Holographic Deep Inferior Epigastric Perforator Exploration in Mixed Reality using Real-Time Cinematic Rendering

Deep Inferior Epigastric Artery perforator flaps (DIEP flaps) have become the gold standard in autologous breast reconstruction; yet they remain complex procedures due to highly individual perforator anatomy. Increasingly, computed tomography (CT) angiography is used for preoperative planning but is conventionally viewed on 2D screens in black and white. With the rise of Virtual and Mixed Reality, early case studies have demonstrated the utility of 3D-Mixed Reality headsets for DIEP flap planning by immersively exploring projections of perforator anatomy. However, thus far, only segmentation- and volume rendering-based approaches have been used clinically. These techniques lack photorealism and do not ideally depict soft-tissue or high-resolution vascular detail. We describe a new holographic photorealistic rendering workflow on Mixed Reality headsets using Cinematic Anatomy that allows more accurate depth perception and, thus, a better understanding of perforator anatomy. Using hand-gestures to interact with a hologram derived by CT angiography, the surgeon can modify the rendering in real-time and interactively dissect parts of the Rectus Abdominis Muscle to get a more nuanced understanding of the sub- and intramuscular course of the vascular tree. Using different visualization settings, the spatial relationship of perforators to surrounding anatomical structures-especially the subcutaneous tissue and the Rectus Abdominis Muscle-can be understood more intuitively. Our technique can be performed by surgeons independently with a laptop and a Microsoft HoloLens, making CT angiography data more accessible and practical for use in plastic surgery. We demonstrate the first use of photorealistic rendering in Mixed Reality to explore perforator anatomy.No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .