Refining perforator selection for deep inferior epigastric perforator flap: The impact of the dominant venous perforator

Abstract

The CTA-guided duplex ultrasonography could direct the perforator-complex selection according to the size of the venous-perforator, and may reduce the intraoperative problems and the incidence of fat necrosis.

Anatomical features associated with venous congestion in DIEP flap using CT angiography with three-dimensional reconstruction

“…Using duplex ultrasonography, Figus et al [20] reported that the identification of the dominant venous perforator of the flap entailed high possibilities of finding an arterial perforator of adequate caliber (93.5%), higher than the possibilities of finding a venous perforator of good caliber after the identification of the dominant arterial perforator (69.8%). Gravvanis et al [21] compared two subgroups of breast reconstructions regarding vascular dissection: dominant arterial perforator-dissected versus dominant venous perforator-dissected DIEPs. A significant higher rate of venous congestion was found in the arterial perforator group.…”

Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: Algorithmic Approach to Maximize Efficiency and Safety

“…28,29 It is critical that the selected perforator also has a strong audible Doppler signal in the artery and vein both along the pedicle and at the entrance of the flap. The assessment of vessel caliber in our practice is made using preoperative computed tomographic imaging and correlated with intraoperative evaluation by an experienced microsurgeon.…”

Integrating Imaging Techniques in Deep Inferior Epigastric Perforator Breast Reconstruction.

“…36,38 It is well-perceived that, although any medially located arterial perforator>1 mm in diameter can perfuse any flap, not every associated vein can drain every flap. 36 Lately the concept of the perforator complex, which includes the triad of an arterial perforator, venous tributaries and nerve in any combination, has been brought in, suggesting that selection of the dominant perforator-complex based on dominant veins ensures optimal flap microcirculation, while diminishing intraoperative incidents and postoperative healing complications.…”

“…38 Our team introduced the perforator-complex imaging protocol termed as "CTA-guided CDU examination", 36 which combines the use of CTA and CDU in the decision-making process of choosing the best suitable perforatorcomplex. The CTA results are used as a guide to conduct a CDU examination to investigate the size and patency of the accompanying venous tributaries.…”

“…[33][34][35] and for hemodynamic evaluation of both arterial and venous conduits of the perforator-complex. 36 In order to increase the accuracy of preoperative mapping, CDU may be used in addition to CTA.…”