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Ehrl D, Alt V, Taha S, Frank K, Wachtel N, Bodenschatz KJ, Demmer W, Fuchs B, Giunta RE, Moellhoff N. Changes in the Microcirculation and Physiologic Perfusion Dynamics of Free DIEP Flaps in the First 72 h After Breast Reconstruction. J Clin Med 2025; 14:520. [PMID: 39860525 PMCID: PMC11765763 DOI: 10.3390/jcm14020520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 12/30/2024] [Accepted: 01/03/2025] [Indexed: 01/27/2025] Open
Abstract
Background/Objectives: The autologous reconstruction of the female breast using a microsurgical DIEP flap is a reliable and safe method. To detect impairments early and preserve the microvascular flap through timely revision, a better understanding of physiologic perfusion dynamics is necessary. This exploratory study examines changes in microcirculation in free DIEP flaps within the first 72 h after vascular anastomosis using laser Doppler flowmetry and white-light spectrophotometry. Methods: This single-center study analyzed retro- and prospectively collected data from female patients who underwent uneventful breast reconstruction using a DIEP flap and were monitored using the O2C device (LEA Medizintechnik, Giessen, Germany). Microcirculation was monitored continuously postoperatively for a period of 72 h. Results: A total of 36 patients with a mean age of 48.86 (9.36) years and a mean BMI of 26.78 (4.12) kg/m2 received 40 DIEP flaps (four bilateral reconstructions). Microcirculatory blood flow showed a continuous increase, reaching up to 15% above its initial value within the first 72 h following anastomosis. The average tissue oxygen saturation (sO2) and relative hemoglobin (rHB) levels remained fairly stable throughout the study period, with overall reductions of 5.46% and 5.30%, respectively. Conclusions: Autologous breast reconstruction using a microvascular DIEP flap is a safe and reliable technique. This study showed an increase in blood flow over the 72 h study period. At the same time, sO2 and rHb showed stable levels. Deviations in these values could be interpreted as indicators of a perfusion disorder of the microvascular flap.
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Affiliation(s)
- Denis Ehrl
- Department for Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Verena Alt
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Sara Taha
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Konstantin Frank
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Nikolaus Wachtel
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Karl J. Bodenschatz
- Department of Pediatric Surgery and Urology, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Wolfram Demmer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Benedikt Fuchs
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Riccardo E. Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
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Pozzo V, Goutard M, Dabi Y, Romano G, Benjoar MD, Benjoar M, Hadji I, Ng ZY, Lellouch AG, Lantieri LA. Predictive Factors of a Dominant Superficial Venous Drainage System in DIEP Flap Surgery With Preoperative Computed Tomography Angiography. Microsurgery 2025; 45:e70008. [PMID: 39831686 DOI: 10.1002/micr.70008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 09/17/2024] [Accepted: 12/04/2024] [Indexed: 01/22/2025]
Abstract
BACKGROUND Venous congestion due to superficial venous system dominance (SVD) in deep inferior epigastric perforator (DIEP) flap surgery occurs in approximately 2% of cases, with attendant sequelae and increased cost to healthcare systems. This study aimed to describe the predictive factors for SVD in DIEP flap breast reconstruction based on preoperative computed tomography angiography (CTA) findings. METHODS All women who required takebacks for additional venous anastomosis to the cephalic vein because of SVD after DIEP flap breast reconstruction between 2015 and 2022 were included. Complication-free DIEP breast reconstruction patients were then randomly selected based on a 1:2 enrollment ratio to form a control group. A retrospective analysis of pre-operative CTAs was performed for both groups to compare the size and location of the perforators, diameter of the superficial inferior epigastric vein (SIEV), diameter of the deep inferior epigastric vein (DIEV), and flap thickness. RESULTS Twenty-four women were identified in the SVD group; however, only 18 were included in the final analysis. CTA analysis suggested that the ratio between SIEV and DIEV (SIEV/DIEV) diameters was significantly higher in the SVD group than in the controls (0.98 vs. 0.83; p = 0.043). The mean flap thickness was also significantly lower in the SVD group than in the controls (29.4 vs. 36.3 mm; p < 0.001). Perforator characteristics and the SIEV diameter did not differ between the two groups. CONCLUSIONS The SIEV/DIEV diameter ratio on preoperative CTA can be used to predict whether the DIEP flap has SVD. This may then be used to anticipate whether additional venous anastomosis is required to reduce postoperative complications.
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Affiliation(s)
- Victor Pozzo
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Marion Goutard
- Service de Chirurgie Plastique, Institut Gustave Roussy, Université Paris Saclay, Paris, France
| | - Yohann Dabi
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Golda Romano
- Service de Chirurgie Plastique, Institut Gustave Roussy, Université Paris Saclay, Paris, France
| | - Marc-David Benjoar
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | | | - Ilyes Hadji
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Zhi Yang Ng
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexandre G Lellouch
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, US
| | - Laurent A Lantieri
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
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Soliman M, Metwally IH, Denewer A, Abdallah A, Denewar FA, Healy NA, Romics L, Agrawal A. Computed tomographic angiography in planning thoraco-dorsal artery perforator flap in breast and soft tissue reconstruction: a systematic review. Br J Radiol 2025; 98:27-35. [PMID: 39378114 DOI: 10.1093/bjr/tqae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/25/2024] [Accepted: 10/01/2024] [Indexed: 10/10/2024] Open
Abstract
OBJECTIVES Thoraco-dorsal artery perforator (TDAP) flaps have been increasingly used in breast and soft tissue reconstruction. Perforator localization is often done using a hand-held doppler, however, false results are not uncommon. This study aimed to systematically review the literature on the value of preoperative computed tomographic angiography (CTA) in TDAP flaps examining scanning protocol, mapping technique, concordance with operative findings, and disadvantages. METHODS A PRISMA-compliant comprehensive search of Medline, Embase, Cochrane Library, and CINAHL databases was conducted in November 2023. We included studies evaluating CTA mapping of free and pedicled TDAPs for breast or soft tissue reconstruction using The Joanna Briggs Institute (JBI) Critical Appraisal Tools. RESULTS Five studies were included and considered at high risk of bias. The studies included 72 patients with a mean age of 43.8 years. Concordance between CT findings and Doppler mapping or operative visualization was reported in two studies. In three studies, CTA was combined with Doppler flowmetry, whilst dynamic infrared thermography was used in one study. Standardized scanning protocol and patient positioning were lacking in all reports. CONCLUSIONS This study highlights the paucity of evidence on the value of CTA in TDA perforator mapping with inconsistent outcomes and non-standardized scanning protocols. Despite difficult imaging acquisition and interpretation, 3D reconstructed images and detailed vascular anatomy may facilitate planning. ADVANCES IN KNOWLEDGE Further research is required to explore the practical value of CTA in TDAP planning and standardizing protocols.
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Affiliation(s)
- Mahmoud Soliman
- North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester, M8 5RB, United Kingdom
- Surgical Oncology Department, Faculty of Medicine, Mansoura University, 35516, Egypt
| | - Islam H Metwally
- Surgical Oncology Department, Faculty of Medicine, Mansoura University, 35516, Egypt
| | - Adel Denewer
- Surgical Oncology Department, Faculty of Medicine, Mansoura University, 35516, Egypt
| | - Ahmed Abdallah
- Surgical Oncology Department, Faculty of Medicine, Mansoura University, 35516, Egypt
| | | | - Nuala Ann Healy
- Beaumont Breast Center, Beaumont Hospital, Dublin, D09V2N0, Ireland
- Department of Radiology, Royal College of Surgeons, Dublin, D02 YN77, Ireland
| | - Laszlo Romics
- Department of Surgery, Greater Glasgow & Clyde NHS (Gartnavel General Hospital & Royal Alexandria Hospital, Paisley), Glasgow, PA2 9PN, United Kingdom
| | - Amit Agrawal
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, United Kingdom
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Gao Y, Yin L, Xiang T, Ni T, Shi J. Reduce Flap Necrosis After Autologous Breast Reconstruction: A Systematic Review. J Craniofac Surg 2024:00001665-990000000-02314. [PMID: 39729252 DOI: 10.1097/scs.0000000000011060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Accepted: 12/14/2024] [Indexed: 12/28/2024] Open
Abstract
BACKGROUND Autologous breast reconstruction provides substantial benefits in terms of aesthetics and longevity. However, the risk of flap necrosis poses potential challenges to patients' appearance and psychological well-being, while also escalating health care costs. Consequently, examining the risk factors, assessment techniques, and therapeutic approaches for flap necrosis is critically important. METHOD The authors conducted a comprehensive search for relevant studies from January 2010 to August 2024 using PubMed, Web of Science, and the Cochrane Library. The search terms included "autologous breast reconstruction", "flap necrosis", "risk factor", "assessment", and "treatment". The authors initially screened titles and abstracts, followed by a detailed review by 3 investigators to determine the studies that met the inclusion criteria. RESULT A total of 68 studies were ultimately selected for analysis. Identified risk factors for flap necrosis include smoking, advanced age, obesity, diabetes, large breast volume, previous radiotherapy, and abdominal surgery. Various assessment methods (e.g., preoperative imaging, intraoperative blood flow monitoring, and postoperative evaluations) can enhance flap survival. The review also covered surgical treatment strategies and non-surgical interventions, including local wound care, hyperbaric oxygen therapy, and pharmacological treatments. CONCLUSION This review highlights the critical role of thorough planning and management in minimizing the risk of flap necrosis after autologous breast reconstruction. Effective preoperative assessments, perioperative monitoring, and specific postoperative interventions can significantly lower the incidence of flap necrosis.
