A New Preoperative Imaging Modality for Free Flaps in Breast Reconstruction: Computed Tomographic Angiography

Sir: Abdominal donor-site free flaps are increasingly used for autologous breast reconstruction. With significant variation in individual vascular anatomy, preoperative imaging is essential.1 The standard imaging modality of the deep inferior epigastric artery (DIEA) has been either Doppler or color duplex ultrasonography,2 with both used extensively for transverse rectus abdominis musculocutaneous (TRAM) and DIEA perforator flaps. However, inconsistencies with operative findings have perpetuated the search for improved imaging modalities. Computed tomographic angiography is a noninvasive and effective investigation for mapping vasculature that has been used previously in various body regions.3,4 To our knowledge, computed tomographic angiography has not been described for preoperative imaging in breast reconstruction. In 2006, a 54-year-old woman undergoing bilateral TRAM flap breast reconstructions underwent preoperative abdominal wall imaging with both Doppler ultrasonography (Philips HDI 5000 unit; Phillips Electronics Company, Eindhoven, The Netherlands) and helical computed tomographic angiography (Siemens Somatom Sensation 64-slice computed tomographic scanner; Siemens Medical Solutions, Malvern, Pa.) with 100 ml of intravenous Ultravist 370 contrast (Berlex Canada, Montreal, Quebec, Canada). Doppler imaging revealed a single-trunk DIEA, with no major perforators or branches identified. Computed tomographic angiographic reconstructions revealed a bifurcating DIEA with two large trunks and several large perforators, with at least one large 2.5-mm-diameter perforator (Figs. 1 and 2).Fig. 1.: Computed tomographic angiogram of the abdominal wall vasculature, with coronal views highlighting the DIEA system. Lateral images demonstrated the precise location and size of several large periumbilical perforators (Fig. 2). The reconstructed images also identified the location, size, and course of the superficial inferior epigastric arteries.Fig. 2.: Computed tomographic angiogram of the abdominal wall vasculature, with lateral reconstructions highlighting the periumbilical perforators.At the time of writing, computed tomographic angiography had not previously been described for preoperative imaging in breast reconstruction. However, its effectiveness in other free flap operations certainly suggests its suitability.3,4 We demonstrate this application of computed tomographic angiography, comparing findings to conventional Doppler ultrasonography. Computed tomographic angiography was highly effective at mapping the course of the DIEA, highlighted by the branching pattern revealed on computed tomographic angiography but missed on Doppler imaging. In addition, the computed tomographic angiography was presented in a manner more suitable to the surgeon in the operating theater. These factors facilitated reduced intraoperative dissection times and the avoidance of surgical error in our case. Computed tomographic angiography was proficient at identifying large perforators of the DIEA, with no perforators identified on Doppler imaging, despite large perforators confirmed during surgery. This suggests that even if perforators were identified on Doppler imaging, larger perforators may still be missed, confirming the high false-negative rates and interobserver variability for Doppler imaging in previous studies. Computed tomographic angiography also effectively identified the superficial inferior epigastric arteries, further enhancing preoperative decision making, for consideration of superficial inferior epigastric artery perforator flaps. In addition, it took less time to perform, taking approximately 15 minutes, compared with 2 hours for perforator mapping with Doppler imaging.2,5 Computed tomographic angiography is noninvasive but associated with some radiation exposure, equivalent to or less than that of a staging abdominal computed tomographic scan.5 The two scans can be performed simultaneously, to avoid multiple presentations and facilitate shorter preoperative investigation times. In subsequent studies, we have obtained more than 70 computed tomographic angiograms for the preoperative imaging of the DIEA and its perforators. These have been compared with Doppler ultrasound and magnetic resonance angiography scans. Computed tomographic angiography has remained the most accurate imaging modality and the one with the highest resolution of those available. We have instituted improvements in computed tomographic angiography technique, maximizing the arterial phase for perforator filling. This eliminates rectus abdominis and venous filling interference. This can be achieved by timing the contrast bolus to the DIEA and scanning from caudal to cranial. Computed tomographic angiography is a suitable alternative to Doppler ultrasonography for the preoperative imaging of the abdominal wall vasculature for TRAM and DIEA perforator flaps. It is effective at demonstrating both the deep and superficial epigastric arterial anatomy and was superior to ultrasonography in its anatomical account. Its use facilitated rapid intraoperative dissection times and avoided surgical error. Warren M. Rozen, M.B.B.S., P.G.Dip.Surg.Anat. Jack Brockhoff Plastic and Reconstructive Surgery Research Unit University of Melbourne Timoth J. Phillips, M.B.B.S., P.G.Dip.Surg.Anat. Department of Radiology Royal Melbourne Hospital Mark W. Ashton, F.R.A.C.S. Jack Brockhoff Plastic and Reconstructive Surgery Research Unit University of Melbourne Damien L. Stella, F.R.A.N.Z.C.R. Department of Radiology Royal Melbourne Hospital G. Ian Taylor, F.R.C.S., F.R.A.C.S. Jack Brockhoff Plastic and Reconstructive Surgery Research Unit University of Melbourne Parkville, Victoria, Australia DISCLOSURE The authors declare that there is no source of financial or other support, or any financial or professional relationships that may pose a competing interest.

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