Skip to main content

Advertisement

SpringerLink
Log in

Current state of the art in perforator flap imaging with computed tomographic angiography

  • Medical Imaging
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Computed tomographic angiography (CTA) has become increasingly adopted for preoperative imaging in perforator flap surgery, as it has been shown to improve operative outcomes and decrease operating times prior to deep inferior epigastric artery perforator (DIEP) flap and anterolateral thigh perforator flap surgery. Current technologies are readily available for the preoperative imaging of all perforator flaps, however only sporadic reports of the use of CTA for the imaging of other perforators have been described. We describe our experience with 325 CTAs performed for the preoperative imaging of perforators prior to 370 perforator flaps throughout several body regions. The scanning techniques, software reconstructions and technical issues are explored. In all cases, CTA was scored by the radiologist as at least “sufficient”, and described as “optimal” in the majority of cases. Similarly, the surgeon described the correlation of imaging to operative findings as at least “good”, and described the correlation as “optimal” in the majority of cases. As such, a standardized protocol for the use of CTA prior to perforator flap surgery is provided, which has been shown to be successful prior to a range of perforator flap operations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Allen RJ, Levine JL, Granzow JW (2006) The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 118:333–339

    Article  PubMed  CAS  Google Scholar 

  2. Allen RJ, Treece P (1994) Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32:32–38

    Article  PubMed  CAS  Google Scholar 

  3. Allen RJ, Tucker CJ (1995) Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 95:1207–1212

    Article  PubMed  CAS  Google Scholar 

  4. Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Cano D, Martinez-Cuesta A, Pina LJ (2006) Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multi-slice-CT angiography: imaging findings and initial experience. J Plast Reconstr Aesthet Surg 59:585–593

    Article  PubMed  CAS  Google Scholar 

  5. Angrigiani C, Grilli D, Siebert J (1995) Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 96:1608–1614

    PubMed  CAS  Google Scholar 

  6. Blondeel PN, Beyens G, Vergaeghe R, Van Landuyt K, Tonnard P, Monstrey SJ, Matton G (1998) Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 51:202–209

    Article  PubMed  CAS  Google Scholar 

  7. Blondeel PN, Van Landuyt KH, Monstrey SJ, Hamdi M, Matton GE, Allen RJ, Dupin C, Feller AM, Koshima I, Kostakoglu N, Wei FC (2003) The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 112:1378–1383

    Article  PubMed  Google Scholar 

  8. Boyd JB, Taylor GI, Corlett RJ (1984) The vascular territories of the superior epigastric and deep inferior epigastric systems. Plast Reconstr Surg 73:1–16

    Article  PubMed  CAS  Google Scholar 

  9. Chang H, Heo C, Jeong J, Baek R, Minn K, Yoon C (2007) Unilateral buttock reconstruction using contralateral inferior gluteal artery perforator flap with the aid of multi-detector CT. J Plast Reconstr Aesthet Surg [Epub ahead of print]

  10. Elbaz JS, Dardour JC, Ricbourg B (1975) Arterial blood supply of the abdominal wall. Ann Chir Plast 20:19–29

    PubMed  CAS  Google Scholar 

  11. Fukaya E, Grossman RF, Saloner D, Leon P, Nozaki M, Mathes SJ (2007) Magnetic resonance angiography for free fibula flap transfer. J Reconstr Microsurg 23:205–211

    Article  PubMed  Google Scholar 

  12. Giunta RE, Geisweid A, Feller AM (2000) The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 105:2381–2386

    Article  PubMed  CAS  Google Scholar 

  13. Hallock GG (1994) Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg 94:644–651

    PubMed  CAS  Google Scholar 

  14. Hallock GG (2003) Doppler sonography and colour duplex imaging for planning a perforator flap. Clin Plast Surg 30:347–357

    Article  PubMed  Google Scholar 

  15. Hamdi M, Salgarello M, Barone-Adesi L, Van Landuyt K (2008) Use of the thoracodorsal artery perforator (TDAP) flap with implant in breast reconstruction. Ann Plast Surg 61:143–146