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Affiliation(s)
- Yiwen Gao
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, P. R. China
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Ahmed H, Thomas-Jones I, Jessop ZM, Fell M, Patel N, Wilson S, Jackson P. Evolving role of staging CT scans during CT-angiography for DIEP flap reconstruction planning. J Plast Reconstr Aesthet Surg 2024; 98:342-347. [PMID: 39332161 DOI: 10.1016/j.bjps.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/12/2024] [Accepted: 09/01/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND Preoperative planning with CT-angiography (CTA) in deep inferior epigastric perforator (DIEP) flap reconstruction is an essential preoperative tool. The aim of this study was to describe the management of the incidental findings following the introduction and further modification of a combined CTA and CT-staging preoperative protocol which includes chest, abdomen, pelvis, and musculoskeletal system. MATERIAL AND METHODS A retrospective case series of 292 patients (Group 1) with breast cancer who underwent DIEP flap between 2015 and 2019. This was followed by a re-assessment between 2019 and 2021 of 101 patients (Group 2) following modification of the staging-CT protocol to include only those patients who received chemotherapy. Group 1 included immediate and delayed reconstruction; whereas Group 2 included only the high-risk delayed reconstruction cases. Both groups had CT staging. RESULT Overall, 30% of Group 1, most likely those who had the delayed reconstruction, had findings which were recommended for further follow-up. This led to a change in staging of the high-risk patients only at the end of 2019 to those who underwent chemotherapy and had delayed reconstruction. Briefly, 56.4% of Group 2 demonstrated incidental findings, 42.1% of them required repeat scanning, 7% were referred to other specialties, and 47.4% did not require further action. There were no cases of occult metastatic breast cancer in either series; however, 1% were diagnosed with de novo primary cancers at non breast sites only in the first series. CONCLUSION The screening of patients with asymptomatic breast cancer as part of CTA scanning prior to autologous reconstruction is not universally practiced and not supported by the NICE guidelines. This unit changed the practice to stop preoperative staging for low-risk patients by the end of 2019, and reserved it for the high-risk patient groups to reduce cost.
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Affiliation(s)
- Hazim Ahmed
- Plastic surgery Department, North Bristol Trust, UK.
| | | | - Zita M Jessop
- Plastic surgery Department, North Bristol Trust, UK.
| | - Matthew Fell
- Plastic surgery Department, North Bristol Trust, UK.
| | - Naomi Patel
- Plastic surgery Department, North Bristol Trust, UK.
| | - Sherif Wilson
- Plastic surgery Department, North Bristol Trust, UK.
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Necker FN, Cholok DJ, Shaheen MS, Fischer MJ, Gifford K, El Chemaly T, Leuze CW, Scholz M, Daniel BL, Momeni A. Increasing DIEA Perforator Detail in Three-Dimensional Photorealistic Volume-Rendering Visualizations. Plast Reconstr Surg 2024; 154:63S-67S. [PMID: 38351515 DOI: 10.1097/prs.0000000000011359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
SUMMARY Preoperative computed tomographic angiography is increasingly performed before perforator flap-based reconstruction. However, radiologic two-dimensional thin slices do not allow for intuitive interpretation and translation to intraoperative findings. Three-dimensional volume rendering has been used to alleviate the need for mental two-dimensional to three-dimensional abstraction. Even though volume rendering allows for a much easier understanding of anatomy, it currently has limited utility, as the skin obstructs the view of critical structures. Using free, open-source software, the authors introduce a new skin-masking technique that allows surgeons to easily create a segmentation mask of the skin that can later be used to toggle the skin on and off. In addition, the mask can be used in other rendering applications. The authors use Cinematic Anatomy for photorealistic volume rendering and interactive exploration of computed tomographic angiography with and without skin. The authors present results from using this technique to investigate perforator anatomy in deep inferior epigastric perforator flaps and demonstrate that the skin-masking workflow is performed in less than 5 minutes. In Cinematic Anatomy, the view onto the abdominal wall and especially onto perforators becomes significantly sharper and more detailed when no longer obstructed by the skin. The authors perform a virtual, partial muscle dissection to show the intramuscular and submuscular course of the perforators. The skin-masking workflow allows surgeons to improve arterial and perforator detail in volume renderings easily and quickly by removing skin and could alternatively be performed solely using open-source and free software. The workflow can be easily expanded to other perforator flaps without the need for modification.
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Affiliation(s)
- Fabian N Necker
- From the Department of Radiology, Stanford Incubator for Medical Mixed and Extended Reality at Stanford
- Department of Surgery, Division of Plastic and Reconstructive Surgery
- Institute of Functional and Clinical Anatomy, Digital Anatomy Laboratory, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg
| | - David J Cholok
- Department of Surgery, Division of Plastic and Reconstructive Surgery
| | | | - Marc J Fischer
- From the Department of Radiology, Stanford Incubator for Medical Mixed and Extended Reality at Stanford
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine
| | - Trishia El Chemaly
- From the Department of Radiology, Stanford Incubator for Medical Mixed and Extended Reality at Stanford
| | - Christoph W Leuze
- From the Department of Radiology, Stanford Incubator for Medical Mixed and Extended Reality at Stanford
| | - Michael Scholz
- Institute of Functional and Clinical Anatomy, Digital Anatomy Laboratory, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg
| | - Bruce L Daniel
- From the Department of Radiology, Stanford Incubator for Medical Mixed and Extended Reality at Stanford
| | - Arash Momeni
- Department of Surgery, Division of Plastic and Reconstructive Surgery
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Necker FN, Cholok DJ, Shaheen MS, Fischer MJ, Gifford K, El Chemaly T, Leuze CW, Scholz M, Daniel BL, Momeni A. The Reconstructive Metaverse - Collaboration in Real-Time Shared Mixed Reality Environments for Microsurgical Reconstruction. Surg Innov 2024; 31:563-566. [PMID: 38905568 PMCID: PMC11411343 DOI: 10.1177/15533506241262946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
Plastic surgeons routinely use 3D-models in their clinical practice, from 3D-photography and surface imaging to 3D-segmentations from radiological scans. However, these models continue to be viewed on flattened 2D screens that do not enable an intuitive understanding of 3D-relationships and cause challenges regarding collaboration with colleagues. The Metaverse has been proposed as a new age of applications building on modern Mixed Reality headset technology that allows remote collaboration on virtual 3D-models in a shared physical-virtual space in real-time. We demonstrate the first use of the Metaverse in the context of reconstructive surgery, focusing on preoperative planning discussions and trainee education. Using a HoloLens headset with the Microsoft Mesh application, we performed planning sessions for 4 DIEP-flaps in our reconstructive metaverse on virtual patient-models segmented from routine CT angiography. In these sessions, surgeons discuss perforator anatomy and perforator selection strategies whilst comprehensively assessing the respective models. We demonstrate the workflow for a one-on-one interaction between an attending surgeon and a trainee in a video featuring both viewpoints as seen through the headset. We believe the Metaverse will provide novel opportunities to use the 3D-models that are already created in everyday plastic surgery practice in a more collaborative, immersive, accessible, and educational manner.
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Affiliation(s)
- Fabian N Necker
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David J Cholok
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mohammed S Shaheen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marc J Fischer
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, CA, USA
| | - Trishia El Chemaly
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Christoph W Leuze
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michael Scholz
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bruce L Daniel
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Arash Momeni
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Ghasroddashti A, Guyn C, Martou G, Edmunds RW. Utility of 3D-printed vascular modeling in microsurgical breast reconstruction: a systematic review. J Plast Reconstr Aesthet Surg 2024; 96:95-104. [PMID: 39067229 DOI: 10.1016/j.bjps.2024.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/08/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Microsurgical breast reconstruction presents a technical challenge in preoperative planning and flap harvest. Given the limitations of computed tomographic angiography as a preoperative aid, 3D printing has emerged as an avenue for creating patient-specific anatomical models for pre- and intraoperative use. This systematic review assesses the current use and utility of 3D-printed vascular models (3DVMs) in microsurgical breast reconstruction. METHODS MEDLINE, Embase, and CENTRAL were searched for English articles published from 1946 to 2024. Studies utilizing 3D-printed vascular modeling in the context of microsurgical breast reconstruction were included if they reported surgical, model-, or user-related outcomes. The Newcastle-Ottawa Scale and Joanna Briggs Institute checklists were used for quality assessment. Results were reported according to PRISMA guidelines. RESULTS Six hundred and nineteen records were retrieved. Following specific inclusion and exclusion criteria, 29 studies underwent full-text review. Eight studies totaling 181 patients and 261 flaps were included in the final analysis. 3DVMs were used to model deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap perforator origin, course, distribution, and surrounding anatomy. They were used for perforator selection, flap harvest, and training. Use of 3DVMs reduced harvest time by up to 23 min per case. No complications or preoperative plan deviations were reported in 3DVM-guided cases. Surgeons endorsed significant model utility in anatomical visualization, preoperative planning, and flap harvest. Model cost, production time, and adoption were identified as barriers to use. CONCLUSIONS 3DVMs can enhance preoperative planning, intraoperative decision-making, and operative efficiency in unilateral DIEP and bilateral MS-TRAM flap breast reconstructions.
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Affiliation(s)
| | - Colm Guyn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Glykeria Martou
- Division of Plastic Surgery, Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Robert Wesley Edmunds
- Division of Plastic Surgery, Department of Surgery, Queen's University, Kingston, ON, Canada
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Liu Y, Wu J, Liu D, Xiang D, Wu X, Wang T. The application of mixed reality technique in oromaxillo-facial reconstruction with the perforator flap for malignant tumor patients. Front Oncol 2024; 14:1437598. [PMID: 39099694 PMCID: PMC11294116 DOI: 10.3389/fonc.2024.1437598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/06/2024] Open
Abstract
Objectives The integration of quantitative imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) with mixed reality (MR) technology holds promise for enhancing the diagnosis, prognosis, and treatment monitoring of cancer. This study compares the characteristics and effects of MR and color Doppler ultrasound (CDU) in the localization of perforator blood vessels in the lower extremities. Methods Two techniques were used to locate the perforator vessels in 40 cases of maxillofacial defect repair using perforator flaps from the lower extremities. The number of perforator vessels located in the flap area and the actual number of perforator vessels explored during the surgery were recorded. The recognition rate was calculated and the operation time and blood loss were recorded for each case. Results The recognition rates of MR technology and CDU in perforating vessels of the lower limbs were 93.9% and 97.2%, respectively (p > 0.05). The operation time was 52-74 minutes, 65-88 minutes (p > 0.05). The average bleeding volumes were 24 and 56 ml (p < 0.05), respectively. All perforator flaps were alive. One flap had a crisis and recovered after emergency exploratory treatment. Thirty donor sites of the lower extremities were directly sutured, and wounds were closed by abdominal skin grafting in 10 cases. Conclusion MR technology for successfully identifying perforator vessels can shorten the operation time, reduce the amount of bleeding in the donor site, and reduce trauma to the donor site.
