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Vascular Mapping for Abdominal-Based Breast Reconstruction: A Comprehensive Review of Current and Upcoming Imaging Modalities
© 2023 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.
Abstract
Background. Preoperative vascular imaging is a very common element of surgical planning for abdominal-based breast reconstruction (ABBR). Surgeons must tailor which flap is best suited for each respective patient based on the patient’s health and vascular anatomy. The goal of this review is to give surgeons practical tools for choosing which imaging technology best suits their patient’s needs for successful breast reconstruction.
Methods. A review of literature was undertaken on Google scholar to assess preoperative imaging modalities used for ABBR. Search terms included breast reconstruction, deep inferior epigastric perforator (DIEP) flap, and abdominal imaging. Articles were included based on relevance and significance to ABBR. Advantages and disadvantages of each imaging modality were then classified according to clinically relevant utility.
Results. Overall, imaging technologies that produce 3-dimensional images were found to have greater resolution for identifying perforators and the pedicle network than 2-dimensional images.
Conclusions. This paper addresses the strengths and weaknesses of the currently used imaging modalities described and also discusses new technologies that may be helpful in the future for planning of ABBR.
Introduction
Preoperative imaging has become an important instrument for abdominal-based breast reconstruction (ABBR).1 Although much of the abdominal flaps’ vascular pedicle and perforator characteristics, variations, and courses are already established in the literature,2-4 specifics can vary significantly for each patient and thereby impact the success of the operation.5 Thus, having knowledge of vascular characteristics before surgery, rather than solely intraoperatively, is extremely helpful.
The purpose of this review paper is to outline the imaging tools that can best assist a surgeon during assessment of flaps for ABBR. Here, we will compare and contrast the common modalities and review the advantages and disadvantages of each imaging technology. Finally, we will introduce the newest technologies available in ABBR.
Common Preoperative Imaging Modalities
Current imaging modalities used for abdominal mapping for ABBR include handheld Doppler ultrasound (HDU), color Doppler ultrasound (CDU), computed tomography-angiography (CTA), and magnetic resonance imaging-angiography (MRA).
HDU
HDU was the first imaging modality used to identify perforators for preoperative flap mapping6 due to its user-friendly function and ability to identify perforators in real time. This handheld instrument allows surgeons to identify single perforating vessels bedside to the patient in a noninvasive modus operandi (Figure 1). To perform this feat, HDU utilizes high-frequency acoustic signaling to measure red blood cell flow, with the largest perforator correlating to the highest density of flow.7 This quality alone contributes to patient comfort (as the patient lies in a supine position during imaging) and a favorable safety profile (due to its lack of radiation).
Although HDU has a simple, straightforward use, its ability to precisely pinpoint perforator locations is vague. Studies found that HDU had difficulty separating the signal of a large caliber perforator from its main trunk, especially when the perforator was deeper than 2 cm.8,9 Authors found that there was a poor correlation between vessel diameter and volume of signal due to its acoustic signal, leading to a markedly high incidence—approximately 50%—of false-positives.8 As a result, if the vessel’s course does not travel nearly perpendicular to the skin, the perforator’s anatomical location can be falsely identified10 and make reliable, preoperative mapping questionable. Due to these known limitations, precise and clinically actionable abdominal mapping can take up to 2 hours with HDU.11
Despite its pitfalls, HDU has regained some popularity among surgeons because of its ease of use and lack of patient radiation exposure compared with the current gold standard imaging method for abdominal mapping, CTA. In one randomized prospective study, preoperative HDU mapping for ABBR showed no significant increase in operating time or postoperative complications when compared with CTA.12
CDU
