A preoperative marking template for deep inferior epigastric artery perforator flap perforators in breast reconstruction

Abstract

Preoperative perforator marking for deep inferior epigastric artery perforator flaps is vital to the success of the procedure in breast reconstruction. Advances in imaging have facilitated accurate identification and preselection of potentially useful perforators. However, the reported imaging accuracy may be lost when preoperatively marking the patient, due to 'mapping errors', as this relies on the use of 2 reported vectors from a landmark such as the umbilicus. Observation errors have been encountered where inaccurate perforator vector measurements have been reported in relation to the umbilicus. Transcription errors have been noted where confusing and wordy reports have been typed or where incorrect units have been given (millimetres vs. centimetres). Interpretation errors have also occurred when using the report for preoperative marking. Furthermore, the marking process may be unnecessarily time-consuming. We describe a bespoke template, created using an individual computed tomography angiography image, that increases the efficiency and accuracy of preoperative marking. The template is created to scale, is individually tailored to the patient, and is particularly useful in cases where multiple potential suitable perforators exist.

Keywords: Breast neoplasms; Free tissue flaps; Mastectomy; Perforator flaps; Tomography, X-ray computed.

Fig. 1

Coronal computed tomography angiography, generated by radiology, with marked midline and umbilical axes (green lines) and perforators (blue arrows) (scale=5 cm, 1 cm² grid) There were 2 perforators on the left and 2 on the right hemi-abdomen, all perforating the rectus sheath: a 1.0-mm calibre subcutaneous segment perforator 31 mm lateral and 18 mm inferior to the umbilicus on the right side (blue arrow), a 0.7-mm subcutaneous segment perforator 53 mm lateral and 19 mm inferior to the centre of the umbilicus on the right side (not marked), a 1.0-mm subcutaneous segment perforator 38 mm lateral and 45 mm inferior to the centre of the umbilicus on the left (blue arrow) and a 1.1-mm subcutaneous segment perforator 53 mm lateral and 26 mm inferior to the centre of the umbilicus (blue arrow).

Fig. 2

Acetate print reproduction of generated computed tomography angiography image (to scale) The 3 largest perforators, which were marked radiologically (arrows), have been cut out of the acetate by using a 3.0-mm biopsy punch (Stiefel Laboratories Inc., North Carolina, USA).

Fig. 3

Preoperative marking process The 'punched' acetate is laid onto the abdomen, also marked pre-operatively from sternal notch to pubic symphysis, carefully centred at the umbilicus and lined up with the patient's midline. The perforator sites are marked directly onto the abdomen through the punched holes.

Fig. 4

Completed preoperative marking After acetate removal, the most suitable perforator is quickly selected using a hand-held Doppler in preparation for surgery.