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Affiliation(s)
- Yixiu Liu
- Head and Neck Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Jian Wu
- Head and Neck Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Daide Liu
- Department of Surgery, People’s Hospital of Shizhu, Chongqing, China
| | - Dalan Xiang
- Department of Surgery, People’s Hospital of Shizhu, Chongqing, China
| | - Xiaoyue Wu
- Head and Neck Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Ting Wang
- Internal Medicine-Oncology, Chongqing University Cancer Hospital, Chongqing, China
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Brown MS, Mirhaidari C, Johnson J, Larson BM, Cook C, Shue R, Ventimiglia AJ, Cody DG. Oncologic Staging Computed Tomography with IV Contrast Has Similar Efficacy to Dedicated Computed Tomography Angiography for Preoperative DIEP Flap Planning. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5709. [PMID: 38798933 PMCID: PMC11124623 DOI: 10.1097/gox.0000000000005709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/12/2024] [Indexed: 05/29/2024]
Abstract
Background Due to variations in perforator vasculature, deep inferior epigastric artery perforator (DIEP) flap preoperative imaging can minimize operative time required to locate the most suitable perforators. Dedicated computed tomography angiography (CTA) has been the gold standard; however, many patients have already undergone a staging computed tomography (CT) per oncologic workup. The benefits from CTA may also be realized with a staging CT or CT with IV contrast. Methods Ten patients who underwent DIEP flap reconstruction with staging CT and CTA within 3 years of one another were included in this study. Reviewers evaluated axial views of both imaging modalities separately to identify each visible perforator in reference to the pubic symphysis from the xiphoid to the pubic symphysis. An intraclass correlation coefficient (ICC) was used to determine agreement in location of perforators between the two imaging studies. Statistical analysis was performed using an ICC and Wilcoxon signed rank-tests. Results The identified perforators within the patient cohort had an excellent correlation between their location on CT and CTA based upon ICC. The mean number of perforators identified in the CT group was 15.3 (SD 4.9) and in the CTA group was 18.8 (SD 6.4), which was not statistically different (P = 0.247). Conclusions CT has similar efficacy in identifying number of perforators and perforator location to dedicated CTA for preoperative planning in DIEP flaps. This has the potential for decreased patient contrast and ionizing radiation exposure as well as improved patient and healthcare resource utilization.
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Affiliation(s)
| | | | - Jordan Johnson
- Northeast Ohio Medical University (NEOMED), Rootstown, Ohio
| | | | - Chad Cook
- Duke University Medical Center, Durham, N.C
| | - Robert Shue
- Summa Health Department of Radiology, Akron, Ohio
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11
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Musmann RJ, Andree C, Munder B, Hagouan M, Janku D, Daniels M, Aufmesser-Freyhardt B, Becker K, Oramary A, Bromba A, Stockhausen N, Wolter A, Fertsch S. Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps. J Plast Reconstr Aesthet Surg 2024; 92:11-25. [PMID: 38489983 DOI: 10.1016/j.bjps.2024.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/02/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.
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Affiliation(s)
- R J Musmann
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany.
| | - C Andree
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf
| | - B Munder
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Hagouan
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - D Janku
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Daniels
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - B Aufmesser-Freyhardt
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - K Becker
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Oramary
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Bromba
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - N Stockhausen
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Wolter
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - S Fertsch
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
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12
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Gravina P, Singh A, Conlon C, Spiegel A. Preoperative Imaging Mapping of DIEP Perforators and Intraoperative Selection: Does It Correlate? J Reconstr Microsurg 2024; 40:205-210. [PMID: 37315932 DOI: 10.1055/a-2110-0350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Preoperative imaging prior to deep inferior epigastric perforator (DIEP) flap harvest is a common practice to locate perforators and identify aberrant anatomy. METHODS We report a retrospective review of 320 consecutive patients who underwent preoperative computed tomographic angiography (CTA) or magnetic resonance angiography prior to DIEP flap breast reconstruction. The locations relative to the umbilicus of preoperatively identified perforators were compared with the selected intraoperative perforators. The diameter of all intraoperative perforators was also measured. RESULTS Across the 320 patient, 1,833 potentially suitable perforators were identified on preoperative imaging. A total of 564 of the 795 perforators selected intraoperatively for DIEP flap harvest were within 2 cm of a predicted perforator, for a rate of 70.1%. The size of the perforator was unrelated to the detection rate. CONCLUSION We were able to demonstrate a sensitivity of 70% of clinically selected DIEP perforators identified on preoperative imaging in this large series. This contrasts with the nearly 100% predictive value reported by others. Continued reporting of findings and methods of measuring are needed to improve the practical efficacy of CTA and raise awareness about the limitations of CTA, despite its well-documented usefulness.
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Affiliation(s)
- Paula Gravina
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Aspinder Singh
- Michael E. DeBakey Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Aldona Spiegel
- Center for Breast Restoration, Houston Methodist Institute for Reconstructive Surgery, Houston, Texas
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13
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Atkinson CJ, Seth I, Xie Y, Ross RJ, Hunter-Smith DJ, Rozen WM, Cuomo R. Artificial Intelligence Language Model Performance for Rapid Intraoperative Queries in Plastic Surgery: ChatGPT and the Deep Inferior Epigastric Perforator Flap. J Clin Med 2024; 13:900. [PMID: 38337594 PMCID: PMC10856538 DOI: 10.3390/jcm13030900] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/23/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024] Open
Abstract
Background: The integration of artificial intelligence in healthcare has led to the development of large language models that can address various medical queries, including intraoperatively. This study investigates the potential of ChatGPT in addressing intraoperative questions during the deep inferior epigastric perforator flap procedure. Methods: A series of six intraoperative questions specific to the DIEP flap procedure, derived from real-world clinical scenarios, were proposed to ChatGPT. A panel of four experienced board-certified plastic surgeons evaluated ChatGPT's performance in providing accurate, relevant, and comprehensible responses. Results: The Likert scale demonstrated to be medically accurate, systematic in presentation, and logical when providing alternative solutions. The mean readability score of the Flesch Reading Ease Score was 28.7 (±0.8), the Flesch-Kincaid Grade Level was 12.4 (±0.5), and the Coleman-Liau Index was 14.5 (±0.5). Suitability-wise, the DISCERN score of ChatGPT was 48 (±2.5) indicating suitable and comprehensible language for experts. Conclusions: Generative AI tools such as ChatGPT can serve as a supplementary tool for surgeons to offer valuable insights and foster intraoperative problem-solving abilities. However, it lacks consideration of individual patient factors and surgical nuances. Nevertheless, further refinement of its training data and rigorous scrutiny under experts to ensure the accuracy and up-to-date nature of the information holds the potential for it to be utilized in the surgical field.
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Affiliation(s)
- Connor J. Atkinson
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
| | - Ishith Seth
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
- Faculty of Medicine and Surgery, Monash University, Clayton, VIC 3800, Australia
- Faculty of Medicine and Surgery, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Yi Xie
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
| | - Richard J. Ross
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
| | - David J. Hunter-Smith
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
- Faculty of Medicine and Surgery, Monash University, Clayton, VIC 3800, Australia
| | - Warren M. Rozen
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
- Faculty of Medicine and Surgery, Monash University, Clayton, VIC 3800, Australia
| | - Roberto Cuomo
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy;
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14
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Cholok DJ, Fischer MJ, Leuze CW, Januszyk M, Daniel BL, Momeni A. Spatial Fidelity of Microvascular Perforating Vessels as Perceived by Augmented Reality Virtual Projections. Plast Reconstr Surg 2024; 153:524-534. [PMID: 37092985 DOI: 10.1097/prs.0000000000010592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Autologous breast reconstruction yields improved long-term aesthetic results but requires increased resources of practitioners and hospital systems. Innovations in radiographic imaging have been increasingly used to improve the efficiency and success of free flap harvest. Augmented reality affords the opportunity to superimpose relevant imaging on a surgeon's native field of view, potentially facilitating dissection of anatomically variable structures. To validate the spatial fidelity of augmented reality projections of deep inferior epigastric perforator flap-relevant anatomy, comparisons of three-dimensional (3D) models and their virtual renderings were performed by four independent observers. Measured discrepancies between the real and holographic models were evaluated. METHODS The 3D-printed models of deep inferior epigastric perforator flap-relevant anatomy were fabricated from computed tomographic angiography data from 19 de-identified patients. The corresponding computed tomographic angiography data were similarly formatted for the Microsoft HoloLens to generate corresponding projections. Anatomic points were initially measured on 3D models, after which the corresponding points were measured on the HoloLens projections from two separate vantage points (V1 and V2). Statistical analyses, including generalized linear modeling, were performed to characterize spatial fidelity regarding translation, rotation, and scale of holographic projections. RESULTS Among all participants, the median translational displacement at corresponding points was 9.0 mm between the real-3D model and V1, 12.1 mm between the 3D model and V2, and 13.5 mm between V1 and V2. CONCLUSION Corresponding points, including topography of perforating vessels, for the purposes of breast reconstruction can be identified within millimeters, but there remain multiple independent contributors of error, most notably the participant and location at which the projection is perceived.
