An Innovative Approach for Preoperative Perforator Flap Planning Using Contrast-enhanced B-flow Imaging

Precise perforator mapping of the epifascial and subcutaneous course of the perforator flaps, including the precise detection of the skin point, is mandatory for successful preoperative flap design and planning of supramicrosurgery. We investigated the effectiveness of contrast-enhanced B-flow (BCEUS) imaging for perforator mapping and preoperative perforator flap planning and compared it with B-flow ultrasound, contrast-enhanced ultrasound, and color Doppler ultrasound. Sixteen patients who received an individualized perforator flap reconstruction were included in the study. Preoperative perforator mapping includes the following structures: subfascial course of the pedicle, fascial penetration point, subcutaneous course (epifascial and subcutaneous), and perforator skin point. The precision of the preoperative perforator mapping was analyzed for color Doppler ultrasound, contrast-enhanced ultrasound, B-flow ultrasound, and BCEUS. Each technique was able to precisely display the subfascial course of the vascular pedicle, including the fascial penetration point. However, only BCEUS enabled precise mapping of the epifascial and subcutaneous (suprafascial) course, including the skin point of the perforators with a clear delineation. Precise knowledge of the suprafascial course of the perforators is mandatory for successful supermicrosurgery and perforator flap planning. BCEUS imaging facilitates full perforator mapping, which improves the safety of flap harvesting. However, BCEUS is technically demanding and requires an experienced sonographer.