Role of computed tomography angiography in deep inferior epigastric perforator flap breast reconstruction surgery: A retrospective observational study

Abstract

Background: Deep inferior epigastric perforator (DIEP) flap is a technique used for breast reconstruction where the skin and subcutaneous tissues of the abdominal wall are transferred to the chest wall post-mastectomy. Computed tomography (CT) angiography localizes perforators along the anterior abdominal wall. Objectives: We conducted a retrospective study with the primary objective of evaluating the role of CT angiography in identifying the ideal perforator for the DIEP flap reconstruction and concordance between the radiologically identified perforator and the perforator preferred by the surgeons. Materials and Methods: Between July 1, 2015 and September 15, 2019, we included 106 patients in this retrospective study conducted in the Departments of Radiodiagnosis, and Plastic and Reconstructive Surgery at the Tata Memorial Hospital in Mumbai, India. These patients had a CT scan of the deep inferior epigastric artery perforator performed prior to reconstructive breast surgery with DIEP flap. Patients who underwent DIEP flap reconstruction surgery without prior imaging, breast reconstruction other than DIEP flap, and those with a history of abdominal surgeries like abdominoplasty or colostomy were excluded. Two radiologists blinded to the surgical details analyzed the pre-operative CT images to identify the ideal DIEP perforator. Radiological findings were compared with the surgical outcomes and complications. Results: The mean age of the patients was 36.7 years (interquartile range, 31.6-41.8). The most common type of the deep inferior epigastric artery in our population was type 2 (deep inferior epigastric artery dividing into two intramuscular branches) on either side. Concordance between the perforator identified on imaging and that selected by the surgeons was 80%. The selection of the larger caliber right sided perforator showed decrease in the recipient site complications; P=0.002. Conclusion: The strong correlation between the perforator selected by the surgeons and the one seen on imaging highlights the importance of imaging before the surgery in improving surgical planning and clinical outcomes. A dedicated protocol based on CT angiogram for DIEP is imperative in order to locate the best perforator which can be correlated intraoperatively and be considered the ideal perforator.

Keywords

• maximum intensity projection
• plastic surgery
• volume rendering