The emergence of CDU within the field of ABBR provided surgeons with the capability to identify a perforator’s precise location, course, and caliber (Figure 2). Unlike its predecessor, CDU can distinguish perforator vessel branches from their main axial trunks by using similar acoustic signaling but with superior association with large caliber and blood flow and other favorable hemodynamic characteristics.8 Given its stronger frequency signals, CDU is better able to identify small-diameter vessels (ie, as small as 0.2 mm).7,13,14 If positioned correctly, the perforator’s full course can be mapped even if it penetrates muscle or fascia.7,13,16 Thus, branching networks of a main axial vessel can be better characterized, giving the surgeon a greater ability to distinguish the signal of a suitable perforator from other vessels more reliably.15
Although the branching networks are better identified using CDU, this technology cannot adequately display the anatomical relationship of these branching networks with one another. Despite the fact that CDU can identify the difference between arteries from veins and vessel offshoots from main trunks,17 there is still a large percentage of false-positives and false-negatives.18 To negate these drawbacks, a radiologist or trained technician with previous experience of identifying perforators may be helpful.7,8 CDU can also be a time-consuming imaging modality for full abdominal vascular mapping, requiring the patient to stay in the same position for approximately an hour.8
Despite these reported disadvantages, CDU preoperative imaging has been evaluated as a strategy to map abdominal flaps for breast reconstruction.18-21 One study compared the accuracy between preoperative and intraoperative findings for ABBR vascular mapping using CTA and CDU.22 Interestingly, the authors reported that CDU was superior to CTA in detecting more perforators that matched intraoperative findings (P < .0001 vs P = .91, respectively) in a retrospective cohort of 98 patients undergoing 125 deep inferior epigastric perforator (DIEP) flap reconstructions. Recently, a new CDU device, the Butterfly iQ, was piloted for preoperative DIEP flap mapping.23 The authors reported that the Butterfly iQ device provided a fast way to identify the pedicle course and aided in perforator selection; however, it failed to visualize smaller vessels.
CTA
Considered one of the leading preoperative imaging modalities for breast reconstruction, CTA was first described by Masia et al and is currently the gold-standard modality for vascular mapping for ABBR.12 CTA has largely replaced previous imaging modalities for breast reconstruction due to its ability to create a real time 3-dimensional (3D) model of a branching network, an advancement over the 2-dimensional (2D) models produced by HDU and CDU (Figure 3). One of the earliest studies reported that CTA was capable of accurately localizing 100% of perforators within the patient cohort (22 of 22) compared with HDU, which was unable to localize 1 (0 of 22).24
Unlike HDU and CDU, CTA’s 3D image is produced by injecting an intravenous (IV) contrast medium before imaging, allowing this technology to reconstruct trilateral images8 with diagnostic accuracy of 100% for perforators over 1 mm.25 CTA is capable of identifying a perforator’s course (ie, intramuscular, subfascial, or subcutaneous) and its respective branching network, making CTA an extremely powerful perforator mapping modality.25,26 Other reported advantages include decreased dissection time, ability to reveal the anatomical relationship of any perforating vessel and its branching network, and increased patient comfort when undergoing this imaging compared with that of previously used modalities. Unlike predecessor imaging methods, CTA images can be obtained while the patient is in the supine position, and patients are required to hold their breath only once to retrieve the scan.27 CTA has also been proven useful in postsurgical evaluation of changes to the vasculature.28
However, toxicity associated with CTA is a concern; to build multiplane images, patients are exposed to both iodinated contrast medium and ionizing radiation. The use of IV iodinated contrast agents has been reported to have caused nephrotoxicity, anaphylaxis, and allergic reactions.8,29,30 After injection of the IV contrast agents, ionizing radiation is then needed to analyze the patient’s vasculature; patients are exposed to a radiation dose that can range from 3.5 to 25 mSV, with an average dose of 8 mSV.31 While the radiation dose per abdominal CTA may appear minimal, use of radiation is precluded in many patient populations with genetic predisposition to cancer, such as patients with the BRCA1 and BRCA2 gene mutation.32 While only a small proportion (1 in 400 people in the US) carry the BRCA1 or BRCA2 gene mutation,33 preliminary research suggests those with genetic predispositions may be more susceptible to developing cancer.34 Considering that ABBR is often performed in breast cancer survivors, this limitation should be considered. Other noted at-risk populations are patients who are young, have other genetic predispositions (such as Li-Fraumeni syndrome), or have had previous abdominal CTA leading to a potential accumulation of radiation dose.8,11 Another disadvantage to CTA is that it cannot provide further details about a perforator’s hemodynamic characteristics, specifically the vessel’s flow characteristic.35
