Application and prospect of preoperative computed tomographic angiography in deep inferior epigastric artery perforator flap for breast reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

PENG Wen , LÜ Chunliu , ZHOU Bo , SONG Dajiang ,  LI Zan

Department of Head and Neck/Oncology Plastic Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China;

Corresponding author：

LI Zan, Email: zzanli@163.com

Keywords：

Computed tomographic angiography; breast reconstruction; deep inferior epigastric artery perforator flap; autologous tissue transplantation

DOI：

10.7507/1002-1892.201907017

Video：

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Objective To generalize the application and prospect of computed tomographic angiography (CTA) in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction.Methods The related literature using CTA for DIEP flap reconstruction of breast in recent years was reviewed and analyzed.Results Preoperative CTA can accurately assess the vascular anatomy of the chest and abdomen wall, precisely locating the perforator in the abdominal donor site, and identifying the dominant perforator; guide the selection of intercostal space to explore internal mammary artery and internal mammary artery perforator in the chest recipient vessels. It can also reconstruct the volume of the abdominal flap with reference to the size of the contralateral breast and pre-shape the abdominal flap, which are crucial to formulate the surgical plan and improve the reliability of flap.Conclusion Preoperative CTA has enormous application potential and prospects in locating donor area perforator, in selecting recipient vessels, and in evaluating breast volume for autologous breast reconstruction with DIEP flap.

Citation： PENG Wen, LÜ Chunliu, ZHOU Bo, SONG Dajiang, LI Zan. Application and prospect of preoperative computed tomographic angiography in deep inferior epigastric artery perforator flap for breast reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(7): 927-931. doi: 10.7507/1002-1892.201907017 Copy

