A. Alonso-Burgos a, *, E. García-Tutor b, G. Bastarrika a, D. Cano a, A. Martínez-Cuesta a, L.J. Pina a

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1 Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-ct angiography: imaging findings and initial experience A. Alonso-Burgos a, *, E. García-Tutor b, G. Bastarrika a, D. Cano a, A. Martínez-Cuesta a, L.J. Pina a a Department of Radiology, Clínica Universitaria, Universidad de Navarra, Avda. Pío XII 36, Pamplona, Spain b Department of Plastic and Reconstructive Surgery, Clínica Universitaria, Universidad de Navarra, Pamplona, Spain Received 21 November 2005; accepted 28 December 2005 KEYWORDS Multislice-CT; Angiography; Perforator; Flap; Tridimensional Summary Background: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. Reconstruction with deep inferior epigastric perforator (DIEAP) flaps requires a precise location and preoperative evaluation of perforating vessels. The objective of this report is to demonstrate the usefulness of multislice-ct (MSCT) angiography for preoperative planning in patients undergoing DIEAP flap reconstruction. Methods: Six consecutive women were considered for breast reconstruction with DIEAP flaps after previous mastectomy for breast cancer. Preoperative MSCT angiography was performed to localise the arterial perforators. Axial images, multiplanar reconstructions (MPR) and 3D volume-rendered images were analysed. Findings were correlated with surgery. Initial experience and imaging findings will be described. Results: Accurate identification of the main perforators was achieved in all six patients with a very satisfactory concordance between MSCT angiography and surgical findings. No unreported vessels were found. Location, course, anatomical variations and relations of the superficial inferior epigastric artery were reported. The very small perforators, were equally evaluated and described. Conclusions: Preoperative evaluation of perforator arteries with MSCT angiography is feasible in patients undergoing breast reconstruction. This technique provides a noninvasive global approach of the vascular anatomy and the entire anterior * Corresponding author. Tel.: C ; fax: C address: alonso@unav.es (A. Alonso-Burgos). S /$ - see front matter q 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 586 A. Alonso-Burgos et al. abdominal wall. However, more patients need to be evaluated in order to clarify the potential aspects pointed in this report. q 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. It is estimated that more than women will be diagnosed with breast cancer in 2005 in the United States. One woman in eight either has or will develop breast cancer in her lifetime. 1 Therapeutic options for breast cancer include tumorectomy, mastectomy, chemotherapy and/or radiotheraphy according to the stage at the time of diagnosis. More than one-third of women with early-stage breast cancer were treated with mastectomy in 2001, 4 even if there is professional consensus that most women with early-stage breast cancer are good candidates for breast-conserving surgery (BCS). 2,3 Surgeons may recommend mastectomy for different reasons including clinical contraindication for BCS, such as multicentric or multifocal disease, and the poor cosmetics that would result from removal of a large tumour. Patients might prefer mastectomy to BCS because of concerns about recurrence of disease, recovery from surgery, or side effects of radiation treatment. 5 After mastectomy, reconstructive breast surgery is an optimal option for patients concerned about aesthetics. Among breast conserving surgical options, autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy because of the match in quality and texture, the easily hidden scar, and the additional abdominal aesthetic benefit for the patient. The pedicled transverse rectus abdominis myocutaneous (TRAM) flap became the gold standard for breast reconstruction in the 1980s. 6 Free TRAM flap improved the results (compared with other reconstructive options) due to a better vascularisation of the flap and less donor site morbidity. Nevertheless, part of the muscle was sacrificed resulting in a risk of abdominal bulging, hernias, abdominal wall weakness, and asymmetries. In an effort to decrease donor site morbidity, 7 the deep inferior epigastric artery perforator (DIEAP) flap has recently emerged as a refinement of the free TRAM flap. 7 The DIEAP flap not only provides the advantages of the free TRAM flap, but also decreases post-operative pain and recovery period, since the rectus abdominis muscle and fascia are protected. Abdominal asymmetries, hernias, and bulging are also minimised However, the use of DIEAP flap for breast reconstruction is technically more demanding, as dissection of single perforator vessels, due mainly to their irregular anatomical distribution, is usually a more time-consuming procedure. For this reason, individual precise preoperative location and evaluation of perforating vessels is highly desirable. Among last generation angiographic diagnostic techniques, multislice-ct (MSCT) has emerged as an outstanding noninvasive operator independent option. The objective of this report is to show the usefulness of MSCT angiography for preoperative planning for DIEAP flaps. Initial experience and imaging findings will be described. Patients and methods Between June and October 2005, six consecutive women aged 51, 41, 40, 54, 57 and 48 years old (patients A F, respectively) were considered for free microvascular flap breast reconstruction after previous mastectomy for breast cancer. Immediate breast reconstruction was performed in four patients (A D) and in one of them (patient B), bilateral breast reconstruction was required. In patients E and F, delayed breast reconstruction was performed after 8 years and 5 months, respectively. After written informed consent was obtained from all patients, a preoperative MSCT angiography was performed for surgical planning using a four-row multi-detector CT scanner (Somatom Volumen Zoom; Siemens, Erlangen, Germany). Scan parameters are summarised in Table 1. MSCT angiography was performed following a target injection of 150 ml of iodixanol contrast medium (270 mg of iodine per ml) (Visipaque w 270; Amersham Health, Little Chalfont, England) at a flow rate of 4 ml/s. No oral contrast medium was given. Axial images were processed and reformatted into MPR, maximum intensity projections (MIP) and 3D-volume rendered (VR) reconstructions, using a commercially available software (Inspace, Leonardo, Siemens). Location of arterial perforators, their origin, course, and anatomical variations were evaluated. Arterial perforators with the widest diameters (parameter evaluated in the MIP reconstruction) and with a predicted easy dissection were reported and marked in each patient (Fig. 1). According to Giunta et al., 11 an arterial perforator with a

