Pre-operative Mapping and Imaging of Perforator Flaps

Successful reconstructive breast surgery demands teamwork between physicians, such as oncological (breast) surgeons, plastic surgeons, and radiologists. Mutual respect’s expertise and bilateral transfer of knowledge and skills can contribute to a better patient treatment quality. This chapter highlights the potential contribution of the radiologist to this team. Possible perforators in the abdominal wall, the medial side of the upper leg, and the backside are described. The radiologist’s job is to describe perforators so that they can be easily retrieved by the surgeon using a handheld doppler ultrasound device. The radiologist uses a workstation with a 3D viewer. He defines an anatomical landmark for each type of perforator that will act as a zero point in a Cartesian coordinate system. The chapter explains the two main radiologically post-processing tasks relevant to perforators’ localization and quality prediction before surgery. The maximum intensity projection (MIP) with a considerable thickness (30–50 mm) gives an overview of the course of the perforators and, with a limited thickness (3 mm), a precise localization of them. The volume rendering technique for mapping perforators (VRT) results in an overview of the patient’s skin surface. Crosslinking the perforator in the three orthogonal planes in MIP mode will result in a marked position on the skin on the VRT image (volume rendering technique). The x- and y-axes are drawn on the VRT image, after which the distance to the perforator is measured in millimeters. The displayed diameter of the perforator in MIP mode is highly dependent on the voxels size. However, the density of the vessel compared to the surrounding vessels is as much important. In the session tips and tricks, is explained how the perforator’s actual diameter is judged.