Benefits of CT-angiography localisation in the surgical planning of deep inferior epigastric perforator flap breast reconstruction

Introduction

The aim of breast reconstruction in the postmastectomy cancer patient is to restore breast contour and dimensions whilst minimising the cosmetic impact. The deep inferior epigastric perforator (DIEP)-flap is a complex but state-of-the-art procedure that provides a durable and natural result. It is rapidly becoming the preferred choice at many institutions, including our regional plastic surgery unit. In achieving superior cosmesis without sacrificing abdominal wall musculature, a successful DIEP-flap requires painstaking and time-consuming microdissection of the inferior epigastric artery perforators. This relies on a high level of surgical expertise and results in prolonged anaesthetic times. As greater volumes of breast reconstructive surgery are performed, there will be increasing requirements for such preoperative imaging. We describe the required optimisation of CTA protocols to obtain the pertinent information and demonstrate how best to convey this complex information to our surgical colleagues.

Methods

Since 2009 we have provided CT-angiography in the preoperative planning for DIEP-flap breast reconstruction. We explored the implications of CT-angiography to optimise localisation of arterial perforators and identified the benefits of this imaging-guided approach.

Results

A total of 60 female patients have benefitted from CTA-guided perforator localisation, providing valuable procedural-planning information to our surgical colleagues. We have shown benefits in terms of markedly shorter operative duration with consequently reduced hospital stays and morbidity. Two patients had unsuspected metastatic disease identified, precluding reconstructive surgery.

Conclusions

An imaging-guided approach optimises preoperative planning. Accurate identification of arterial perforators enables targeted intraoperative localisation. This results in decreased operative time and patient morbidity, providing benefits for the cost of healthcare provision.