Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region

Abstract

Background Numerous new and novel imaging techniques for preoperative perforator selection in deep inferior epigastric artery perforator (DIEP) flap planning have been introduced. To what extent, these have been adopted into or replaced routine practice has hitherto remained unknown. The purpose of this study was to identify the currently preferred technique by reconstructive surgeons, the criteria that they regard as most relevant and what impact these have on the preoperative decision-making. Methods An online survey consisting of 25 questions was sent to members of the Benelux Societies for Plastic Surgery. Information regarding experience and preferred imaging modality was requested. Specific questions addressed the utilization of computed tomography angiography (CTA) and factors that could inform preoperative perforator selection. Results were anonymously collected, managed using REDCap, and analyzed using Chi-square statistic. Results Seventy-nine principal surgeons could be included. A variation in surgeon experience was observed. On CTA, the preferred imaging modality, large-caliber vessels, the location of the perforator in the flap, and its intramuscular course were considered the most significant criteria. Surgeons doing more than 20 DIEP flaps per year are less concerned about the distance of the perforator from the umbilicus (p = 0.003) but more likely to choose a medial perforator (p = 0.011). No statistical difference was found in surgeons' experience between those who would choose and use one specific (medial or lateral) perforator when they are analogous on CTA, and those who would delay the decision until both perforators have been exposed. Conclusion Advantages and disadvantages of the current practice of preoperative perforator selection by surgeons who are primarily responsible for harvesting a DIEP flap have been clearly identified. Indications are that these could be widely representative in which case, the quest for a protocol or modality that maximizes the benefit and minimizes harm in preoperative perforator mapping is urgently required.

Preoperative Imaging Mapping of DIEP Perforators and Intraoperative Selection: Does It Correlate?

“…Ninety-one percent of surgeons in that study opted for CTA as their imaging modality of choice with the additional 6% preferring MRA. 14 Our study showed that CTA/MRA detected the perforators on which the DIEP was ultimately based with a sensitivity of 70.1%. This value is somewhat lower than what is currently described in the cadaveric and small studies populating the literature.…”

“…Ninety-one percent of surgeons in that study opted for CTA as their imaging modality of choice with the additional 6% preferring MRA. 14…”

Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

“…39 While preoperative imaging allows for vascular mapping and better understanding of perforator anatomy, we do not recommend it routinely. [40][41][42] Instead, it adds an additional procedure for the patient and an inconvenience factor especially since a large portion of breast reconstructions are done in an ambulatory surgery center, in which case the imaging would have to be done elsewhere first. Furthermore, increased BMI also limits CTA for presurgical planning due to decreased visualization of perforators with increased body weight.…”

Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery

“…3 4 5 In fact, a recent survey of practicing microsurgeons in Belgium, the Netherlands, and Luxembourg showed that 97% preferred CTA for routine postoperative imaging despite the existence of nonradiation requiring alternatives. 15…”