In ABBR, one experimental study found that preoperative CTA significantly reduced the time to identify the available perforators and decide which perforator(s) to use, as well as reduced the vascular dissection time and total operative time when compared with intraoperative assessment alone (P < .001).36 When CTA was used in conjunction with HDU in another study, the addition of CTA decreased surgical time and abdominal wall bulges in patients compared with HDU alone.37 Another retrospective study evaluating CTA for preoperative imaging of DIEP flaps found similar results.38 However, a 2018 study found that previous studies had poor supporting evidence and potential bias embedded within their conclusions: Wade et al performed a meta-analysis of 14 previously published articles that reported on preoperative imaging using CTA and MRA and their respective operation times and postoperative complications. Their study questioned whether there was credible evidence behind one imaging modality having reduced dissection times and postoperative complications compared with another and concluded that further investigation was needed.39
In most cases, CTA can identify a favorable flap for ABBR, even in the setting of prior abdominal surgery. In 2019, Ngaage et al found that DIEP can be identified in both scarred abdomens (93%) and “virgin” abdomens (96%), demonstrating no significant difference in 106 patients.40 However, that same year, Orfaniotis et al emphasized the need for intraoperative assessment in conjunction with CTA. The authors reported 3 DIEP flap breast reconstruction cases in which CTA was unable to identify 2 of 3 DIEP perforators preoperatively due to iatrogenic vascular anomalies. Therefore, while preoperative imaging using CTA can help identify potential perforators, it should not be the single guiding factor for designing a flap for ABBR.27
Preoperative imaging also makes a significant impact on minimizing postoperative complications by informing surgeons about atypical vascular networks and allowing for additional venous anastomoses. Currently, DIEP breast reconstruction has a 6.3% venous congestion rate.41 As Davis et al demonstrated in 2019, CTA is able to predict venous congestion based on identifying branching networks preoperatively.
With recent innovations in technology, CTA capabilities have been further enhanced in multiple ways. Newer technologies have utilized CTA for more advanced free flap harvesting, such as in robotic DIEP flap surgeries, a refined harvesting modality with potential for improved postoperative recovery.42 Another group developed a handheld device that projected different color dots on a patient’s abdomen to indicate the course and location of a desired perforator based on CTA images.43 After analyzing 69 DIEP flaps for breast reconstruction in 60 patients, the authors reported a significantly decreased operative time (by approximately 19 minutes) and increased ability to capture other viable perforators compared with intraoperative use of HDU (61% vs 41%, respectively). CTA has also successfully aided in predicting clinically applicable anastomoses for bipedicle unilateral DIEP-superficial inferior epigastric perforator flap breast reconstruction.44
Newer technologies have incorporated the use of tablet apps when analyzing preoperative imaging for ABBR.45 In combination with an ultrasound probe connected to a Galaxy S2 tablet (Samsung Electronics Co, Ltd), perforator mapping was generated based on arterial signals, perforator fascial penetration course, and diameter at the site of fascial penetration. All preoperative findings were recorded using the Lumify app (Philips Healthcare). When comparing these techniques with CTA preoperative imaging, the authors reported excellent correlation and indicated that they no longer perform preoperative CTA scans for DIEP flaps. 45 However, more research is needed to explore the advantages of this low-cost technology.
