Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging

BACKGROUND: In deep inferior epigastric perforator (DIEP) flap breast reconstruction, many surgeons use preoperative imaging for perforator mapping as a method to plan the operation, reduce operative times, and potentially limit morbidity. This study compared operative times for specific portions of DIEP flap harvest with and without preoperative computed tomographic angiography imaging. METHODS: Two patient groups undergoing DIEP flap breast reconstruction were studied prospectively. In the experimental group, the harvesting surgeon was blinded to the preoperative computed tomographic angiography scan; in the control group, the harvesting surgeon assessed the scan preoperatively. Times for initial perforator identification, perforator selection, flap harvest time, and total procedure times were compared. Perforator choice was evaluated. Correlation of perforator choice preoperatively and intraoperatively was also performed. RESULTS: Times were recorded in 60 DIEP flaps (27 blinded and 33 unblinded). The nonblinded group was more efficient in all categories: time to first perforator identification (28.6 minutes versus 17.8 minutes; p < 0.0001), time to perforator decision-making (23.1 minutes versus 5.6 minutes; p < 0.0001), time to flap harvest (128 minutes versus 80 minutes; p < 0.0001), and total operative time (417 minutes versus 353 minutes; p < 0.001). Perforator location was not different between groups. Blinded intraoperative decisions correlated with preoperative imaging in 74 percent of flaps. More perforators were included in the blinded flaps compared to the nonblinded flaps (2.3 versus 1.4; p < 0.001). CONCLUSIONS: Use of preoperative computed tomographic angiography leads to decreased operative times, specifically with regard to perforator identification and perforator selection. Without preoperative computed tomographic angiography, surgeons included more perforators in the flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.