3 Preoperative MSCT for DIEAP planning 587 Table 1 CT parameters Range 2 cm above umbilicus 12 cm below Bolus tracking Abdominal aorta. 2 cm above common iliac bifurcation Collimation 1 mm kvp 120 mas 200 Slice thickness 1.25 mm Delay between end of 5 a,15 b,30 c s bolus tracking and scanning (s) Trigger threshold H.U. d Rotation speed 0.5 s Table speed 5 mm/rotation Reconstruction Reconstructions 0.7 mm intervals Kernel B20f Contrast material Volume 150 ml Ratio 4 cm 3 /s a Patient A. b Patient B. c Patient C F. d Housefield units. perpendicular fascia penetration pattern and a minimum intramuscular course was consider as the most satisfactory to work and the easiest for microsurgical mobilisation. Arterial perforators with a subfascial or epifascial course usually require a more time consuming dissection and were considered as potential alternatives. The fascia penetration pattern, intramuscular course of the perforators, their origin from the deep inferior epigastric artery, and any other anatomical variations present on the studies were also analysed (Fig. 2). Subcutaneous course and relationship of the perforators and superficial epigastric arteries were evaluated in each patient (Figs. 3 and 4). Finally, fatty infiltration of the anterior abdominal wall muscles, as well as the presence of muscular diastasis or hernias were described (Figs. 2 and 4(b)). This pre-operative evaluation was carried out in conjunction both a radiologist (A.A-B) and a plastic surgeon (E.G-T). Considering the umbilicus as a central reference position, the exact location and course of the arterial perforators and the point at which they pierced the fascia was pinpointed on the skinsurface 3D-VR reconstruction with the aid of a grid (Fig. 5(a) (c)). Selected images were made available in JPEG format and taken to the operating Figure 1 Caudo-craneal view of the initial MIP (a) and VR reconstruction (b) showing a main perforator in the left anterior abdominal wall (arrow) with the widest calibre found in this patient. Note the perpendicular fascia penetration pattern as well a lineal intramuscular course. A mild fatty infiltration can be observed in the left rectus around the vessel. Cubes in the right lower corner indicate the angle of view.

4 588 room in a portable USB-memory stick and projected in a personal computer. At the time of surgery, the surgeon marked the location described in the patient s skin with the aid of a metric-rule (Fig. 5(d)). Results Accurate identification of the main perforators was achieved in all six patients (Fig. 6(a) (c)) with a very satisfactory concordance between CT images and findings at surgery. No CT-unreported vessels were found during the surgical procedure. Table 2 summaries the main preoperative parameters reported in each patient as well as the correlation with the intraoperative findings. Partial dissection of the arterial perforators marked in the MSCT angiography was performed in each patient in order to correlate them with the surgical findings. Even A. Alonso-Burgos et al. the small-diameter arterial perforators that were found during the surgical procedure had been demonstrated in the MSCT angiography. In patients A, B, D and E, a direct and bilateral anastomosis between the superficial inferior epigastric artery and the main perforator was seen (Fig. 3). In patient C, a double right deep inferior epigastric artery (medial and lateral deep inferior epigastric artery) was noticed. In this patient, the two arterial perforators with the widest diameter (originated from the intramuscular bifurcation of the medial artery) were observed and reported. Direct anastomosis between the lateral deep inferior epigastric artery and the lateral branch of the medial artery was also demostrated (Fig. 2(a) and (b)). In patient C, the narrow diameters of the arterial perforators and the uncommon intramuscular course of the lateral deep inferior epigastric artery bifurcated-branch (Fig. 2(b)) suggested a difficult dissection of vessels at the MSCT angiography. The Figure 2 Image of an anatomical variation with a medial and lateral right deep inferior epigastric artery (arrow and arrow-head in (a)). An intramuscular bifurcation in the medial right deep inferior epigastric artery can be seen (short arrows in (a)). The origin of the two arterial perforators with the widest calibre on the right side (arrows in (b)) was shown in each one of these vessels.