MRA
While CTA is still considered by many to be the gold standard for preoperative ABBR mapping,10,28 MRA is gaining traction as a preferred imaging modality at some institutions. In contrast to the previously described methods, MRA uses radiofrequency signals to measure hydrogen nuclei under a magnetic field to produce a 3D image of the vasculature (Figure 4).47 MRA usually uses IV contrast mediums, either with or without iodine, to produce an image of the branching networks; however, a contrast agent is not always needed.48 MRA can be performed with the patient in either the prone or the supine position.47
The main advantage of MRA is that it does not always require ionizing radiation for image analysis whereas CTA does.1 This quality alone may be favored by patients in at-risk populations with an increased sensitivity to radiation, such as those with breast cancer who carry BRCA1, BRCA2, PTEN, and TP53 gene mutations.49 In addition, the contrast resolution is usually greater than CTA imaging.1 MRA has been used to better understand the branching networks and how superficial and deep systems connect to each other. In 2016, Kurlandera et al analyzed 53 patients’ deep and superficial inferior epigastric vasculature system anastomosis points using MRA, reporting that 84% of the hemi-abdomens analyzed had 1 anastomosis between deep and superficial inferior epigastric networks.50 MRA has also been used to further characterize differences in vessel diameter among patients. Similarly to CTA, MRA has also been used to monitor postoperative complications, such as venous obstruction.51
Despite these advantages, MRA has several drawbacks that should be considered. The 3D image reconstruction produced by MRA cannot accurately portray the anatomic relationships of a perforator network if the perforator’s course goes through muscle or if the vessels are too small.1 Although MRA can discriminate between arteries and veins, this can be especially difficult when identifying the vasculature’s entry and exit points of the flap if the course is through muscle. Another disadvantage is that the procedure can be more expensive and time-consuming.47,49 Although patients have more flexibility in how they lie (prone or supine), claustrophobic patients can feel uncomfortable during imaging, especially since patient breathing must be minimized and more than 1 breath hold is needed to produce an accurate image.1,8,49
While iodine-based contrast agents come with the same risks as previously described in CTA, non–iodine-based contrast agents come with their own unique challenges. A popular non–iodine-based contrast agent, gadolinium, has been recently issued a warning by the US Food and Drug Administration for its likelihood to deposit, in the long-term, in deep gray matter in the brain.52 Finally, MRA is usually contraindicated with patients with metal-containing implants, including most tissue expanders.
Neil-Dwyer et al introduced preoperative imaging for ABBR using MRA, and the modality has since shown tremendous potential.53 Conducted in 2009, their study was one of the first to directly compare the imaging capabilities between CTA and MRA on DIEP branching systems, finding that CTA identified 100% of DIEPs (18 of 18) while MRA only accurately identified half (11 of 22).25 The authors attributed these results to MRA’s lower spatial resolution.
Since then, major progress has been made in fine-tuning MRA protocols. A later study conducted by a different group concluded CTA and MRA were equivalently accurate in identifying abdominal wall perforators for ABBR.54 In 2013, Cina et al found MRA to be a viable alternative to CTA and could serve as CTA’s equivalent. A more recent study comparing CTA with prone liver phase MRA demonstrated that the latter, when used in conjunction with MRI, produces an image with remarkable perforator accuracy, particularly when displaying pedicle length within local muscles.55 The authors highlight the importance of prone liver phase MRA’s accuracy when sculpting the donor site and choosing which flap spares the muscle the most.55 One study emphasized the importance of postoperative MRA to monitor fat necrosis and distinguish it from cancer recurrence.56 MRA has also been used to compare the differences between left and right DIEP vasculature networks, with one study of 55 patients concluding that optimal perforators measuring at least 2.7 mm were more commonly located on the left.49
Newer Preoperative Imaging Modalities
Newer ABBR vascular imaging modalities include indocyanine green angiography (ICGA), dynamic infrared thermography (DIRT), 3D printing, laser speckle contrast imaging (LSCI), multispectral imaging (MSRI), and holographic augmented reality (HAR).