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Affiliation(s)
| | - Marc J Fischer
- Department of Radiology, Stanford University School of Medicine
| | | | | | - Bruce L Daniel
- Department of Radiology, Stanford University School of Medicine
| | - Arash Momeni
- From the Division of Plastic and Reconstructive Surgery
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15
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Di Via Ioschpe A, Golijanin B, Benharush D, Berl A, Perhulov V, Egozi D. Preoperative planning using virtual reality and computed tomography angiogram in deep inferior epigastric perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 87:161-169. [PMID: 37862767 DOI: 10.1016/j.bjps.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 08/02/2023] [Accepted: 08/13/2023] [Indexed: 10/22/2023]
Abstract
The gold standard for preoperative planning of deep inferior epigastric perforator (DIEP) flap breast reconstruction uses computed tomography angiography (CTA). Virtual reality (VR) circumnavigates the limitations of CTA by reconstructing a fully immersive and interactive 3D representation of the scan. Scans of 44 patients who underwent DIEP flap breast reconstruction were retrospectively reviewed and compared using CTA and VR imaging modalities. The objective of this research was to compare perforators found using VR to the ones identified using conventional CTA. A correlation was found between the imaging modalities for unilateral (R = 0.96 (CI = 0.92, 0.98)) and bilateral (R = 0.93, (CI = 0.83, 0.97)) DIEP flap surgeries when comparing perforator location related to the umbilicus. Multivariable ordinal logistic regression found that higher intramuscular course length (IMC) is associated with the number of perforators found per side (OR = 1.79 (CI = 1.24, 2.6)), and medial location (OR = 2.85 (CI = 1.38, 5.87)). Larger vessel caliber (VC) is associated with shorter IMC (T2 vs. T3, OR = 3.34 (CI = 1.49, 7.49)), and branching in adipose tissue (AB) is associated with higher VC (T1 vs. T3, OR = 0.02 (CI = 0.007, 0.08); T2 vs. T3, OR = 0.24 (CI = 0.11, 0.55)). Overall, preoperative planning using VR was easy to use, safe, more intuitive, and provided in a time-efficient manner, more information about perforant characteristics. VR can improve the surgeon's decision accuracy, relating to the best perforators for harvesting, in a shorter time period.
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Affiliation(s)
| | | | - David Benharush
- Department of Plastic Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Ariel Berl
- Department of Plastic Surgery, Meir Medical Center, Kfar Saba, Israel
| | | | - Dana Egozi
- Department of Plastic Surgery, Kaplan Medical Center, Rehovot, Israel; The Faculty of Medicine, The Hebrew University, Jerusalem, Israel.
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16
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Santanelli di Pompeo F, Paolini G, D'Orsi G, Atzeni M, Catalano C, Cannavale G, Cilia F, Firmani G, Sorotos M. Free-style technique versus computed tomographic angiography-guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study. Microsurgery 2023; 43:790-799. [PMID: 36847143 DOI: 10.1002/micr.31031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/11/2023] [Accepted: 02/17/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Computed tomographic angiography (CTA) is the preferred diagnostic tool in preoperative deep inferior epigastric perforator (DIEP) flap assessment, though some surgeons prefer approaching perforator selection with intraoperative findings alone. METHODS This prospective observational study conducted between 2015 and 2020 assessed our intraoperative decision-making "free-style" technique for DIEP flap harvest. Any patient with indication for immediate or delayed breast reconstruction using abdominally based flaps and who received preoperative CTA was enrolled. Only unilateral cases performed by the same surgeon were considered. Allergy to iodine-based contrast media, renal impairment and claustrophobia were other exclusion criteria. Primary endpoint consisted in comparing operative times and complication rates between free-style technique and CTA-guided approach. Secondary endpoints included evaluation of agreement rate between intraoperative findings and CTA, and identification of variables affecting operative time and complication rate. Demographics, surgical information, agreement versus non-agreement and complications were collected. RESULTS Starting from 206 patients, 100 were enrolled. Fifty were assigned to Group A, receiving DIEP flap with free-style technique. The other 50 were assigned to Group B, receiving DIEP flap with CTA-guided perforators selection. Study groups' demographics were homogenous. Operative time was statistically lower (p = .036) in free-style group (252.4 ± 44.77 min vs. 265.6 ± 31.67 min). Complication rates were higher in CTA-guided group (10% vs. 2%) though this was not significant (p = .092). Overall agreement rate in dominant perforator selection between intraoperatively and CTA-based assessment was 81%. Multiple regression analysis showed no variable increased complication rate, though CTA-guided approach, BMI > 30 and harvesting more than one perforator were respectively associated with B-coefficient of 17.391 (2.430-32.351, 95% CI) [p = .023], 3.50 (0.640-6.379, 95% CI) [p = .017] and 18.887 (6.232-31.542, 95% CI) [p = .004], predicting increased operative time. CONCLUSIONS The free-style technique proved to be a useful tool for guiding DIEP flap harvest with good sensibility in detecting the dominant perforator suggested by CTA without statistically increasing surgery duration and complications.
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Affiliation(s)
- Fabio Santanelli di Pompeo
- Department of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Guido Paolini
- Department of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Gennaro D'Orsi
- Department of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Matteo Atzeni
- Department of Plastic Surgery and Microsurgery, Azienda Ospedaliera Universitaria Cagliari, Cagliari, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Cannavale
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Francesco Cilia
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Guido Firmani
- Department of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Michail Sorotos
- Department of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
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17
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Ammar HM, Kim J, Lee KT. Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases. Microsurgery 2023; 43:611-616. [PMID: 37280042 DOI: 10.1002/micr.31071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 06/08/2023]
Abstract
Choosing reliable recipient vessels is crucial for successful free flap reconstruction of lower extremity defects, especially in patients with ischemic vasculopathy. This report describes our experience with the intraoperative use of indocyanine green angiography (ICGA) for selecting recipient vessels in lower extremity free flap reconstruction cases. Three patients with lower extremity defects and ischemic vasculopathy underwent free flap reconstruction. Intraoperatively, the candidate vessels were evaluated using ICGA. In the first case, a 10 × 6 cm defect on the anterior side of the lower third of the leg caused by minor trauma and associated with peripheral arterial occlusive disease was reconstructed using a super-thin anterolateral thigh flap based on one perforator. In the second case, a 12 × 8 cm defect on the posterior side of the right lower leg caused by a dog bite and associated with severe atherosclerosis throughout all three major vessels in the lower leg was reconstructed using a muscle-sparing latissimus dorsi myocutaneous flap. In the third case, a 13.5 × 5.5 cm defect on the right lateral malleolar region, where the peroneus longus tendon was exposed due to Buerger's disease, was reconstructed using a one perforator-based super-thin anterolateral thigh flap. In all cases, ICGA was used to evaluate the functionality of the candidate recipient vessels. In two cases, the candidate vessels showed acceptable blood flow, and the operations proceeded as planned. In the third case, the planned vessels of posterior tibial vessels were not identified to have sufficient blood flow, and one of their branches showing enhancement in ICGA was selected and used as a recipient vessel. All flaps survived completely. No adverse events occurred during the follow-up period of postoperative 3 months. Our results suggest that ICGA may be a valuable diagnostic tool for evaluating the quality of candidate recipient vessels in cases where their functionality cannot be guaranteed with conventional imaging modalities.
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Affiliation(s)
- Hamad M Ammar
- Department of Plastic and Burn Surgery, Bahrain Defence Force Hospital, Royal Medical Services, Riffa, Bahrain
| | - Jina Kim
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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18
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Cevik J, Seth I, Hunter-Smith DJ, Rozen WM. A History of Innovation: Tracing the Evolution of Imaging Modalities for the Preoperative Planning of Microsurgical Breast Reconstruction. J Clin Med 2023; 12:5246. [PMID: 37629288 PMCID: PMC10455834 DOI: 10.3390/jcm12165246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Breast reconstruction is an essential component in the multidisciplinary management of breast cancer patients. Over the years, preoperative planning has played a pivotal role in assisting surgeons in planning operative decisions prior to the day of surgery. The evolution of preoperative planning can be traced back to the introduction of modalities such as ultrasound and colour duplex ultrasonography, enabling surgeons to evaluate the donor site's vasculature and thereby plan operations more accurately. However, the limitations of these techniques paved the way for the implementation of modern three-dimensional imaging technologies. With the advancements in 3D imaging, including computed tomography and magnetic resonance imaging, surgeons gained the ability to obtain detailed anatomical information. Moreover, numerous adjuncts have been developed to aid in the planning process. The integration of 3D-printing technologies has made significant contributions, enabling surgeons to create complex haptic models of the underlying anatomy. Direct infrared thermography provides a non-invasive, visual assessment of abdominal wall vascular physiology. Additionally, augmented reality technologies are poised to reshape surgical planning by providing an immersive and interactive environment for surgeons to visualize and manipulate 3D reconstructions. Still, the future of preoperative planning in breast reconstruction holds immense promise. Most recently, artificial intelligence algorithms, utilising machine learning and deep learning techniques, have the potential to automate and enhance preoperative planning processes. This review provides a comprehensive assessment of the history of innovation in preoperative planning for breast reconstruction, while also outlining key future directions, and the impact of artificial intelligence in this field.
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Affiliation(s)
- Jevan Cevik
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, VIC 3199, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, VIC 3199, Australia
| | - Ishith Seth
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, VIC 3199, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, VIC 3199, Australia
| | - David J. Hunter-Smith
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, VIC 3199, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, VIC 3199, Australia
| | - Warren M. Rozen
- Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, VIC 3199, Australia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, VIC 3199, Australia
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19
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Saritas S, Jul Kiil B, Sværdborg M. Knee-saving Amputation by Use of a Bipedicled Four-zone Deep Inferior Epigastric Artery Perforator Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5195. [PMID: 37583396 PMCID: PMC10424887 DOI: 10.1097/gox.0000000000005195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/29/2023] [Indexed: 08/17/2023]
Abstract
Degloving traumatic lower extremity injuries can lead to an above-knee amputation with decreased functional capacity compared with below-knee amputation. The unique properties of the deep inferior epigastric artery perforator flap providing a substantial amount of skin and subcutaneous tissue combined with reliability and low donor-site morbidity makes the flap ideal for coverage of below-knee amputation stumps when soft tissue is required. A bipedicled four-zone deep inferior epigastric artery perforator flap with a skin area of 13 × 33 cm was used as coverage of a degloved lower leg amputation stump, in a 27-year-old woman with a left-sided Gustillo type 3B comminute diaphyseal tibial fractur and major degloving injury. Hereby, above-knee amputation was avoided. Ten months postoperatively the patient had achieved full prosthetic function.
