Preoperative Imaging for Perforator Flaps: A Quality-Improving Measure?

We read with great interest the recent comprehensive review highlighting the current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction.[1] We would like to comment on some of the issues raised by the authors.

As the authors have referenced, the preoperative visualization of perforators might lead to reduced postoperative pain, lower abdominal morbidity, better muscle preservation, and shorter procedure times due to the ease of perforator dissection. Notably, to date no randomized controlled study of adequate power has demonstrated the superiority of multidetector computed tomography in contrast with Doppler ultrasound, for example. In evidence-based medicine, we seek to provide good evidence even in surgical trials to change practice. Although the current publication focuses mainly on multidetector computed tomography angiography for preoperative perforator imaging, we believe this has to be taken into account despite the documented accuracy for perforator imaging.

The authors limit the use of Doppler ultrasound because Doppler ultrasound may “not provide the three-dimensional information of CTA [computed tomographic angiography] or magnetic resonance angiography.” However, given the achievements and refinements of three- and even four-dimensional ultrasound (for example, in second-trimester pregnancy scans),[2] [3] we would like to highlight that such high-end ultrasound techniques might be applicable in preoperative perforator imaging in the very near future without the inherent risks of radiation as far as CTA is concerned.

Beside the enormous scientific efforts undertaken to date to delineate the effects of CTA and magnetic resonance angiography, the real-work application and transfer of the published results to daily practice are somewhat undetermined. We have questioned German plastic reconstructive surgeons who perform perforator flap surgery regarding their current practice of preoperative perforator imaging.[4] Preoperative perforator imaging was applied in 77% of all institutions in 2008. Duplex sonography was predominant with 70%, followed by color Doppler ultrasound (42%). CTA (7%) and magnetic resonance angiography (8%) were underutilized in this recent German survey. The amount of perforator flaps performed did not favor any preoperative perforator imaging device. However, among surgeons performing more than 30 perforator flaps per year, only 2% did not perform any perforator imging at all.

Last, we would like to focus on the potential quality-improving effect of any preoperative perforator visualization. Given the learning curve in perforator dissection, it appears to us that especially novice perforator surgeons might benefit from the preoperative information regarding the potential course of the perforators. Stress levels seem to be reduced when preoperative CTA is performed, at least in a retrospective assessment published by Rozen et al in 2008.[5] Therefore, a valid and accurate preoperative measure to determine the course of a given perforator might improve surgical quality considering both the surgeons' ability to harvest the perforator flap in reduced procedural times as well as improved clinical outcome of a given perforator flap.

REFERENCES

• 1 Mathes D W, Neligan P C. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction.  J Reconstr Microsurg. 2009;  December 19 [Epub ahead of print]
• 2 Tonni G, Centini G, Taddei F. Can 3D ultrasound and Doppler angiography of great arteries be included in second trimester ecocardiographic examination? A prospective study on low-risk pregnancy population.  Echocardiography. 2009;  26 815-822
• 3 Yagel S, Cohen S M, Messing B, Valsky D V. Three-dimensional and four-dimensional ultrasound applications in fetal medicine.  Curr Opin Obstet Gynecol. 2009;  21 167-174
• 4 Knobloch K, Gohritz A, Reuss E, Redeker J, Spies M, Vogt P M. Preoperative perforator imaging in reconstructive plastic surgery: current practice in Germany.  Plast Reconstr Surg. 2009;  124 183e-184e
• 5 Rozen W M, Anavekar N S, Ashton M W et al.. Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?.  Microsurgery. 2008;  28 516-523