ICGA
ICGA has been used in medicine since the mid-20th century57 and was only recently introduced as an imaging option within ABBR. Indocyanine green is a dye that is injected IV into the body as a fluorescent agent that binds to red blood cells and allows vascular networks to be visualized using infrared energy pulses (Figure 5).30,58 The dye itself has a short half-life, which minimizes systemic toxicity and allows for multiple injections into the patient if the situation calls for it.30 As a result, ICGA enables intraoperative measurement of blood flow, a major advantage. However, ICGA is unable to produce a 3D model of the vasculature branching networks, which is a limiting factor when compared with CTA and MRA.
ICGA can be used intraoperatively to monitor flap perfusion with reasonable accuracy in ABBR.30,59 One study assessed the intraoperative use of ICGA to monitor unilateral DIEP flap perfusion for breast construction using proprietary software and demonstrated efficacy when measuring flap perfusion.60 Another study analyzed when using ICGA for assessment of flap perfusion is most advantageous, either at the donor site before pedicle dissection or after anastomosis at the recipient site; the authors concluded that it was optimized for use on the donor site.61 However, its application across all phases of the reconstruction was not significant.
A noted use of ICGA in ABBR is monitoring high-risk areas prone to fat necrosis. One study, which assessed blood perfusion in unilateral DIEP flaps through intraoperative ICGA, saw decreased incidence of fat necrosis by 50% compared with that seen in cases in which ICGA was not used.62 A more recent retrospective study characterized the efficacy of ICGA for reducing fat necrosis and poor postoperative outcome in 506 DIEP flaps for breast reconstruction and found significantly decreased odds of developing fat necrosis when ICGA was used.63 In addition to reducing intraoperative complications, ICGA has also recently been shown to improve postoperative ischemic complications in breast reconstruction with immediate expanders, despite nipple-sparing mastectomy and higher initial expander fill volumes.64 Considering fat necrosis is a common postoperative complication after using a DIEP flap for breast reconstruction,60 ICGA may be a viable intraoperative imaging modality suitable for ensuring proper flap perfusion.
DIRT
DIRT is a noninvasive, real-time, thermal imaging modality that has recently been investigated as an alternative to CTA for ABBR vascular mapping.65 Unlike other imaging technologies, such as CTA, MRA, and ICGA, DIRT imaging does not involve the IV injection of any contrast medium. Instead, DIRT uses temperature changes on the abdomen to measure perforating vessels with high blood flow versus tissue with little blood perfusion (Figure 6).65,66 In 2016, Weum et al compared the efficacy of DIRT versus CTA for preoperatively identifying perforator “hot spots” in 25 patients.68 This study found that DIEP flap vascular imaging using DIRT correlated with CTA images and intraoperative findings in every case.
Another 2020 study aimed to quantitatively standardize DIRT protocols to enhance its use in ABBR for pre-, intra-, and postoperative assessment of flap perfusion.35 Thiessen et al demonstrated the ability of DIRT to match pre- and intraoperative findings in all 21 patients except for 1, concluding that this technology can be clinically practical for perforator selection and monitoring blood flow without the use of ionizing radiation.
One group incorporated the use of smartphones to detect thermal hotspots on patient abdomens.67 DIEP flap perforators in patients detected using DIRT were compared with findings from HDU and CTA imaging in 13 patients and reported a significant correlation of perforator detection between HDU and DIRT (P = .003) and between CTA and DIRT (P = .012), citing this imaging modality as a potential preoperative imaging approach.67 Major limitations of using DIRT for ABBR vascular mapping, however, include this technology’s capability of producing only a 2D view of the vasculature network and detecting only superficial perforators (without giving information about the deeper pedicle). This technology is safe and capable of being quickly performed by the surgeon and can be used as an adjunct imaging modality to CTA or MRA (particularly in the operating room).
DIRT has been found to have a similar sensitivity and specificity to CTA in detecting perforators.68,69 However, in contrast to CTA, DIRT can only capture perforators greater than 1 mm in diameter and does not provide the high spatial resolution offered by CTA (location precision of <1 cm).70 Additionally, DIRT is only useful in identifying cutaneous perforators, whereas CTA is able to identify deeper perforators as well.