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Affiliation(s)
- Sinem Saritas
- From the Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Jul Kiil
- From the Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mille Sværdborg
- From the Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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20
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Karmakar S, Singla P. An Unreported Variation of Origin of Posterior Tibial Artery Encountered During Free Fibula Flap Harvest. Ann Plast Surg 2023; 91:101-103. [PMID: 37450867 DOI: 10.1097/sap.0000000000003577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
ABSTRACT Variations in the division of popliteal artery and origin of the 3 vascular systems are well documented. Here, we report a case in which the posterior tibial artery originated from the peroneal artery, in lower leg and then followed the normal course. The anomaly was detected intraoperatively precluding the harvest of free fibula flap. The procedure was abandoned and fibula was fixed using plates and screws and a free radial forearm flap was done over 2 mini-plates, which spanned the bone gap. A second bone flap procedure was to be planned in another sitting.The anomalous origin of posterior tibial artery from the peroneal artery in lower leg did not fall into any of the categories described previously by Kim et al (Ann Surg 1989;210:776-81.). In the event such atypical anatomy is encountered, it must be delineated, and the surgical plan adjusted accordingly. Flexibility in surgical approach can prevent vascular catastrophe.
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Affiliation(s)
- Shilpi Karmakar
- From the Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, India
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21
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Malekpour M, Malekpour F, Wang HTH. Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome. World J Clin Cases 2023; 11:2201-2212. [PMID: 37122510 PMCID: PMC10131028 DOI: 10.12998/wjcc.v11.i10.2201] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/13/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Implant-based reconstruction is the most common method of breast reconstruction. Autologous breast reconstruction is an indispensable option for breast reconstruction demanding keen microsurgical skills and robust anatomical understanding. The reconstructive choice is made by the patient after a discussion with the plastic surgeon covering all the available options. Advantages and disadvantages of each technique along with long-term oncologic outcome are reviewed.
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Affiliation(s)
- Mahdi Malekpour
- Department of Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
| | - Fatemeh Malekpour
- Department of Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
| | - Howard Tz-Ho Wang
- Department of Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
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22
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Aravind P, Colakoglu S, Bhoopalam M, Ibrahim A, Mathes D, Kaoutzanis C, Mureau M, Reddy S. Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2023; 39:138-147. [PMID: 35714621 DOI: 10.1055/s-0042-1750124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators "surgeon-specific." This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes. METHODS We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3. RESULTS Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I 2 = 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I 2 = 0%) were used. CONCLUSION Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.
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Affiliation(s)
- Pathik Aravind
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Myan Bhoopalam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed Ibrahim
- Private Practice at Clevens Face and Body Specialists, Melbourne, Florida
| | - David Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado - CU Anschutz Medical Campus, Aurora, Colorado
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, University of Colorado - CU Anschutz Medical Campus, Aurora, Colorado
| | - Marc Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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23
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Bajus A, Kubek T, Dražan L, Veselý J, Novák A, Berkeš A, Streit L. Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment. J Plast Reconstr Aesthet Surg 2023; 76:105-112. [PMID: 36512993 DOI: 10.1016/j.bjps.2022.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/20/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Perforator mapping using diagnostic methods facilitates deep inferior epigastric perforator (DIEP) flap planning. Computed tomographic angiography (CTA) is a well-proven tool for perforator mapping. However, the benefits of color Doppler ultrasonography (CDU) are as follows: 1) CDU involves dynamic real-time examination and 2) does not use radiation. Comparing the accuracies of both methods in a cohort of patients, this study aimed to evaluate the learning curve of surgeon-conducted CDU perforator mapping. METHODS Twenty patients undergoing DIEP flap breast reconstruction were enrolled in a cohort study. All patients underwent CTA perforator mapping preoperatively. XY coordinates of significant perforators were subtracted by a radiologist. A single surgeon (sonographer) with minimal experience with CDU performed CDU perforator mapping, including XY coordinates subtraction. The sonographer was blinded to the CTA data. The reference coordinates of dissected perforators were measured during surgery. Deviations from reference coordinates for both methods were compared, and CDU mapping learning curve was assessed using Joinpoint Regression. RESULTS We included 20 women (32 DIEP flaps and 59 dissected perforators). The mean deviation between mapped and reference coordinates was 1.00 (0.50-1.12) cm for CDU and 0.71 (0.50-1.12) cm for CTA. The learning curve of CDU mapping showed the breaking point after the seventh patient (≈ 21 localized perforators). After the breaking point, no significant differences between the deviations of both methods were found (p = 0.980). CONCLUSION A limited number of examinations were needed for the surgeon to learn CDU DIEA perforator mapping with accuracy similar to that of CTA mapping.
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Affiliation(s)
- Adam Bajus
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomáš Kubek
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Luboš Dražan
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Veselý
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Adam Novák
- Department of Radiology, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Andrej Berkeš
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Libor Streit
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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24
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Singh N, Aghayev A, Ahmad S, Azene EM, Ferencik M, Hedgire SS, Kirsch DS, Lee YJ, Nagpal P, Pass HA, Pillai AK, Ripley B, Tannenbaum A, Thomas R, Steigner ML. ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery): 2022 Update. J Am Coll Radiol 2022; 19:S357-S363. [PMID: 36436962 DOI: 10.1016/j.jacr.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Ayaz Aghayev
- Panel Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Ahmad
- University of Toronto, Toronto, Ontario, Canada; American College of Physicians
| | - Ezana M Azene
- Director of PERT, Chair Cancer Advisory Council, Medical Governor, Gundersen Health System, La Crosse, Wisconsin
| | - Maros Ferencik
- Section Head of Cardiovascular Imaging, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Sandeep S Hedgire
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Yoo Jin Lee
- University of California San Francisco, San Francisco, California
| | - Prashant Nagpal
- Head, Cardiovascular Imaging, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Helen A Pass
- Chief of Breast Surgery and Co-Director of the Breast Center, Stamford Hospital, Stamford, Connecticut; American College of Surgeons
| | - Anil K Pillai
- Section Chief, Interventional Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | | | - Richard Thomas
- Section Chief of Thoracic Imaging and Cardiac CT and Associate Magnetic Resonance Medical Director, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Michael L Steigner
- Director, Vascular CT/MR, Medical Director 3D Lab, Specialty Chair, Brigham & Women's Hospital, Boston, Massachusetts
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25
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Wu Y, Suo Y, Wang Z, Yu Y, Duan S, Liu H, Qi B, Jian C, Hu X, Zhang D, Yu A, Cheng Z. First clinical applications for the NIR-II imaging with ICG in microsurgery. Front Bioeng Biotechnol 2022; 10:1042546. [PMID: 36329697 PMCID: PMC9623121 DOI: 10.3389/fbioe.2022.1042546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/03/2022] [Indexed: 11/30/2022] Open
Abstract
In microsurgery, it is always difficult to accurately identify the blood supply with ease, such as vascular anastomosis, digit replantation, skin avulsion reconstruction and flap transplantation. Near-infrared window I (NIR-I, 700—900 nm) imaging has many clinical applications, whereas near-infrared window II (NIR-II, 1,000–1700 nm) imaging has emerged as a highly promising novel optical imaging modality and used in a few clinical fields recently, especially its penetration distance and noninvasive characteristics coincide with the needs of microsurgery. Therefore, a portable NIR-II imaging instrument and the Food and Drug Administration (FDA) approved indocyanine green (ICG) were used to improve the operation efficiency in microsurgery of 39 patients in this study. The anastomotic vessels and the salvaged distal limbs were clearly visualized after intravenous injection of ICG. The technique enabled identification of perforator vessels and estimation of perforator areas prior to the flap obtention and made it easier to monitor the prognosis. Overall, this study highlights the use of the portable NIR- II imaging with ICG as an operative evaluation tool can enhance the safety and accuracy of microsurgery.