1.	Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical perforator-based flaps. Ann Plast Surg, 1992, 29(1): 12-17.
2.	Koshima I, Moriguchi T, Fukuda H, et al. Free, thinned, paraumbilical perforator-based flaps. J Reconstr Microsurg, 1991, 7(4): 313-316.
3.	Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg, 1994, 32(1): 32-38.
4.	Koshima I, Inagawa K, Urushibara K, et al. Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg, 1998, 102(4): 1052-1057.
5.	Koshima I, Inagawa K, Yamamoto M, et al. New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plast Reconstr Surg, 2000, 106(1): 61-65.
6.	Minqiang X, Lanhua M, Jie L, et al. The value of multidetector-row CT angiography for pre-operative planning of breast reconstruction with deep inferior epigastric arterial perforator flaps. Br J Radiol, 2010, 83(985): 40-43.
7.	Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg, 2006, 59(6): 571-579.
8.	Wu LC, Bajaj A, Chang DW, et al. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg, 2008, 122(3): 702-709.
9.	Voigt K, Goerttler U. Super-selective cerebral angiography. I. Animal experiments and methods of a simple technique (author's transl). Rofo, 1975, 122(3): 195-199.
10.	Rozen WM, Anavekar NS, Ashton MW, et al. Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction? Microsurgery, 2008, 28(7): 516-523.
11.	Rosson GD, Holton LH, Silverman RP, et al. Internal mammary perforators: a cadaver study. J Reconstr Microsurg, 2005, 21(4): 239-242.
12.	Masia J, Clavero JA, Larrañaga J, et al. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg, 2008, 122(2): 80e-81e.
13.	Al-Dhamin A, Berry R, Prasad V, et al. Coding system for computed tomographic angiography of inferior epigastric artery perforators in DIEP flaps. Plast Reconstr Surg, 2012, 129(2): 387e-388e.
14.	Aubry S, Pauchot J, Kastler A, et al. Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skeletal Radiol, 2013, 42(3): 319-327.
15.	Imai R, Matsumura H, Tanaka K, et al. Comparison of Doppler sonography and multidetector-row computed tomography in the imaging findings of the deep inferior epigastric perforator artery. Ann Plast Surg, 2008, 61(1): 94-98.
16.	Wong C, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg, 2009, 124(1): 18-27.
17.	Gravvanis A, Dionyssiou DD, Chandrasekharan L, et al. Paramuscular and paraneural perforators in DIEAP flaps: radiographic findings and clinical application. Ann Plast Surg, 2009, 63(6): 610-615.
18.	Whitaker IS, Rozen WM, Smit JM, et al. Peritoneo-cutaneous perforators in deep inferior epigastric perforator flaps: a cadaveric dissection and computed tomographic angiography study. Microsurgery, 2009, 29(2): 124-127.
19.	Katz RD, Manahan MA, Rad AN, et al. Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction. Microsurgery, 2010, 30(8): 593-602.
20.	Mathes DW, Neligan PC. Preoperative imaging techniques for perforator selection in abdomen-based microsurgical breast reconstruction. Clin Plast Surg, 2010, 37(4): 581-591.
21.	Rozen WM, Whitaker IS, Ashton MW, et al. Changes in vascular anatomy following reconstructive surgery: an in vivo angiographic demonstration of the delay phenomenon and venous recanalization. J Reconstr Microsurg, 2012, 28(6): 363-365.
22.	Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cía T, et al. Computed tomographic angiography with VirSSPA three-dimensional software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg, 2010, 125(1): 24-31.
23.	Saint-Cyr M, Chang DW, Robb GL, et al. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg, 2007, 120(7): 1769-1773.
24.	Follmar KE, Prucz RB, Manahan MA, et al. Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction. Plast Reconstr Surg, 2011, 127(1): 34-40.
25.	Haywood RM, Raurell A, Perks AG, et al. Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels. Br J Plast Surg, 2003, 56(7): 689-691.
