Image overlay of deep inferior epigastric artery in breast reconstruction.

Sir:

The use of computer tomography angiography (CTA) is combined with ultrasound duplex scanning to identify perforating arteries preoperatively for abdominal free flap breast reconstruction.[1] CTA shows the course of the blood vessels on the computer’s display, whereas duplex scan takes much time for perforator mapping on real patient’s abdominal wall.

Augmented reality and image overlay navigation with computer in laparoscopic and robotic surgery are now rapidly developing.[2] We applied those technologies to preoperative planning of breast reconstruction and describe a quicker-to-perform method of marking perforators on real patient’s abdominal skin before surgery by using image overlay technique.

CTA studies were prospectively performed in patients before undergoing breast reconstructive surgery, using 64-multidetector computed tomography scanner (Siemens Healthcare SOMATOM Definition AS+, Siemens Japan, Japan). A MacBook Air 1.7 GHz dual-core Intel Core i7 Processor was used, and axial source DICOM data were transferred to OsiriX (Pixmeo, Geneva, Switzerland), a free, open-source medical application (available for only MacOS X) to convert into maximum intensity projection image in coronal plane (Fig. 1). The images were directly projected on the patient’s abdominal skin by a portable projector (PRJ-5, Sanwa Supply, Japan) fixed to a hand-built stand and were superimposed on the patient’s body surface to match the visual landmarks; umbilicus, iliac crest, and symphysis pubis were set as fixed points. Then, the deep inferior epigastric arteries and those perforators were traced by a permanent marker (Fig. 2). The whole procedure took about 10 minutes. Intraoperative findings of the deep inferior epigastric arteries and the perforators were exactly matched with the preoperative surface markings.

Fig. 1.

A 50-mm-thick maximum intensity projection reconstruction in coronal plane including the deep inferior epigastric arteries course from the iliac arteries to the middle abdomen. Umbilicus is marked white as a landmark.

Fig. 2.

Tracing the arteries and perforators on patient’s abdominal body surface. Deep inferior epigastric arteries are marked with red marker (red arrows). Perforators are marked with black marker (black arrow). Umbilicus is used as one of the fixed points (white arrow).

Although methods for identifying perforator arteries have been described, both CTA and ultrasound scanning have good and bad points[1,3]; a time-consuming task. We have described a new, precise, quick, and easy way to mark the perforators in the real patient.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.