Advancing Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction through Multidetector Row Computed Tomography: An Evolution in Preoperative Imaging

Perforator flaps have become increasingly popular tools in microvascular breast reconstruction. Previous criticism of these techniques, particularly deep inferior epigastric artery perforator (DIEAP) flap, have included the variability in the path of the perforators through the rectus muscle, the tedious and time-consuming need to look for and to clamp various perforators to determine the "dominant'' perforator, and uncertainty whether adequate perforators exist following previous abdominal surgery. Preoperative imaging has contributed significantly to the reliability, speed, and minimal donor site morbidity of these procedures. A major evolution in preoperative imaging has been the introduction of multidetector row computed tomography (MDCT) as a replacement for color duplex imaging. There are multiple advantages to MDCT with few disadvantages, and so it has become the gold standard for the preoperative planning of DIEAP flap breast reconstruction in the practices of both authors, completely eliminating the use of color duplex. Improvements in the preoperative understanding of the anatomy of each perforator from its branching pattern in the subcutaneous fat, to its perforation through the anterior rectus sheath and rectus muscle toward the groin facilitate this type of surgery in a manner only possible with MDCT and not duplex imaging.