Ultrasound in deep inferior epigastric artery flap perforator mapping: techniques, applications, and future directions

The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction, with successful outcomes depending heavily on accurate perforator identification and selection. Computed tomographic angiography (CTA) remains the gold standard for preoperative planning; however, its limitations - including radiation exposure, contrast-related risks, and inability to provide real-time intraoperative assessment - have prompted increasing interest in ultrasound-based approaches. Ultrasound enables dynamic, real-time evaluation of both anatomical and physiological characteristics of perforator vessels, including caliber, flow velocity, and vascular resistance. Despite growing adoption, the literature describing standardized techniques and practical integration of ultrasound into plastic and reconstructive surgery workflows remains limited. This review synthesizes current evidence regarding ultrasound use in DIEP perforator mapping and presents a detailed, technique-oriented framework for its application in preoperative planning, intraoperative decision-making, and postoperative monitoring. Advantages, limitations, and emerging technologies are discussed. With appropriate training, ultrasound represents a powerful adjunct to established modalities, with the potential to enhance surgical precision, improve flap outcomes, and expand accessibility of perforator mapping and perioperative assessment in microsurgical breast reconstruction.