    Article  PubMed  CAS  Google Scholar 

  16. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S (2008) Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg [Epub ahead of print]

  17. Heitmann C, Felmerer G, Durmus C, Matejic B, Ingianni G (2000) Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg 53:205–208

    Article  PubMed  CAS  Google Scholar 

  18. Hung LK, Lao J, Ho PC (1996) Free posterior tibial perforator flap: anatomy and a report of six cases. Microsurgery 17:503–511

    Article  PubMed  CAS  Google Scholar 

  19. Kato H, Hasegawa M, Takada T, Torii S (1999) The lumbar artery perforator based island flap: anatomical study and case reports. Br J Plast Surg 52:541–546

    Article  PubMed  CAS  Google Scholar 

  20. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A (1993) The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 91:678–683

    PubMed  CAS  Google Scholar 

  21. Koshima I, Soeda S (1989) Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 42:645–648

    Article  PubMed  CAS  Google Scholar 

  22. Masia J, Clavero JA, Larranaga JR, Alomar X, Pons G, Serret P (2006) Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 59:594–599

    Article  PubMed  CAS  Google Scholar 

  23. Masia J, Larranaga JR, Clavero JA, Vives L, Pons G, Pons JM (2008) The Value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap. Ann Plast Surg 60:29–36

    Article  PubMed  CAS  Google Scholar 

  24. Milloy FJ, Anson BJ, McAfee DK (1960) The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 110:293–302

    PubMed  CAS  Google Scholar 

  25. Onishi K, Maruyama Y (1986) Cutaneous and fascial vasculature around the rectus abdominis muscle: anatomic basis of abdominal fasciocutaneous flaps. J Reconstr Microsurg 2:247–253

    Article  PubMed  CAS  Google Scholar 

  26. Phillips TJ, Stella DL, Rozen WM, Ashton MW, Taylor GI (2008) Abdominal wall CT angiography: a detailed account of a newly established preoperative imaging technique. Radiology 249:32–44

    Article  PubMed  Google Scholar 

  27. Ribuffo D, Atzeni M, Corrias F, Guerra M, Saba L, Sias A, Balestrieri A, Mallarini G (2007) Preoperative angio-CT preliminary study of the TRAM flap after selective vascular delay. Ann Plast Surg 59:611–616

    Article  PubMed  CAS  Google Scholar 

  28. Ribuffo D, Atzeni M, Saba L, Milia A, Guerra M, Mallarini G (2008) Angio CT preoperative evaluation for anterolateral thigh flap harvesting. Ann Plast Surg (in press)

  29. Rozen WM, Anavekar NS, Ashton MW, Stella DL, Grinsell D, Bloom R, Taylor GI (2008) Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction? Microsurgery 28:516–523

    Article  PubMed  Google Scholar 

  30. Rozen WM, Ashton MW, Ferris S, White D, Stella DL, Phillips TJ, Taylor GI (2008) Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT-guided stereotaxy. Microsurgery 28:227–232

    Article  PubMed  CAS  Google Scholar 

  31. Rozen WM, Ashton MW, Grinsell D, Stella DL, Phillips TJ, Taylor GI (2008) Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators. Microsurgery 28(5):306–313

    Article  PubMed  CAS  Google Scholar 

  32. Rozen WM, Ashton MW, Pan WR, Kiil BJ, McClure VK, Grinsell D, Stella DL, Corlett RJ (2009) Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study. Microsurgery 29(1):16–23

    Article  PubMed  Google Scholar 

  33. Rozen WM, Ashton MW, Stella DL, Phillips TJ, Taylor GI (2008) Magnetic resonance angiography and computed tomographic angiography for free fibular flap transfer. J Reconstr Microsurg 24(6):457–458