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Affiliation(s)
- Yifan Wu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yongkuan Suo
- Joint Laboratory for Molecular Medicine, Institute of Molecular Medicine, Northeastern University, Shenyang, Liaoning, China
| | - Zheng Wang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yifeng Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shuang Duan
- Joint Laboratory for Molecular Medicine, Institute of Molecular Medicine, Northeastern University, Shenyang, Liaoning, China
| | - Hongguang Liu
- Joint Laboratory for Molecular Medicine, Institute of Molecular Medicine, Northeastern University, Shenyang, Liaoning, China
| | - Baiwen Qi
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao Jian
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiang Hu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Zhang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Aixi Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Aixi Yu, ; Zhen Cheng,
| | - Zhen Cheng
- State Key Laboratory of Drug Research, Molecular Imaging Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
- Shandong Laboratory of Yantai Drug Discovery, Bohai Rim Advanced Research Institute for Drug Discovery, Yantai, Shandong, China
- *Correspondence: Aixi Yu, ; Zhen Cheng,
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26
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McKinnon VE, Riaz S, Stubbs E, McRae MH, McRae MC. Identification of the anatomy of the deep temporal vein using computed tomography imaging: A retrospective cross-sectional review of patient imaging. Microsurgery 2022; 42:757-765. [PMID: 36082800 DOI: 10.1002/micr.30956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/19/2022] [Accepted: 08/26/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The deep temporal vein (DTV) can be used in free flap procedures when the superficial temporal vein is inadequate. Despite its potential utility, its branching patterns have only been examined in one small anatomic study. The purpose of this study was to examine computed tomography angiography (CTA) images to determine DTV location, variation, and suitability as a microvascular recipient, to provide surgeons with a guide for its use in head and neck defects. METHODS A retrospective chart review identified 152 patient CTA images (76 female; 76 male) in a single academic center imaging database, selected consecutively from January 2017 to April 2020. Patients under 19 years were excluded; ages ranged from 19 to 80 years (average 51.6 years). Reason for imaging, DTV caliber, laterality, distance to zygomatic arch (ZA [coronal and sagittal]), distance to lateral orbital rim (LOR), and branching pattern were recorded. RESULTS The predominant reason for imaging was to rule out cerebrovascular accident (96.2%). Average caliber was 3.46 ± 1.29 mm (95% confidence interval [CI] [3.32, 3.61]; range, 1.00-10.8). Bilateral DTVs were observed in 98.7% of patients. Average distance to landmarks were as follows: ZA (coronal), 13.8 ± 5.85 mm (95% CI [13.2, 14.5]; range, 2.7-33.8); ZA (sagittal), 15.1 ± 6.12 mm (95% CI [14.1, 16.1]; range, 2.8-47.2); LOR, 47.1 ± 9.09 mm (95% CI [46.0, 48.1]; range, 10.8-62.9). Seven branching patterns were identified, including a posterior vertical variant that bypasses the superficial temporal fat pad. CONCLUSIONS The DTV is a "lifeboat" option for head and neck reconstruction. Its average caliber is sufficient for use in microsurgery. Knowledge of both its typical and aberrant courses allow for efficient preoperative planning and surgical dissection. CTA is a useful adjunct when planning to use the DTV for free tissue transfer.
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Affiliation(s)
- Victoria E McKinnon
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shaista Riaz
- Department of Diagnostic Radiology, McGill University, Montreal, Quebec, Canada
| | - Euan Stubbs
- Department of Diagnostic Imaging, McMaster University, Hamilton, Ontario, Canada
| | - Mark H McRae
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Matthew C McRae
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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27
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Importance of Incidental Findings in Preoperative Computed Tomography Angiography for Abdominal-Based Free Flap Breast Reconstruction: A Multi-institutional Study. Plast Reconstr Surg 2022; 150:527-535. [PMID: 35748758 DOI: 10.1097/prs.0000000000009388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Besides its intended purpose of perforator mapping, CTA can also identify incidental findings that may require further evaluation. In this multi-institutional study, we evaluated the frequency of incidental findings and their significance and impact on treatment course. We also aimed to identify risk factors for detecting such findings. METHOD A retrospective review of patients who underwent perforator mapping with CTA was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information were reviewed, as well as CTA reports and follow up visits and treatment outcomes. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings. RESULTS From January 2015 to July 2020, a total of 656 patients were identified that met inclusion criteria. Overall, 342 incidental findings were found, out of which 76 required additional imaging or consultation. Ultimately, 10 (1.5%) patients had findings that altered reconstructive management, including 5 (0.8%) patients having severe disease that cancelled their reconstruction altogether. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings. CONCLUSION Incidental findings can be commonly identified on preoperative CTA for DIEP flap breast reconstruction. Suspicious findings should be investigated thoroughly as they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation.
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28
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Chen K, Beeraka NM, Sinelnikov MY, Zhang J, Song D, Gu Y, Li J, Reshetov IV, Startseva OI, Liu J, Fan R, Lu P. Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations. Front Surg 2022; 9:729181. [PMID: 35242802 PMCID: PMC8887567 DOI: 10.3389/fsurg.2022.729181] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/19/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Objective Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery. Evidence We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: “DIEP flap”, “Breast reconstruction”, “Patient management”, “Postoperative DIEP”, “Intraoperative anticoagulant therapy”, “Clinical recommendations”. A total of 106 research papers were retrieved pertaining to this systematic review. Conclusion A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.
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Affiliation(s)
- Kuo Chen
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Narasimha M. Beeraka
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Jin Zhang
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
| | - Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yuanting Gu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingruo Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - I. V. Reshetov
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
- L.L. Levshin Institute of Cluster Oncology, Moscow, Russia
- Academy of Postgraduate Education, The Federal State Budgetary Unit FSCC, Federal Medical Biological Agency, Moscow, Russia
| | - O. I. Startseva
- Ministry of Health of the Russian Federation, Sechenov University, Moscow, Russia
| | - Junqi Liu
- Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Ruitai Fan
| | - Pengwei Lu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Pengwei Lu
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29
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Perez-Iglesias CT, Laikhter E, Kang CO, Nassar AH, Maselli AM, Cauley R, Lee BT. Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps. J Reconstr Microsurg 2022; 38:221-227. [DOI: 10.1055/s-0041-1740955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Background The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative.
Methods An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps.
Results This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications.
Conclusion This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.
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Affiliation(s)
- Carolina Torres Perez-Iglesias
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Laikhter
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine O. Kang
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amer H. Nassar
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy M. Maselli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T. Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Mahajan A, Jain K, Jaiswal D, Shankhdhar V, Agarwal U, Mantri M, Popat P, Mathews S, Yadav P. Role of computed tomography angiography in deep inferior epigastric perforator flap breast reconstruction surgery: A retrospective observational study. CANCER RESEARCH, STATISTICS, AND TREATMENT 2022. [DOI: 10.4103/crst.crst_303_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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31
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Yang JH, Colakoglu S, Mureau MA, Siddikoglu D, Johnson AC, Cohen JB, Lee BT, Chong TW, Mathes DW, Kaoutzanis C. Midline Epigastric Scars Can Be Associated with Higher Umbilical Complications Following DIEP Flap Harvest. J Plast Reconstr Aesthet Surg 2022; 75:1826-1832. [DOI: 10.1016/j.bjps.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 12/12/2021] [Accepted: 01/09/2022] [Indexed: 11/15/2022]
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32
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Hauck T, Arkudas A, Horch RE, Ströbel A, May MS, Binder J, Krautz C, Ludolph I. The third dimension in perforator mapping-Comparison of Cinematic Rendering and maximum intensity projection in abdominal-based autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2021; 75:536-543. [PMID: 34756655 DOI: 10.1016/j.bjps.2021.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cinematic Rendering (CR) is a recently introduced post-processing three-dimensional (3D) visualization imaging tool. The aim of this study was to assess its clinical value in the preoperative planning of deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, and to compare it with maximum intensity projection (MIP) images. The study presents the first application of CR for perforator mapping prior to autologous breast reconstruction. METHODS Two senior surgeons independently analyzed CR and MIP images based on computed tomography angiography (CTA) datasets of 20 patients in terms of vascular pedicle characteristics, the possibility to harvest a DIEP or MS-TRAM flap, and the side of the flap harvest. We calculated inter- and intra-observer agreement in order to examine the accordance of both image techniques. RESULTS We observed a good inter- and intra-observer agreement concerning the type of flap and the side of the flap harvest. However, the agreement on the pedicle characteristics varies depending on the considered variable. Both investigators identified a significantly higher number of perforators with MIP compared with CR (observer 1, p<0.0001 and observer 2, p<0.0385). CONCLUSION The current study serves as an explorative study, showing first experiences with CR in abdominal-based autologous breast reconstruction. In addition to MIP images, CR might improve the surgeon's understanding of the individual's anatomy. Future studies are required to compare CR with other 3D visualization tools and its possible effects on operative parameters.
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Affiliation(s)
- Theresa Hauck
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany.
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Armin Ströbel
- Center for Clinical Studies, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU, Germany)
| | - Matthias S May
- Department of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Johannes Binder
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Christian Krautz
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
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Ultrahigh-Resolution Computed Tomography Improves Preoperative Computed Tomography Angiography for Deep Inferior Epigastric Artery Perforator Flap Reconstruction. J Comput Assist Tomogr 2021; 46:29-33. [PMID: 34581707 DOI: 10.1097/rct.0000000000001235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare computed tomography (CT) angiography (CTA) imaging of deep inferior epigastric artery perforator (DIEP) using the ultrahigh-resolution CT (UHRCT) and conventional multidetector CT (MDCT). METHODS This retrospective study enrolled 20 patients who underwent CTA of DIEP flap with UHRCT and MDCT. Computed tomography values were measured at 4 large vessels (thoracic aorta, abdominal aorta, common iliac artery, and external iliac artery) and 5 peripheral vessels (proximal and distal internal thoracic artery, proximal and distal deep inferior epigastric artery, and DIEP). RESULTS There were no significant differences in mean CT values of the major vessel between UHRCT and MDCT. Ultrahigh-resolution CT shows higher CT values of the peripheral vessels than MDCT (P < 0.05 for all). The median CT values of the DIEP in UHRCT were approximately 3 times higher than those in MDCT (P < 0.001). CONCLUSIONS Ultrahigh-resolution CT provides higher-quality CTA of DIEP compared with MDCT.
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Colakoglu S, Tebockhorst S, Freedman J, Douglass S, Siddikoglu D, Chong TW, Mathes DW. CT angiography prior to DIEP flap breast reconstruction: a randomized controlled trial. J Plast Reconstr Aesthet Surg 2021; 75:45-51. [PMID: 34332925 DOI: 10.1016/j.bjps.2021.05.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 04/13/2021] [Accepted: 05/27/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND CT angiogram (CTA) has become the preferred method for the planning of abdominal-based microsurgical breast reconstruction to gather information about location, number, caliber and trajectory of the abdominal perforators and to decrease overall flap dissection and operating room time. However, the high-level evidence to support its utility has been limited to nonrandomized retrospective and prospective studies. METHODS Patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction were prospectively randomized to preoperative CTA and no imaging groups. Patient demographics, operative times, selected row and number of perforators for flap harvest, agreement in perforator selection between radiologist and surgeon, and clinical outcomes data were collected. Two-way ANOVA, Fisher's exact and Student's t-tests were used for statistical analysis. RESULTS Overall, 37 patients with 63 flaps were included in this study. Seventeen patients had CT scan prior to surgery. Mean age was 50.5 ± 9.6 years. Flap dissection time was significantly shorter in the CT group (150.8 ± 17.8 vs 184.7 ± 25.1 min and p< 0.001). Although overall odds ratio (OR) time was also shorter in the CT group, this only reached a statistical significance in bilateral surgeries (575.9 ± 70.1 vs 641.9 ± 79.6 min and p = 0.038). Hemiabdomen side, selected DIEP row, and the number of dissected perforators did not affect the overall dissection time. Complication rates were similar between the two groups. CONCLUSION This prospective, randomized study demonstrates that preoperative CTA analysis of perforators decreases flap harvest and overall OR time with equivalent postoperative outcomes.