5 Preoperative MSCT for DIEAP planning 589 Figure 3 3D-VR of the main perforators vessels (arrow heads) correlated with the surgical findings in a case of a bilateral DIEAP flap breast reconstruction. The location and course of the superficial inferior epigastric artery (arrows) was also described and reported as well as the anatomical variation of a bilateral and direct anastomosis between the superficial inferior epigastric artery and the perforators. Figure 4 Image of 3D-VR reconstruction with intraoperative surgical correlation. Note the sub-fascial penetration pattern (arrows) of the right perforator and a mild rectus diastasis.

6 590 A. Alonso-Burgos et al. Figure 5 Location of perforators. The selected arterial perforators are seen in the 3D-VR (arrows in (a) and (b)). These vessels are exactly located and pinpointed in the skin-surface 3D-VR with the aid of a grid-coordinate system provided by the workstation (arrows in (c)). The same procedure was performed to locate the superficial epigastric artery of each side (arrowheads in (a) (c)). The umbilicus was selected in all the patients as origin and the surgeon marked the described vessels in the patient s skin, with the aid of a metric-rule, in the operating room (arrows and arrowheads in (c)). Cubes in the right lower corner indicate the angle of view. intraoperative dissection of the flap confirmed these findings and two arterial perforators were employed for the DIEAP flap: one from the right anterior abdominal wall (the medial intramuscular branch of the medial deep inferior epigastric artery) and another one from the left anterior abdominal wall, also reported at the MSCT angiography, with a satisfactory result. Discussion Indications for mastectomy in patients with breast cancer include large tumour size, tumour recurrence, unfavourable tumour location, multifocal tumoural disease, and patient anxiety. 12,13 Following mastectomy more women are requesting breast reconstruction to help restore their appearance and self-image. 14 For this purpose, the DIEAP flap, the superior gluteal artery perforator flap 17,18 and, more recently, the thoracodorsal artery perforator flap have been employed. 20 Compared with the classic myocutaneous flap, the decisive advantage of these flaps is the reduction in donor-site defects caused by muscle preservation, especially regarding to nerve supply. 19 Preoperative location of adequate vessels would make the surgical procedure much easier and would decrease patient morbidity 11 preventing unnecessary perforator dissections and proceeding in a faster and safer way. Therefore, it is desirable to conduct a careful examination of the origin, course and anatomical variations of perforator arteries before undertaking a perforator flap operation. Different noninvasive diagnostic techniques have been proposed for this purpose. Many authors have recommended preoperative Doppler and duplex ultrasound (US) for the surgical planning of perforator flaps However, Blondeel et al. 16 and Giunta et al. 11 have recently reported a very high proportion of false positives. According to Giunta et al., this high false positive rate may be because Doppler US not only detects suitable vessels for perforator flap reconstruction, but this

7 Preoperative MSCT for DIEAP planning 591 Figure 6 Representative 3D-VR image with surgical findings correlation. The widest arterial perforators on the right anterior (yellow arrow) and left anterior abdominal wall (blue arrow) were exactly located by the surgeon during the intervention ((b) and (c)). technique also allows to detect very small perforating vessels surgically not suitable because of their narrow diameters. 11 Blondeel et al. describe similar findings. 17 Other drawbacks of Doppler ultrasound are the amount of time that the study takes, operator-dependence, and the lack of routine intraoperative assessment for the surgeon. The high spatial and temporal resolution achieved with MSCT angiography allows a precise description of the origin, course and relations of small calibre vessels. Not many reports have been published on the use of CT for mapping the inferior epigastric artery 21 and as we show in this initial experience, MSCT angiography would provide an accurate noninvasive vascular supply map when preoperative evaluation of a potential breast reconstruction with DIEAP flap is considered. To our knowledge, this is the first report emphasising the value of MSCT scanning for this purpose. This technique has shown to be, in these first six patients, extremely useful to accurately locate the perforator arteries and providing a global approach not only of the vascular anatomy but also of the entire anterior abdominal wall. Conventional axial images from the MSCT angiography processed into MPR provide a clear multi-dimensional view of anterior abdominal wall vascular anatomy in an easy way. Limitations of this technique refer mainly to limitations inherent to any MSCT angiographic study (X-ray, iodinate contrast medium, and technical resources) and the time necessary to perform the 3D-reconstructions (in our case, 30 min/exam). The evaluation of images and cooperation between the radiologist and plastic surgeon is essential for preoperative DIEAP flap planning, not only to evaluate, select and mark the vessels but also to perform the 3D-reconstructions more usefully and faster for the surgeon. As described, initial evaluation of MIP reconstructions allowed us to identify the widest arterial vessels to perform a DIEAP flap. Three-dimensional VR-images, which show a virtual-reality surgical field, would allow to precisely plan the surgical flap

