Plastic Surgery>>>>>Breast, trunk and perineum
Question 34#

The following statements are true except:

A. Cutaneous perforators that do not originate from the deep inferior epigastric artery (peritoneocutaneous perforators) are rare findings when raising a DIEP flap
B. Pre-operative evaluation of the vasculature of the abdominal wall has been shown to reduce operating times in perforator flap reconstruction
C. The use of computed tomography of the abdominal wall has been shown to be cost-effective in some studies
D. The radiation exposure associated with computed tomographic angiography of the abdominal wall is similar to a background radiation dose of 2.5 years
E. The use of the DIEP flap to reconstruct lower limb defects has not been described

Correct Answer is E

Comment:

The use of the DIEP flap to reconstruct lower limb defects has not been described. This statement is incorrect; the use of DIEP flaps to reconstruct lower limb defects in 25 patients with promising results was described in 2005 1. A study of 375 DIEA perforator (DIEP) flaps (325 with preoperative CTA and 50 cadaveric dissections) showed that peritonealcutaneous perforators were rare anatomical variations (4/375: 1.1%) and that they may affect outcomes in DIEP flap surgery if not assessed preoperatively. Computed axial tomography (CTA) was significantly able to detect this anomaly and aid operative planning 2. In a study of 138 DIEP breast reconstructions, 70 underwent pre-operative CTA analysis, and 68 had pre-operative Doppler investigation. Surgery time in the CTA group was significantly lower (p<0.001) than in the control group (264min [SD+/-62] versus 354min [SD+/-83]), respectively. The study suggested that the use of CTA helped reduce surgery time, and reduce the risk of postoperative complications 3. In addition, the time saved during DIEP flap surgery was shown to compare favourably to the cost of the computed tomographic angiography pre-operatively 4. A paper reviewing the radiation dose of routine investigations compared it to abdominal wall CTA and the background equivalent radiation dose (Table below) 5.

Radiation exposure with CTA in DIEP flap planning:

References:

  1. Van Landuyt K, Blondeel P, Hamdi M, Tonnard P, Verpaele A, Monstrey S. The versatile DIEP flap: its use in lower extremity reconstruction. Br J Plast Surg 2005; 58(1): 2-13.
  2. Whitaker IS, Rozen WM, Smit JM, Dimopoulou A, Ashton MW, Acosta R. Peritoneocutaneous perforators in deep inferior epigastric perforator flaps: a cadaveric dissection and computed tomographic angiography study. Microsurgery 2009; 29(2): 124-7.
  3. Smit JM, Dimopoulou A, Liss AG, Zeebregts CJ, Kildal M, Whitaker IS, Magnusson A, Acosta R. Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg 2008, Jul 31.
  4. Rozen WM, Ashton MW, Whitaker IS, Wagstaff MJ, Acosta R. The financial implications of computed tomographic angiography in DIEP flap surgery: a cost analysis. Microsurgery 2009; 29(2): 168-9.
  5. Rozen WM, Whitaker IS, Stella DL, Phillips TJ, Einsiedel PF, Acosta R, Ashton MW. The radiation exposure of computed tomographic angiography (CTA) in DIEP flap planning: low dose but high impact. J Plast Reconstr Aesthet Surg 2008, Dec 31.