Imaging in Autologous Breast Reconstruction

Abstract

The evolution of imaging actively shapes clinical management in the field. Ultrasonography (US), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) stand out as the most extensively researched imaging modalities for ABR. Ongoing advancements include "real-time" angiography and three-dimensional (3D) surface imaging, and future prospects incorporate augmented or virtual reality (AR/VR) and artificial intelligence (AI). These technologies may further enhance perioperative efficiency, reduce donor-site morbidity, and improve surgical outcomes in ABR.

Keywords: X-ray computed; artificial intelligence; autologous; breast neoplasms; breast reconstruction; deep inferior epigastric flap perforator; imaging techniques; magnetic resonance angiography; microsurgery; surgical flaps; tomography; ultrasonography.

Figure 1

Computed tomography angiography (CTA) scan indicating a good candidate for a robotic-assisted deep inferior epigastric perforator (DIEP) flap due to the single dominant perforating vessel’s short intramuscular course (<3 cm long). The left deep inferior epigastric artery (DIEA) has a type 1 branching pattern. The perforator penetrates the fascia 6.0 cm below umbilicus reference point and 3.7 cm to the left (A). The subcutaneous segment courses anteriorly and branches throughout the subcutaneous fat. The subfascial segment is 1.1 cm long, coursing caudal (B). The intramuscular segment is 2.0 cm long, coursing caudal and lateral deep to muscle to join the main trunk, which courses 7.4 cm caudally.

Figure 2

Magnetic resonance angiography (MRA) perforator mapping of the abdomen. The image shows patient right (R) and left (L) perforator locations in relation to the umbilicus (UMB).

Figure 3

Magnetic resonance angiography (MRA) of the chest for preoperative planning. The blue arrows indicate internal mammary veins on each side of the artery bilaterally.

Figure 4

Magnetic resonance angiography (MRA) of the abdomen with perforator mapping. R5 is located 9.0 mm inferior to the umbilicus and 44.3 mm to the right of midline. The perforator can be seen coursing laterally though the subcutaneous tissues, primarily perfusing the skin and fat of Hartrampf zone III. The vessel diameter is 1.5 mm. The perforator drops straight down through the fascia to meet with the lateral intramuscular branch of the deep inferior epigastric artery (DIEA).

Figure 5

Magnetic resonance angiography (MRA) image with volumetric analysis of the abdominal donor site. Anatomical locations and views are labeled: anterior (A), posterior (P), right (R), left (L), head (H), and feet (F).

Figure 6

Indocyanine green (ICG) angiography to evaluate intraoperative perfusion of a deep inferior epigastric perforator (DIEP) flap. (A) Intravenously injected ICG dye appears as a bright gray/white color in tissues when evaluating with the SPY portable handheld imager (SPY-PHI) thereby demonstrating active perfusion to those tissues. Areas of the flap appearing dark black do not exhibit ICG and are therefore not perfused (or are under-perfused). (B) The unlit area (overlaid in blue) is poorly perfused and must be trimmed intraoperatively. The brightest tissue areas (overlaid in red) demonstrate the best perfusion.