Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging

Sir: We read with great interest the article entitled “Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging” by Haddock et al.,1 which aimed to verify the value of preoperative computed tomographic angiography data in reducing operative time of breast reconstruction with the deep inferior epigastric perforator (DIEP) flap. Compared with the traditional transverse rectus abdominis musculocutaneous flap, application of the DIEP flap in breast reconstruction not only fully protects the integrity of the rectus abdominis but also greatly reduces the functional damage to the abdominal wall and the occurrence of donor-site complications. Therefore, it has become the preferred option for breast reconstruction with an abdominal flap. Among the influencing factors that affect the outcome of breast reconstruction with the DIEP flap, the primary factor is the diameter of the donor vascular pedicle—that is, the blood supply level of the arterial system to the tissue and the degree of drainage of the venous system for the flap. Compared with the venous system, arterial-related postoperative complications are often more serious and irreversible. Therefore, preoperative and intraoperative selection of the predominant DIEP perforator is particularly critical. In this study, the authors found that surgeons tended to include a greater number of perforators when there was no intraoperative reference to abdominal computed tomographic angiography data. The authors attributed this result to the relative lack of confidence in single-perforator reconstruction without knowledge of the anatomical distribution of the vascular pedicle. However, we believe that even when a single perforator approach is proposed, techniques such as indocyanine green fluorescence imaging are needed to determine the actual perfusion of the flap. In cases of poor perfusion, more vascular perforators often needed to be included to ensure adequate blood flow to the flap. Therefore, in the absence of preoperative imaging data as a reference, the surgeon may initially choose a nondominant perforator, resulting in an increase in the number of perforators subsequently incorporated. Moreover, we believe that the significance of preoperative abdominal computed tomographic angiography is not only to clarify the course of the deep inferior epigastric artery and its perforator but also to pinpoint other anatomical information, such as the diameter of the superficial inferior epigastric artery (SIEA). As the SIEA runs in the superficial layer of the rectus abdominis fascia, injury to the rectus abdominis is avoided during dissection of the vascular pedicle. Therefore, compared with the DIEP flap, the SIEA flap leads to less damage to the donor site and greatly reduces the incidence of postoperative donor site–related complications. Our previous studies have shown that there is a trade-off between the perfusion levels of the superficial and deep arterial systems of the abdominal wall. Especially for populations with larger body weights, breast reconstruction with the SIEA flap might be more advantageous than reconstruction with the DIEP flap in terms of perfusion. In the absence of preoperative abdominal computed tomographic angiography data, directly searching for the perforators during the operation may not only lose the opportunity of applying the SIEA flap but also increase the operation time to the free vascular pedicle, which is consistent with the authors’ conclusion in this study.2 The significance of preoperative computed tomographic angiography is not only to visualize the territory of abdominal vessels but also to assist in the selection of recipient vessels. When the internal thoracic artery (ITA) perforator is selected as the recipient vessel, preoperative chest computed tomographic angiography can show where the ideal perforator is. When the main trunk of the internal thoracic artery is selected, computed tomographic angiography data can show the exact intercostal level where the donor and the recipient vessels are optimally matched in terms of diameter. In addition, in cases where computed tomographic angiography imaging shows a large difference in diameter between the donor and recipient vessels, the surgeon can preoperatively anticipate the measures that might be taken intraoperatively to reduce the mismatch. On the contrary, if there is no imaging to use as a reference, the internal thoracic artery diameter at the selected level of the intercostal space during the procedure may not match the diameter of the donor vessel. In this situation, adjusting measures, such as end-to-side anastomosis or fish mouth–type ectomy, may further increase the operative time. However, the differences between the experimental and control groups in the procedure time required were not reported in the selection of the donor vessels nor in the vascular anastomosis. Despite these limitations, the authors’ effort is essential for verifying the necessity of preoperative computed tomographic angiography imaging in autologous tissue breast reconstruction. We anticipate further studies in this field and new assistive techniques for preoperative determination of vascular anatomy. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Xiaoyu Zhang, M.D.Department of Aesthetic and Reconstructive Breast SurgeryPlastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People’s Republic of China Yinxiang Huang, B.M.Jinzhou Medical UniversityJinzhou, People’s Republic of China Dali Mu, M.D., Ph.D.