Preoperative Perforator Imaging in Reconstructive Plastic Surgery: Current Practice in Germany

Sir: With the advent of perforator-based flap designs in reconstructive plastic surgery, preoperative assessment of perforator flaps has received significant attention during the past decade. Starting in 1994, color duplex sonography has been proposed for preoperative identification and calibration of relevant perforators.1 In the same year, magnetic resonance imaging was suggested as a useful imaging tool for locating and assessing the number of perforators in musculocutaneous flaps.2 With technical advancement of both techniques, today three- and even four-dimensional computed tomographic angiography and venography are feasible for assessing the perfusion of perforator flaps.3 Computed tomographic angiography has been described to be superior to Doppler ultrasound in demonstrating the course of the deep inferior epigastric artery and its branching pattern and in visualizing its perforators.4 Despite the preoperative visualization of perforators with recent advances in imaging technology, the current clinical practice of preoperative perforator monitoring is still disputed. We questioned 121 German plastic reconstructive surgeons regarding their current practice in perforator-based reconstructive microsurgery. Forty-five percent performed perforator-based flaps on a routine basis. Preoperative perforator imaging was performed by 90.4 percent of German plastic surgeons, the majority of whom performed duplex sonography (72 percent) followed by color Doppler sonography (48 percent). Only 4 percent of all plastic surgeons obtained a preoperative computed tomographic angiography scan and 4 percent performed magnetic resonance imaging angiography. Depending on the number of perforator flaps performed per year, the preoperative perforator diagnosis was determined (Table 1). Those surgeons who performed more than 30 perforator flaps per year used either duplex or color Doppler sonography but did not use computed tomographic angiography or magnetic resonance imaging angiography for preoperative perforator imaging.Table 1: Number of Perforator Flaps Performed Annually and Preoperative Perforator Imaging Technique among German Plastic SurgeonsApproximately one-third of all plastic surgeons used a combination of these diagnostic techniques. The majority combined duplex and color Doppler sonography (28 percent), whereas only 2 percent combined duplex sonography with computed tomographic angiography and 2 percent color Doppler with magnetic resonance imaging angiography (Table 2).Table 2: Number of Perforator Flaps Performed Annually and Combination Preoperative Perforator Imaging Techniques among German Plastic SurgeonsFrom these data, we conclude that although the proven efficacy and reliability of computed tomographic angiography or magnetic resonance imaging angiography for perforator imaging, duplex and color Doppler sonography remain the preferred tools for preoperative perforator diagnosis in Germany. Furthermore, clinical trials are pending to demonstrate that the preoperative perforator imaging shows beneficial effects in improving clinical outcome or the ease of flap dissection and in reducing operating room time with lower financial case costs. Thus, lower financial case costs and lower postoperative complications based on thorough preoperative planning of perforator flaps may be the result of the current advances in imaging technology. Karsten Knobloch, M.D., Ph.D. Andreas Gohritz, M.D. Ebischa Reuss, M.D. Joern Redeker, M.D. Marcus Spies, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D.