|Preoperative mapping for DIEP flaps|
|Thursday, 01 July 2010|
Rozen WM, Garcia-Tutor E, Alonso-Burgos A, et al. Planning and optimising DIEP flaps with virtual surgery: the Navarra experience.J Plast Reconstr Aesthet Surg; Feb 2010: 289-97.
In a nutshell
Rozen et al have reviewed the idea of preoperative imaging, mapping perforating vessels enabling virtual surgery to be performed preoperatively. Rozen et al utilise Doppler ultrasound, colour Doppler (duplex) ultrasound, computed tomography and magnetic resonance angiography. Their article is succinct and discussed the vascular anatomy of Deep Inferior Epigastric Perforator (DIEP) flaps; optimising supply and discusses the ideal vascular pedicle described in terms of (1) large calibre deep internal epigastric artery and vascular pedicle; (2) large calibre perforator; (3) central location within the flap; (4) short intramuscular course; (5) perforating veins communicating with the superficial venous network; (6) broad subcutaneous branching, particularly into the flap (7) longer subfascial course and; (8) avoids tendinous intersections. All these are important in the view of the authors to plan preoperatively in order to facilitate a flap that survives and has survivability. The article includes superb 3-D computer generated images of the location of the perforators and, as mentioned in the beginning of the article, can actually almost perform virtual surgery preoperatively.
Without question, preoperative mapping, imaging and planning is essential in flap surgery. It has always been difficult to pre-plan surgery and, up until fairly recently, the only realistic options were Doppler ultrasound and duplex ultrasound to visualise vessels on the surface and mark them externally. This technique shows even amongst different institutions, different surgeons and radiologists, the outcomes can be improved with the use of advanced imaging technologies performed preoperatively. Of course, the benefit is that unfavourable anatomy can be selected out prospectively and anything that can save operative time is beneficial, not just to the surgeons who spend many hours looking for perforators but also to the patient who spends less time on the operating table. The financial cost is complex and has not been evaluated but is in the order of $250 and up to $600. As the article says, these costs are only significant when discussed in the context of cost savings from the reduction in operating time and length of stay, and success of the flap.