3D printing
A newer technology, 3D printing incorporates preoperative imaging scans with modeling software to reconstruct perforator vasculature. The modeling software, such as Osirix and 3D slicer (Version 4.3, Surgical Planning Laboratory) analyzes MRA or CTA imaging scans and prints patient vasculature models that can aid in appreciation of the perforator networks.71 One study found no significant difference between predicted and intraoperative findings of DIEP flap volume and weight after 3D reconstruction of the breast.72 To take 3D imaging to the next level, Chae et al published a case report in 2018 in which a 3D-printed “perforasome template” was used for preoperative planning of a DIEP flap (Figure 7).73 A more recent prospective case series found that 3D-printed templates of patients’ abdominal anatomy derived from CTA imaging significantly reduced time for intraoperative perforator identification, and surgeons found the models to be helpful in preoperative marking and planning.74
LSCI
Another emerging technology is LSCI, which uses a laser to create a speckle pattern on the surface to provide information about speed and concentration of erythrocytes in the capillaries (Figure 8). Although ICGA can provide accurate objective measures of perfusion, it is limited in that it requires injection of dye, takes a relatively long time, and may not identify venous congestion; LSCI is advantageous in that it is fast, noninvasive, and does not require any IV injection. In addition, it provides high spatial and temporal resolution compared with other noninvasive methods. However, LSCI has a penetration depth of only 0.5 mm, which means it cannot be used for the identification of perforators, although it can be used to analyze more superficial microcirculation. A recent prospective study of 23 patients who underwent DIEP flap breast reconstruction demonstrated that LSCI is efficacious in measuring flap perfusion and preventing postoperative ischemic complications.75
MSRI
There is an early body of evidence regarding the use of MSRI in ABBR vascular mapping. MSRI emits near infrared waves and quantifies the number of waves reflected. This technology is particularly advantageous as oxygenated and deoxygenated hemoglobin differentially absorb these infrared waves, which enables the surgeon to map tissue oxygen content in various anatomic regions (Figure 9). In addition, MSRI is able to provide the surgeon with sequential real-time information on perforator supply.76
HAR
Finally, a 2021 report by Wesselius et al described a successful system to utilize HAR in ABBR. This technology is particularly useful for the surgeon in visualizing the trajectory of the inferior epigastric arteries intraoperatively in real-time. In addition, HAR remains synced to the patient’s anatomy even when the patient or surgeon changes position, which provides for high-utility anatomic representation (Figure 10). The modality is limited in that depth perception with the holograph is somewhat difficult, but the technology is nonetheless a promising use of virtual reality in medicine.77
Conclusion
All forms of ABBR are technically challenging and require multistep procedures. The success of flap harvesting is dependent on correctly identifying and locating an optimal perforator while dissecting the vessels in a way that least damages the vasculature. To do this relies on knowledge of vessel branching patterns and, if possible, hemodynamic characteristics. Considering the broad variations of patient vasculature, having a one-size-fits-all template is no longer adequate for identifying a suitable perforator and other approaches are needed to better classify a patient’s vasculature on an individual basis.
Preoperative imaging allows surgeons a personalized method to illustrate a patient’s abdominal vasculature before performing ABBR. Each of the discussed modalities have unique advantages and disadvantages and are variably appropriate in different clinical scenarios (Table 1). There is a general consensus, however, that imaging technologies that produce 3D images have greater resolution for identifying perforators and the pedicle network than 2D images. While HDU and CDU can provide some amount of information about whether individual perforators are candidates for perforator flap ABBR, these 2D technologies fail to produce the whole vasculature picture. Instead, 2D imaging technologies are most useful for quick observations intraoperatively at known perforator locations already determined by 3D imaging technologies. Additional factors to consider include the ability of the imaging modality to measure hemodynamic and flow characteristics of the perforator.
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