Planning and optimising DIEP flaps with virtual surgery: the Navarra experience

Methods to improve operative outcomes in deep inferior epigastric artery perforator flap surgery have previously focussed on operative technique and postoperative-course modification. Recently, preoperative imaging has become capable of mapping the entire course of perforating vessels, including those vessels as small as 0.3 mm, enabling 'virtual surgery' to be performed preoperatively. This has been shown to facilitate faster and safer surgery. The recent 'Navarra' meeting classified current imaging modalities and discussed the current status of imaging modalities for this role. This article discusses the current expectations and optimal techniques for achieving these outcomes through the available imaging modalities: Doppler ultrasound, colour Doppler (duplex) ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Features of imaging that are of importance to the surgeon are explored, and a consensus statement has been developed that describes exactly what the current imaging modalities should aim to deliver to the surgeon prior to operating, as well as the benefits and pitfalls of each of these modalities. The techniques described herein permit the radiologist and the surgeon to perform virtual surgery together, preoperatively.