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Affiliation(s)
- Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | | | - Jonathan Freedman
- Division of Plastic and Reconstructive Surgery, University of Colorado, Aurora, CO, United States
| | - Sara Douglass
- Division of Plastic and Reconstructive Surgery, University of Colorado, Aurora, CO, United States
| | - Duygu Siddikoglu
- Department of Biostatistics, Canakkale OnSekiz Mart Faculty of Medicine, Canakkale, Turkey
| | - Tae W Chong
- Division of Plastic and Reconstructive Surgery, University of Colorado, Aurora, CO, United States
| | - David W Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado, Aurora, CO, United States.
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Incidence, Impact, and Management of Incidentalomas on Preoperative Computed Tomographic Angiograms for Breast Cancer Patients with and without Genetic Mutations. Plast Reconstr Surg 2021; 147:1259-1269. [PMID: 33974589 DOI: 10.1097/prs.0000000000007941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings. METHODS All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management. RESULTS Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas. CONCLUSIONS The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.
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Chung JH, Yeo HD, Jung SP, Park SH, Yoon ES. The effect of previous scar on breast reconstruction using abdominal flap: a retrospective analysis of 122 consecutive cases and a strategy to reduce complication rates. Gland Surg 2021; 10:1598-1608. [PMID: 34164304 DOI: 10.21037/gs-21-112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Free abdominal tissue transfer is considered the gold standard for autologous breast reconstruction. However, many plastic surgeons are concerned about the theoretical risk of flap-related or donor-site complications associated with previous abdominal surgery. Also, studies have reported conflicting results in the literature due to difference in surgical strategies used in each study. This study analyzes the effect of prior incision on the complications and risk factors in our institution. Methods In this retrospective cohort study, we analyzed a total of 122 patients who had undergone reconstructive surgery between March 2012 and February 2019. To assess the effect of prior incision, we divided all patients into a scar group (n=59) and a control group (n=63). Based on our operative approach, patient demographics and postoperative complications were analyzed. Results No significant differences were found between patients in the scar group and the control group in flap-related (13.3% vs. 16.4%, P=0.62) and donor-site complications (31.7% vs. 31.4%, P=0.67). In binary logistic regression modeling, only diabetes mellitus was significantly related with donor-site complications (P=0.030). Conclusions This result suggested that previous abdominal scars are no longer a reluctant factor for breast reconstruction using an abdominal flap, when an appropriate flap design was used and the surgical techniques were tailored to each scar. In patients with vertical midline or subcostal scar, it requires careful preoperative planning with CT angiography and attentive follow-up are needed.
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Affiliation(s)
- Jae-Ho Chung
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Hyun-Dong Yeo
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Seung Pil Jung
- Division of Breast and Endocrine Surgery, Korea University Hospital, Seoul, Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
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Abstract
LEARNING OBJECTIVES After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes. SUMMARY Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.
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Kiely J, Kumar M, Wade RG. The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2020; 74:945-956. [PMID: 33342741 DOI: 10.1016/j.bjps.2020.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 10/21/2020] [Accepted: 12/02/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Perforator mapping may be performed prior to deep inferior epigastric perforator (DIEP) flap breast reconstruction to guide perforator selection. However, the accuracy of different imaging modalities remains unknown. This review aimed to evaluate the accuracy of different modalities for locating perforators for unipedicled DIEP flap breast reconstruction. METHODS MEDLINE and EMBASE were searched from inception to 24th September 2019 for studies concerning adult women undergoing DIEP flap breast reconstruction with preoperative perforator mapping. The index test was pre-operative imaging and the reference standard was intraoperative identification. RESULTS 21 articles with 1146 women were included. Six methods were described; handheld doppler, colour doppler (duplex) ultrasonography, computed tomography angiography, magnetic resonance angiography (MRA), direct infrared thermography with and without doppler. Meta-analysis revealed 94% (95% CI 88-99%) of DIEPs identified as the 'dominant perforator' on imaging were chosen as dominant perforators intraoperatively. Colour doppler (Duplex) ultrasonography had the lowest agreement (mean 74% [95% CI 67-81%]) whilst MRA had the highest agreement (mean 97% [95% CI 86-100%]). There was no statistically significant difference in the performance of different tests. All studies were subject to bias as the operators had knowledge of the index test prior to conducting the reference standard. CONCLUSIONS Based upon limited evidence, cross sectional (CT/MR) imaging modalities for preoperative DIEP mapping appear to have similar accuracy and perform better than ultrasound.
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Affiliation(s)
- John Kiely
- Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Trust, Bradford, UK.
| | - Mayank Kumar
- Department of Trauma & Orthopaedics, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK; Leeds Institute for Medical Research, The University of Leeds, Leeds, UK
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Chung JH, Sohn SM, Jung SP, Park SH, Yoon ES. Effects of pre-existing abdominal scar on postoperative complications after autologous breast reconstruction using abdominal flaps: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2020; 74:277-289. [PMID: 33293246 DOI: 10.1016/j.bjps.2020.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND A previous abdominal scar is generally considered as a challenge for breast reconstruction using abdominal flaps. Since it may interfere with the perfusion of abdominal tissue and weaken the abdominal fascia, many plastic surgeons are concerned about the theoretical risk of postoperative complications. This study aims to assess the effects of previous scar on complications in abdominal flap-based breast reconstruction. METHODS This systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline using MEDLINE, Ovid, and Cochrane databases in March 2020. All studies comparing the complication rates between patients with previous abdominal scars and control group without a scar were included. However, articles such as case series fewer than 10 patients, letters and animal studies were excluded. RESULTS A total of 2109 patients underwent 2792 abdominal flap tissue transfers for breast reconstruction in the 11 studies reviewed. A previous scar increased the risk of overall flap complications (RR 1.12; 95% CI, 0.95-1.32; fixed-effect model, I2 = 13%) and donor-site complications (RR 1.35; 95% CI, 1.13-1.62; fixed-effect model, I2 = 42%, p > 0.05). In particular, the risk of donor-site wound problem was significantly higher than that in the control group (RR 1.83; 95% CI, 1.35-2.46; fixed-effect model, I2 = 19%, p > 0.05). CONCLUSIONS This study result showed that the previous scar increased the risk for all types of complications compared with the control group. In patients with a vertical midline scar, it requires careful preoperative planning with CT angiography and attentive follow-up. However, with careful preoperative planning and an appropriate strategy, it is possible to overcome the detrimental effect of previous scar. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Jae-Ho Chung
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Sung-Min Sohn
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Seung-Pil Jung
- Division of Breast and Endocrine Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Hospital, Seoul, Republic of Korea.
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Muñoz KDR, Powers JM, Zhang S, Kale SS. Prevalence and Utilization of Obturator Artery Anatomic Variant in Autologous Breast Reconstruction. J Reconstr Microsurg 2020; 37:256-262. [PMID: 33032357 DOI: 10.1055/s-0040-1717153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The objective of this study is to quantify the prevalence and describe the utilization of an anatomic vascular variant in which the obturator artery (OA) arises from the trunk of the deep inferior epigastric artery (DIEA) in stacked/dual-pedicled autologous breast reconstruction. When this variant is identified preoperatively on computed tomography angiography (CTA), it may be utilized in a "flow-through" fashion to direct antegrade internal mammary artery (IMA) flow into a second free flap to facilitate anastomotic arrangement and optimize perfusion. METHODS Preoperatively obtained abdomen/pelvis CTA imaging of 121 autologous breast reconstruction patients were retrospectively reviewed for the unilateral or bilateral presence of the OA branch arising from the DIEA (OA variant). The results were analyzed using descriptive statistics. RESULTS Our analysis revealed the presence of the OA variant in 60 of the 121 (49.6%) breast reconstruction candidates, either unilaterally or bilaterally. Out of these patients, the variant was present unilaterally in 33 (55%) and bilaterally in 27 (45%) patients. Of the unilateral variants, 12 (36.4%) patients demonstrated right-sided laterality, while 21 (63.6%) patients demonstrated left-sided laterality. Clinically, this anatomic variant has been utilized in several cases of autologous breast reconstruction with flap survival in all cases. CONCLUSION Utilization of this anatomic variant in stacked or dual-pedicled autologous breast reconstruction results in antegrade IMA perfusion of both primary and secondary flaps, as well as improved size match compared with other anastomotic options. Knowledge of the vascular anatomy and variations in the inferior epigastric system is crucial to both preventing complications and optimizing flap planning and outcome.
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Affiliation(s)
| | - Jeremy M Powers
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Virginia Commonwealth University Health, Richmond, Virginia
| | - Shuhao Zhang
- Department of Plastic Surgery, Mercy Medical Group, Sacramento, California
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Abstract
Since propeller flaps are elevated as island flaps and most often nourished by a single perforator nearby the defect, it is challenging to change the flap design intraoperatively when a reliable perforator cannot be found where expected to exist. Thus, accurate preoperative mapping of perforators is essential in the safe planning of propeller flaps. Various methods have been reported so far: (1) handheld acoustic Doppler sonography (ADS), (2) color duplex sonography (CDS), (3) perforator computed tomographic angiography (P-CTA), and (4) magnetic resonance angiography (MRA). To facilitate the preoperative perforator assessment, P-CTA is currently considered as the gold standard imaging tool in revealing the three-dimensional anatomical details of perforators precisely. Nevertheless, ADS remains the most widely used tool due to its low cost, faster learning, and ease of use despite an undesirable number of false-positive results. CDS can provide hemodynamic characteristics of the perforator and is a valid and safer alternative particularly in patients in whom ionizing radiation and/or contrast exposure should be limited. Although MRA is less accurate in detecting smaller perforators of caliber less than 1.0 mm and the intramuscular course of perforators at the present time, MRA is expected to improve in the future due to the recent developments in technology, making it as accurate as P-CTA. Moreover, it provides the advantage of being radiation-free with fewer contrast reactions.
