BACKGROUND: Preoperative computed tomograph angiography (CTA) has produced a paradigm shift in perforator flap breast reconstruction. Preoperative CTA is significantly more accurate and easier to interpret than the previously used handheld or duplex Doppler. By identifying the optimal perforators prior to incision, preoperative CTA can guide skin island design and decrease operative time. We present our experience of abdominal perforator flap breast reconstruction using preoperative CTA.
METHODS: A retrospective review was done of 68 consecutive abdominal perforator flaps performed for breast reconstruction from December 2007 to February 2009. Preoperative imaging with CTA was performed on all of the flaps to allow for visualization of the microvascular anatomy. The largest perforators with the most direct course to the primary vascular pedicle were mapped on an x-y axis, with the umbilicus as the central reference point. The best perforators were identified based on size, location, intramuscular course, and tortuosity. Based on preoperative imaging, a detailed operative plan was created prior to marking the patient. Operative time and outcomes were compared to historical controls.
RESULTS: Of 68 total abdominal perforator flaps, preoperative CTA resulted in the selection of a medial row perforator or a septocutaneous perforator in 50 flaps (73%). When compared to historical controls, operative time among DIEP flaps that were performed after preoperative CTA was decreased by 1.5 hours. There was decreased donor site morbidity and decreased muscle denervation. One patient had clinically significant fat necrosis. There were no flap losses.
CONCLUSIONS: Preoperative CTA has revolutionized perforator flap breast reconstruction. By allowing preoperative visualization of the microvascular anatomy of the donor site, an accurate assessment can be made as to which perforator should be selected for flap harvest. The ability to make the right decision prior to the operation saves time and donor site morbidity. Preoperative CTA can significantly alter flap design and vessel selection, and it enhances the ability of the surgeon to select the optimal perforator. In our practice, preoperative CTA has now become the standard of care.