Plastic Surgery Research Council

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Preoperative CTA Efficiently Facilitates Perforator Decision-Making in DIEP Flap Breast Reconstruction: a Blinded Prospective Study
Danielle O. Dumestre, MD FRCSC, Sumeet Teotia, MD, Avinash Jayaraman, BA, Austin Hembt, MD, Nicholas Haddock, MD.
UT Southwestern, Dallas, TX, USA.

Purpose
To compare operative times for specific portions of deep inferior epigastric perforator (DIEP) flap harvest as well as perforator selection in cases where preoperative CTA imaging had been reviewed by the harvesting surgeon preoperatively vs. not reviewed.
Methods
This is a prospective pilot study of two patient groups undergoing breast reconstruction using DIEP flaps. We utilize a two-surgeon approach for all DIEP flaps and for the experimental group the harvesting surgeon was blinded to the results of the preoperative CTA, whereas in the control group the harvesting surgeon had assessed the CTA preoperatively. Patients were randomized to the blinded vs. non-blinded group based on surgical day. Operative times were recorded for initial perforator identification, perforator selection, and total flap harvest time and were compared between groups. The choices of perforators (medial, intermediate, or lateral) were also compared between groups. Within the blinded group, perforator selection by the blinded harvesting surgeon was compared to the pre-operative perforator selection by the non-blinded, non-harvesting surgeon based on CTA imaging.
Results
From June-November, 2018, 13 DIEP flaps were performed where the surgeon was blinded to the preoperative CTA results, and 49 flaps were not blinded. The mean time to first perforator identification was longer in the blinded vs. the non-blinded group [29.2 minutes (SD=8.2) blinded group, 15.1 minutes (SD=6.7) non-blinded, p<0.0001]. Time to perforator decision-making was also longer in the blinded vs. the non-blinded group [25.3 minutes (SD=9.11) blinded, 5.75 minutes (SD=11.2) non-blinded, p<0.0001]. Mean total harvest time was significantly longer in the blinded vs. the non-blinded group [114.6 min (SD=32.5) blinded, 72.6 min (SD=23.7) non-blinded, p<0.0001]. Medial row perforators were used in 53.4% (7/13) of flaps in the blinded group, and 42.8% (21/49) of flaps in the non-blinded group, p=.479. Intermediate row perforators were used in 15.4% (2/13) of flaps in the blinded group, and 18.3% (9/49) of flaps in the non-blinded group, p=.802. Lateral row perforators were used in 61.5% (8/13) of flaps in the blinded group, and in 55.1% (27/49) of flaps in the non-blinded group, p=.677. Blinded intraoperative perforator selection correlated to the perforator selected on CTA by the non-blinded surgeon in 76.9% (10/13) of flaps. Significantly more perforators were included in the blinded flaps compared to the non-blinded flaps (average number of perforators included=2.23 blinded, 1.57 non-blinded, p=0.01).
Conclusion
Use of preoperative CTA leads to decreased operative times, specifically with regards to perforator identification and perforator selection. Without the use of preoperative CTA, surgeons included more perforators in the flaps.


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