8 592 A. Alonso-Burgos et al. Table 2 CT-angiography and surgical correlation Patient NAPPS FPP IC AV CT-S MSCT-USF A 2 Perpendicular direct (both) B 2 Subfascial!2 cm perpendicular direct Direct and bialateral anastomosis between superficial epigastric artery and main DIEAP vessels Direct and bilateral anastomosis between superficial epigastric artery and main DIEAP vessels C 3 Perpendicular direct Double deep inferior epigastric artery. Main perforators arising from the medial artery D 2 Subfascial!2 cm (both) Direct and bilateral anastomosis between superficial epigastric artery and main DIEAP vessels E 2 Perpendicular!2 cm Direct and bilateral anastomosis between superficial epigastric artery and main DIEAP vessels Very good Very good Very good Very good Very good F 1 Subfascial!2 cm None Unexact Direct FPP of the described artery. Muscle fatty infiltration simulating fascia at CT NAPPS, number of arterial perforantors preoperatively selected; FPP, fascia penetration pattern described at the MSCT angiography; IC, Intramuscular Course described at the MSCT angiography; AV, anatomical variations described at the MSCT angiography; CT-S, concordance reported by the surgeon between parameters described at the MSCT angiography about the widest arterial perforators, and surgical findings; MSCT-USF, MSCT angiography-unreported surgical findings. No No No No No approach. Operator-dependence and false positive pitfalls documented in the Doppler US studies seem to be avoided with the use of MSCT angiography; however, a larger series will be required to highlight the impact, limitations and usefulness of this preoperative planning strategy. In conclusion, this initial experience with the use of MSCT angiography for preoperative DIEAP flap evaluation yielded promising results. This technique would allow not only to locate DIEAP vessels but also to globally assess presurgical planning in noninvasive way. However, more patients will need to be evaluated in order to clarify the potential aspects pointed in this report. Financial and products disclosure Each author discloses at the time of submission any commercial associations that might pose or create a conflict of interest with information presented in this manuscript. Such associations include consultancies, stock ownership, or other equity interests, patent-licensing arrangements, and payments for conducting or publicising a study described in the manuscript. References 1. In URL: 2. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer and Canadian Association of Radiation Oncologists: mastectomy or lumpectomy? The choice of operation for clinical stages I and II breast cancer. CMAJ 1998;158:S15 S Morrow M, Strom EA, Bassett LW, et al. : Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin 2002;52: National Cancer Institute: SEER public-use data Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 2005;23: Holmstrom H. The free abdominoplasty flap and its use in breast reconstruction. Scand J Plast Reconstr Surg 1979;13: Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42: Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994;32: Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg 1994;47: Blondeel PN, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEAP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997;50:

9 Preoperative MSCT for DIEAP planning Giunta RE, Geisweid A, Feller AM. The value of preoperative doppler sonography for planning free perforator flaps. Plast Reconstr Surg 2000;105: Nold RJ, Beamer RL, Helmer SD, et al. Factors influencing a woman s choice to undergo breast-conserving surgery versus modified radical mastectomy. Am J Surg 2000;180: Small W, Morrow M. Local management of primary breast cancer. Cancer Control 1997;4: Neyta MJ, Blondeelb PN, Morrisonc CM, et al. Comparing the cost of delayed and immediate autologous breast reconstruction in Belgium. Br J Plast Surg 2005;58: Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical perforator-based flaps. Ann Plast Surg 1992;29: Allen RJ, Tucker C. Superior gluteal artery perforator free flap for breast reconstruction. PlastReconstrSurg1995;95: Blondeel PN, Beyens G, Verhaege R, et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998;51: Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91: Feller AM, Galla TJ. The deep inferior epigastric artery perforator flap. Clin Plast Surg 1998;25: Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96: Saber AA, Meslemani AM, Davis R, et al. Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 2004; 239:182 5.

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