    Article  PubMed  Google Scholar 

  34. Rozen WM, Houseman ND, Ashton MW (2009) The Circummuscular or Paramuscular variants of deep inferior epigastric perforators detected with CTA: should these be called variants at all? Aesthetic Plast Surg 33(1):119–120

    Article  PubMed  Google Scholar 

  35. Rozen WM, Murray ACA, Ashton MW, Bloom R, Stella DL, Phillips TJ, Taylor GI (2008) The cutaneous course of deep inferior epigastric perforators: implications for flap thinning. J Plast Reconstr Aesth Surg [Epub ahead of print]

  36. Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI (2008) Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 121:9–16

    Article  PubMed  CAS  Google Scholar 

  37. Rozen WM, Phillips TJ, Ashton MW, Stella DL, Taylor GI (2008) A new imaging modality for free flaps in breast reconstruction: CT angiography. Plast Reconstr Surg 122:38e–40e

    Article  PubMed  Google Scholar 

  38. Salmon M (1936) Artéres de la peau. Masson et Cie, Paris, pp 1–122

    Google Scholar 

  39. Smit JM, Dimopoulou A, Liss AG, Zeebregts CJ, Kildal M, Whitaker IS, Magnusson A, Acosta R (2008) Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg [Epub ahead of print]

  40. Taylor GI (2003) In: Discussion of Blondeel PN, Van Landuyt KH, Monstrey SJ, Hamdi M, Matton GE, Allen RJ, Dupin C, Feller AM, Koshima I, Kostakoglu N, Wei FC. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 112 1384–1387

    Google Scholar 

  41. Taylor GI, Doyle M, McCarten G (1990) The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg 43:1–16

    Article  PubMed  CAS  Google Scholar 

  42. Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body: experimental study and clinical application. Br J Plast Surg 40:113–141

    Article  PubMed  CAS  Google Scholar 

  43. Uppal RS, Casaer B, Van Landuyt K, Blondeel P (2008) The efficacy of preoperative mapping of perforators in reducing operative times and complications in perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg [Epub ahead of print]

  44. Verpaele AM, Blondeel PN, Van Landuyt K, Tonnard PL, Decordier B, Monstrey SJ, Matton G (1999) The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores. Br J Plast Surg 52:385–391

    Article  PubMed  CAS  Google Scholar 

  45. Whitaker IS, Rozen WM, Smit JM, Dimopoulou A, Ashton MW, Acosta R (2009) Peritoneo-cutaneous perforators in deep inferior epigastric perforator flaps: a cadaveric dissection and computed tomographic angiography study. Microsurgery 29(2):124–127

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Institutional Ethical Approval was obtained through Melbourne Health HREC #2006.231.

Conflict of interest statement

There was no source of funding for the article. The authors declare that there is no source of financial or other support, or any financial or professional relationships which may pose a competing interest.

Author information

Authors and Affiliations

  1. Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, The University of Melbourne, Parkville, VIC, Australia

    Warren Matthew Rozen, Damien Grinsell & Mark W. Ashton

  2. Section of Plastic Surgery, Department of Surgery, University of Cagliari Hospital, Cagliari, Italy

    Diego Ribuffo & Matteo Atzeni

  3. Department of Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia

    Damien L. Stella

  4. Department of Radiology, University of Cagliari Hospital, Cagliari, Italy

    Luca Saba

  5. Division of Plastic Surgery, San Gallicano Hospital, Rome, Italy

    Maristella Guerra

Authors
  1. Warren Matthew Rozen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Diego Ribuffo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matteo Atzeni
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Damien L. Stella
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Luca Saba
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Maristella Guerra
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Damien Grinsell
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mark W. Ashton
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Warren Matthew Rozen.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rozen, W.M., Ribuffo, D., Atzeni, M. et al. Current state of the art in perforator flap imaging with computed tomographic angiography. Surg Radiol Anat 31, 631–639 (2009). https://doi.org/10.1007/s00276-009-0484-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-009-0484-0

Keywords

Search

Navigation