Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA

Abstract

Background: Deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle flaps are commonly used flaps for autologous breast reconstruction. CT-angiography allows to analyse the perforator course preoperatively. Our aim was to compare the different aspects of perforator anatomy in the most detailed study. Methods: CT-angiographies of 300 female patients with autologous breast reconstruction of 10 years were analysed regarding the anatomy of the deep inferior epigastric artery and every perforator. Results: Overall, 2260 perforators were included. We identified correlations regarding the DIEA branching point and number of perforators and their intramuscular course. The largest perforator emerged more often from the medial branch of the DIEA than the smaller perforators (70% (416/595) vs. 54% (878/1634), p < 0.001) and more often had a direct connection to the SIEV (large 67% (401/595) vs. small 39% (634/1634), p < 0.01). Medial row perforators were larger than the laterals (lateral 1.44 mm ± 0.43 (n = 941) vs. medial 1.58 mm ± 0.52 (n = 1304) (p < 0.001)). The larger and more medial the perforator, the more likely it was connected to the SIEV: perforators with direct connection to the SIEV had a diameter of 1.65 mm ± 0.53 (n = 1050), perforators with indirect connection had a diameter of 1.43 ± 0.43 (n = 1028), perforators without connection had a diameter of 1.31 mm ± 0.37 (n = 169) (p < 0.001). Medial perforators were more often directly connected to the SIEV than lateral perforators (medial 56% (723/1302) vs. lateral 35% (327/941), p < 0.001). A lateral perforator more often had a short intramuscular course than medial perforators (69% (554/800) vs. 45% (474/1055), p < 0.001), which was also more often observed in the case of a small perforator and a caudal exit of the rectus sheath. Conclusion: The largest perforator emerges more often from the medial branch of the DIEA and frequently has a direct connection to the SIEV, making medial row perforators ideal for DIEP flap transplantation.

Interdisciplinary Surgical Therapy of Extremity Soft-Tissue Sarcomas: A Personalized Resection and Reconstruction Algorithm

“…However, one should evaluate the vessel status of the extremities, especially around the tumor region, before planning surgical regimens for each individual patient. Therefore, CT angiography can be used preoperatively to provide detailed information about the vessel anatomy [ 41 ]. Moreover, imaging techniques such as indocyanine green angiography or blood flow analysis can be used intraoperatively to further ameliorate reconstruction safety and prevent flap loss [ 42 , 43 ].…”

Main factors determining the use of free MS-TRAM and DIEP flaps and comparing the results of breast reconstruction

“…Indicators for problems in MS-TRAM- and DIEP-flap breast reconstruction, as well as their severity, have been well established. Clinical evidence demonstrates that both reconstruction techniques are trustworthy and safe and can maximize surgical outcomes when used appropriately [ 10 ].…”

Photoacoustic-enabled automatic vascular navigation: accurate and naked-eye real-time visualization of deep-seated vessels

“…With the development of augmented-reality and mixed-reality technology, a series of augmented-reality and mixed-reality devices have emerged to combine preoperative images with real surgical surfaces, greatly improving the efficiency of surgery and reducing surgical risks. For example, using the Microsoft HoloLens for perforator flap transplantation, computed tomography angiography (CTA) 6 , 7 was used to image the complete vascular anatomy, and the HoloLens was used to combine the real surgical surface with CTA vascular images to accurately locate the perforators 8 – 10 In another case, researchers proposed directly projecting the preoperative CTA vascular image on the surgical surface to locate perforators 11 …”