S IFR 133 INSERM, University of Franche-Comté, 25030, Besançon, France

    Julien Pauchot, Sebastien Aubry, Adrian Kastler, Olivia Laurent, Bruno Kastler & Yves Tropet

  3. Department of Radiology, University Hospital of Besançon, Boulevard Flemming, 25030, Besançon, France

    Sebastien Aubry, Olivia Laurent & Bruno Kastler

  4. Department of Radiology, University Hospital of Clermont-Ferrand, Place Henry Dunant, 63000, Clermont-Ferrand, France

    Adrian Kastler

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  1. Julien Pauchot
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Correspondence to Julien Pauchot.

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Pauchot, J., Aubry, S., Kastler, A. et al. Preoperative imaging for deep inferior epigastric perforator flaps: a comparative study of computed tomographic angiography and magnetic resonance angiography. Eur J Plast Surg 35, 795–801 (2012). https://doi.org/10.1007/s00238-012-0740-0

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  • DOI: https://doi.org/10.1007/s00238-012-0740-0

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