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Affiliation(s)
- Shimpei Ono
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiroyuki Ohi
- Hand and Microsurgery Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Rei Ogawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
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Vles MD, Terng NCO, Zijlstra K, Mureau MAM, Corten EML. Virtual and augmented reality for preoperative planning in plastic surgical procedures: A systematic review. J Plast Reconstr Aesthet Surg 2020; 73:1951-1959. [PMID: 32622713 DOI: 10.1016/j.bjps.2020.05.081] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Virtual and augmented reality (VR and AR) are fast-developing technologies that allow the three-dimensional visualization of digital information. OBJECTIVE This systematic review aimed to compare the application of VR and AR to conventional methods in preoperative planning of plastic surgical procedures. METHOD A systematic literature search was conducted in Embase, Medline (Ovid), Web-of-Science, Cochrane, and Google Scholar databases on October 11, 2019. All literature comparing AR and/or VR with conventional methods for preoperative planning was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy of the procedure, operative time, complications, and costs of total intervention. RESULTS No articles on VR were found. Six articles were found on interventions performed with AR assistance. AR showed to be significantly better for the accuracy of osteotomies in mandibular angle osteotomies and intraoral mandible distraction compared to conventional methods. For synostotic plagiocephaly and orbital hypertelorism correction, the use of AR demonstrated a precise osteotomy. Intraoperative perforator identification in DIEP flap procedures was more accurate with AR compared to Doppler ultrasound. Harvesting time (p < 0.012) and operative time (p < 0.01) in DIEP-flap procedures and mandibular angle osteotomies, respectively, were significantly reduced if AR was used. No articles were found regarding the costs of using AR for preoperative planning. CONCLUSION AR technology has the potential to assist the plastic surgeon in operating more accurately, safely, and fast. Studies on VR technology for preoperative planning in plastic surgery are lacking. More comparative studies are necessary, including data on clinical outcomes and cost-effectiveness.
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Affiliation(s)
- M D Vles
- Erasmus Medical Center, Rotterdam, the Netherlands
| | - N C O Terng
- Leiden University Medical Center, Leiden, the Netherlands
| | - K Zijlstra
- Delft University of Technology, Delft, the Netherlands
| | - M A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Office NA-2214, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - E M L Corten
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Office NA-2214, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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Park JW, Lee H, Jeon BJ, Pyon JK, Mun GH. Assessment of the risk of bulge/hernia formation after abdomen-based microsurgical breast reconstruction with the aid of preoperative computed tomographic angiography-derived morphometric measurements. J Plast Reconstr Aesthet Surg 2020; 73:1665-1674. [PMID: 32522519 DOI: 10.1016/j.bjps.2020.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/28/2019] [Accepted: 05/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND No preoperative risk assessment tool is available to predict postoperative bulge formation after abdomen-based breast reconstruction. The authors evaluated the association between clinical variables and morphometric measurements on preoperative computed tomographic (CT) angiography and postoperative abdominal wall morbidity. METHODS The authors evaluated all cases of postoperative bulge/hernia and normal controls in patients who underwent preoperative CT angiography and abdomen-based microsurgical breast reconstruction between July 2009 and January 2018. CT-based abdominal wall profiles, including abdominal wall protrusion, abdominopelvic cavity cross-sectional area (CSA), and abdominopelvic cavity-to-total body CSA ratio, were obtained and analyzed. A novel risk stratification scoring system to stratify the risk of bulge/hernia was developed. RESULTS Among 463 patients who underwent abdomen-based breast reconstruction, 23 were diagnosed as having a bulge/hernia. Age (OR 2.912; 95% CI 1.157-7.333), lateral row perforator (OR 5.065; 95% CI 1.834-13.986), and abdominal wall protrusion (OR 3.687; 95% CI 1.494-9.100) were significant risk factors associated with postoperative bulge/hernia in the multivariate analysis. Using the risk stratification scoring system, the incidence rates of postoperative bulge/hernia were 1.7%, 4.8%, and 19.0% for low-, intermediate-, and high-risk patients, respectively (p<0.001). CONCLUSIONS Age, lateral row perforator, and abdominal wall protrusion were significantly associated with postoperative bulge/hernia formation after abdomen-based microsurgical breast reconstruction. The authors' risk score based on the three variables may help predict and minimize donor-site morbidity.
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Affiliation(s)
- Jin-Woo Park
- Department of Plastic Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Republic of Korea
| | - Hojune Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Jai-Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea.
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Smartphone thermal imaging for preoperative perforator mapping in DIEP flap breast reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01687-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Homsy C, McCarthy ME, Lim S, Lindsey JT, Sands TT, Lindsey JT. Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery. Ann Plast Surg 2020; 84:S424-S430. [DOI: 10.1097/sap.0000000000002203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hennessy O, Potter SM. Use of infrared thermography for the assessment of free flap perforators in autologous breast reconstruction: A systematic review. JPRAS Open 2019; 23:60-70. [PMID: 32158907 PMCID: PMC7061583 DOI: 10.1016/j.jpra.2019.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/27/2019] [Indexed: 11/11/2022] Open
Abstract
Perforator-based flaps have in recent years become the mainstay of autologous breast reconstruction practice. Imaging modalities ranging from Doppler ultrasound to CT angiography demonstrate varying utility in the preoperative identification and localisation of perforators. Despite these available radiological investigations, finding and quantitatively assessing perforators remain a time-consuming and tedious process that is often complicated by a number of factors including variable anatomy prior surgery and body habitus. Thermographic imaging shows promise as a novel modality for preoperative localisation of perforator vessels. This review summarises the currently available evidence for its application in perforator mapping for abdominal-based autologous breast reconstruction. We discuss the development of the technology over the years, its current use, its advantages and how it may impact on reconstructive breast surgery.
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Affiliation(s)
- Orla Hennessy
- Department of Plastic Surgery, Galway University Hospital, Galway, Ireland
| | - Shirley M Potter
- Department of Plastic Surgery, Galway University Hospital, Galway, Ireland
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Ultrasound and Plastic Surgery: Clinical Applications of the Newest Technology. Ann Plast Surg 2019; 80:S356-S361. [PMID: 29668508 DOI: 10.1097/sap.0000000000001422] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Color Doppler ultrasound (CDUS) has not been routinely used in plastic and reconstructive surgery. Barriers to use have included large, cumbersome equipment, low-definition images, cost, and availability. In addition, programs in plastic surgery have not included training with ultrasound (US); thus, many current-day practitioners are unfamiliar with and reluctant to use this technology. Nevertheless, recent studies have demonstrated the utility of US in surgical planning. With the miniaturization, clearer imaging, and decreased costs of the latest US technology, previous barriers to use have largely been eliminated. METHODS Fifty-six patients scheduled for either reconstructive or aesthetic surgery were evaluated preoperatively and/or intraoperatively by a single surgeon with the linear 12-4 probe of a Philips Lumify CDUS device (Philips, Reedsville, Penn). For patients undergoing flap reconstruction, potential donor sites were imaged in order to locate the largest perforator. For patients undergoing abdominal procedures, intraoperative visualization of the abdominal muscular layers was used for the delivery of anesthesia during transversus abdominis plane block. Lastly, the superficial fascial system (SFS) was subjectively evaluated in all preoperative patients. RESULTS For flap reconstruction, 11 patients were preoperatively examined with CDUS in order to locate the largest perforators prior to perforator flap reconstruction. Flaps studied included the deep inferior epigastric perforator, anterolateral thigh, tensor fascia lata, thoracodorsal artery perforator, superior gluteal artery perforator, and the gracilis musculocutaneous. Color Doppler ultrasound findings were confirmed intraoperatively for all cases (100%). In 2 (18.2%) of 11 cases, CDUS identified perforators not detected by computed tomography angiography. Twenty-five patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction had successful intraoperative visualization of the abdominal wall muscular layers, thus allowing administration of transversus abdominis plane blocks by the operating surgeon. Twenty patients undergoing body contouring surgery had preoperative visualization of the SFS. The SFS was found to be varied not only among different patients but also within individual patients. CONCLUSIONS The newest, miniaturized CDUS technology has a variety of applications that may improve patient outcomes and experience in plastic surgery. Our observations require further investigation to quantify the perceived benefits of this new technology.
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When to assess the DIEP flap perfusion by intraoperative indocyanine green angiography in breast reconstruction? Breast 2019; 47:102-108. [DOI: 10.1016/j.breast.2019.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 11/20/2022] Open
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Van M, Javed MU, Hiew L. Clinically significant incidental findings on computed tomographic angiography in patients evaluated for deep inferior epigastric free flap reconstructive breast surgery in South Wales. J Plast Reconstr Aesthet Surg 2019; 72:1576-1606. [PMID: 31130516 DOI: 10.1016/j.bjps.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/02/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Martin Van
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, West Glamorgan, United Kingdom.
| | - Muhammad Umair Javed
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, West Glamorgan, United Kingdom
| | - Leong Hiew
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, West Glamorgan, United Kingdom
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Chang EI, Chu CK, Chang EI. Advancements in imaging technology for microvascular free tissue transfer. J Surg Oncol 2018; 118:729-735. [DOI: 10.1002/jso.25194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - Carrie K. Chu
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
| | - Edward I. Chang
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
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