26.	Hamdi M, Blondeel P, Van Landuyt K, et al. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators. Br J Plast Surg, 2004, 57(3): 258-265.
27.	Masia J, Kosutic D, Clavero JA, et al. Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg, 2010, 26(1): 21-28.
28.	Kim H, Lim SY, Pyon JK, et al. Preoperative computed tomographic angiography of both donor and recipient sites for microsurgical breast reconstruction. Plast Reconstr Surg, 2012, 130(1): 11e-20e.
29.	Fansa H, Schirmer S, Frerichs O, et al. Significance of abdominal wall CT-angiography in planning DIEA perforator flaps, TRAM flaps and SIEA flaps. Handchir Mikrochir Plast Chir, 2011, 43(2): 81-87.
30.	Fansa H, Schirmer S, Cervelli A, et al. Computed tomographic angiography imaging and clinical implications of internal mammary artery perforator vessels as recipient vessels in autologous breast reconstruction. Ann Plast Surg, 2013, 71(5): 533-537.
31.	Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part IV--aesthetic breast surgery. Plast Reconstr Surg, 2009, 124(2): 372-382.
32.	Gravvanis A, Smith RW. Shaping the breast in secondary microsurgical breast reconstruction: single-vs. two-esthetic unit reconstruction. Microsurgery, 2010, 30(7): 509-516.
33.	Dionyssiou D, Demiri E, Tsimponis A, et al. Predesigned breast shaping assisted by multidetector-row computed tomographic angiography in autologous breast reconstruction. Plast Reconstr Surg, 2014, 133(2): 100-108.
34.	Suami H, Chang DW. Overview of surgical treatments for breast cancer-related lymphedema. Plast Reconstr Surg, 2010, 126(6): 1853-1863.
35.	Nahabedian MY. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Gland Surg, 2012, 1(1): 1-2.
36.	Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg, 1984, 73(1): 1-16.
37.	Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg, 1993, 91(5): 853-863.
38.	El-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches. Plast Reconstr Surg, 2002, 109(2): 539-543.
39.	Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg, 1988, 82(5): 815-832.
40.	Garvey PB, Salavati S, Feng L, et al. Abdominal donor-site outcomes for medial versus lateral deep inferior epigastric artery branch perforator harvest. Plast Reconstr Surg, 2011, 127(6): 2198-2205.
41.	Garusi C, Lohsiriwat V, de Lorenzi F, et al. A subfascial variant of the deep inferior epigastric artery demonstrated by preoperative multidetector computed tomographic angiography: a case report. Microsurgery, 2010, 30(2): 156-158.
42.	Acosta R, Smit JM, Audolfsson T, et al. A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice. J Reconstr Microsurg, 2011, 27(2): 91-98.
43.	Mathes DW, Neligan PC. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr Microsurg, 2010, 26(1): 3-10.
44.	Masia J, Larrañaga J, Clavero JA, et al. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg, 2008, 60(1): 29-36.
45.	Rozen WM, Phillips TJ, Ashton MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg, 2008, 121(1): 9-16.
46.	Cho MJ, Haddock NT, Teotia SS. Clinical decision making using CTA in conjoined, bipedicled DIEP and SIEA for unilateral breast reconstruction. J Reconstr Microsurg, 2020, 36(4): 241-246.
47.	Tong WM, Dixon R, Ekis H, et al. The impact of preoperative CT angiography on breast reconstruction with abdominal perforator flaps. Ann Plast Surg, 2012, 68(5): 525-530.
48.	Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg, 2006, 59(6): 594-599.
49.	Rozen WM, Ashton MW. Modifying techniques in deep inferior epigastric artery perforator flap harvest with the use of preoperative imaging. ANZ J Surg, 2009, 79(9): 598-603.
50.	Midgley SM, Einsiedel PF, Phillips TJ, et al. Justifying the use of abdominal wall computed tomographic angiography in deep inferior epigastric artery perforator flap planning. Ann Plast Surg, 2011, 67(5): 457-459.
51.	Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg, 2010, 26(1): 11-20.

1. Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical perforator-based flaps. Ann Plast Surg, 1992, 29(1): 12-17.
2. Koshima I, Moriguchi T, Fukuda H, et al. Free, thinned, paraumbilical perforator-based flaps. J Reconstr Microsurg, 1991, 7(4): 313-316.
3. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg, 1994, 32(1): 32-38.
4. Koshima I, Inagawa K, Urushibara K, et al. Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg, 1998, 102(4): 1052-1057.
5. Koshima I, Inagawa K, Yamamoto M, et al. New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plast Reconstr Surg, 2000, 106(1): 61-65.
6. Minqiang X, Lanhua M, Jie L, et al. The value of multidetector-row CT angiography for pre-operative planning of breast reconstruction with deep inferior epigastric arterial perforator flaps. Br J Radiol, 2010, 83(985): 40-43.
7. Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg, 2006, 59(6): 571-579.
8. Wu LC, Bajaj A, Chang DW, et al. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg, 2008, 122(3): 702-709.
9. Voigt K, Goerttler U. Super-selective cerebral angiography. I. Animal experiments and methods of a simple technique (author's transl). Rofo, 1975, 122(3): 195-199.
10. Rozen WM, Anavekar NS, Ashton MW, et al. Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction? Microsurgery, 2008, 28(7): 516-523.
11. Rosson GD, Holton LH, Silverman RP, et al. Internal mammary perforators: a cadaver study. J Reconstr Microsurg, 2005, 21(4): 239-242.
12. Masia J, Clavero JA, Larrañaga J, et al. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg, 2008, 122(2): 80e-81e.
13. Al-Dhamin A, Berry R, Prasad V, et al. Coding system for computed tomographic angiography of inferior epigastric artery perforators in DIEP flaps. Plast Reconstr Surg, 2012, 129(2): 387e-388e.
14. Aubry S, Pauchot J, Kastler A, et al. Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skeletal Radiol, 2013, 42(3): 319-327.
15. Imai R, Matsumura H, Tanaka K, et al. Comparison of Doppler sonography and multidetector-row computed tomography in the imaging findings of the deep inferior epigastric perforator artery. Ann Plast Surg, 2008, 61(1): 94-98.
16. Wong C, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg, 2009, 124(1): 18-27.
17. Gravvanis A, Dionyssiou DD, Chandrasekharan L, et al. Paramuscular and paraneural perforators in DIEAP flaps: radiographic findings and clinical application. Ann Plast Surg, 2009, 63(6): 610-615.
18. Whitaker IS, Rozen WM, Smit JM, et al. Peritoneo-cutaneous perforators in deep inferior epigastric perforator flaps: a cadaveric dissection and computed tomographic angiography study. Microsurgery, 2009, 29(2): 124-127.
19. Katz RD, Manahan MA, Rad AN, et al. Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction. Microsurgery, 2010, 30(8): 593-602.
20. Mathes DW, Neligan PC. Preoperative imaging techniques for perforator selection in abdomen-based microsurgical breast reconstruction. Clin Plast Surg, 2010, 37(4): 581-591.
21. Rozen WM, Whitaker IS, Ashton MW, et al. Changes in vascular anatomy following reconstructive surgery: an in vivo angiographic demonstration of the delay phenomenon and venous recanalization. J Reconstr Microsurg, 2012, 28(6): 363-365.
22. Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cía T, et al. Computed tomographic angiography with VirSSPA three-dimensional software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg, 2010, 125(1): 24-31.
23. Saint-Cyr M, Chang DW, Robb GL, et al. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg, 2007, 120(7): 1769-1773.
24. Follmar KE, Prucz RB, Manahan MA, et al. Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction. Plast Reconstr Surg, 2011, 127(1): 34-40.
25. Haywood RM, Raurell A, Perks AG, et al. Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels. Br J Plast Surg, 2003, 56(7): 689-691.
26. Hamdi M, Blondeel P, Van Landuyt K, et al. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators. Br J Plast Surg, 2004, 57(3): 258-265.
27. Masia J, Kosutic D, Clavero JA, et al. Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg, 2010, 26(1): 21-28.
28. Kim H, Lim SY, Pyon JK, et al. Preoperative computed tomographic angiography of both donor and recipient sites for microsurgical breast reconstruction. Plast Reconstr Surg, 2012, 130(1): 11e-20e.
29. Fansa H, Schirmer S, Frerichs O, et al. Significance of abdominal wall CT-angiography in planning DIEA perforator flaps, TRAM flaps and SIEA flaps. Handchir Mikrochir Plast Chir, 2011, 43(2): 81-87.
30. Fansa H, Schirmer S, Cervelli A, et al. Computed tomographic angiography imaging and clinical implications of internal mammary artery perforator vessels as recipient vessels in autologous breast reconstruction. Ann Plast Surg, 2013, 71(5): 533-537.
31. Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part IV--aesthetic breast surgery. Plast Reconstr Surg, 2009, 124(2): 372-382.
32. Gravvanis A, Smith RW. Shaping the breast in secondary microsurgical breast reconstruction: single-vs. two-esthetic unit reconstruction. Microsurgery, 2010, 30(7): 509-516.
33. Dionyssiou D, Demiri E, Tsimponis A, et al. Predesigned breast shaping assisted by multidetector-row computed tomographic angiography in autologous breast reconstruction. Plast Reconstr Surg, 2014, 133(2): 100-108.
34. Suami H, Chang DW. Overview of surgical treatments for breast cancer-related lymphedema. Plast Reconstr Surg, 2010, 126(6): 1853-1863.
35. Nahabedian MY. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Gland Surg, 2012, 1(1): 1-2.
36. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg, 1984, 73(1): 1-16.
37. Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg, 1993, 91(5): 853-863.
38. El-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches. Plast Reconstr Surg, 2002, 109(2): 539-543.
39. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg, 1988, 82(5): 815-832.
40. Garvey PB, Salavati S, Feng L, et al. Abdominal donor-site outcomes for medial versus lateral deep inferior epigastric artery branch perforator harvest. Plast Reconstr Surg, 2011, 127(6): 2198-2205.
41. Garusi C, Lohsiriwat V, de Lorenzi F, et al. A subfascial variant of the deep inferior epigastric artery demonstrated by preoperative multidetector computed tomographic angiography: a case report. Microsurgery, 2010, 30(2): 156-158.
42. Acosta R, Smit JM, Audolfsson T, et al. A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice. J Reconstr Microsurg, 2011, 27(2): 91-98.
43. Mathes DW, Neligan PC. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr Microsurg, 2010, 26(1): 3-10.
44. Masia J, Larrañaga J, Clavero JA, et al. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg, 2008, 60(1): 29-36.
45. Rozen WM, Phillips TJ, Ashton MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg, 2008, 121(1): 9-16.
46. Cho MJ, Haddock NT, Teotia SS. Clinical decision making using CTA in conjoined, bipedicled DIEP and SIEA for unilateral breast reconstruction. J Reconstr Microsurg, 2020, 36(4): 241-246.
47. Tong WM, Dixon R, Ekis H, et al. The impact of preoperative CT angiography on breast reconstruction with abdominal perforator flaps. Ann Plast Surg, 2012, 68(5): 525-530.
48. Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg, 2006, 59(6): 594-599.
49. Rozen WM, Ashton MW. Modifying techniques in deep inferior epigastric artery perforator flap harvest with the use of preoperative imaging. ANZ J Surg, 2009, 79(9): 598-603.
50. Midgley SM, Einsiedel PF, Phillips TJ, et al. Justifying the use of abdominal wall computed tomographic angiography in deep inferior epigastric artery perforator flap planning. Ann Plast Surg, 2011, 67(5): 457-459.
51. Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg, 2010, 26(1): 11-20.

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