American Association for Hand Surgery
Theme: Beyond Innovation

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Utility of Preoperative Imaging in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction - a Randomized Controlled Trial
Kathryn J Sawa, BMSc, MD, FRCSC1; Snell J Laura, MD, MSc, FRCSC2; Catherine McMillan, BSc, MSc1; Robyn Pugash, MD, FRCPC1; Elizabeth N David, MD, FRCPC1; Sarah E Appleton, MD, MSc, FRCSC1; Elizabeth C Matheson, BScKin, BScPA, CCPA1; Alanna Rigoban, BSc, MSc1; Lipa E Joan, MD, MSc, FRCSC, FACS2
1University of Toronto, Toronto, ON, Canada, 2 Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, Canada

Background
Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction can be associated with challenging surgical dissection and lengthy operative times. Routine preoperative imaging with computed tomography angiography (CTA) or magnetic resonance angiography (MRA) has been adopted by many surgeons, citing increased surgeon efficiency, reduced surgical costs and positive impact on patient outcomes in retrospective series. However, other surgeons purport that preoperative imaging is not necessary. Given the absence of level one evidence to support preoperative imaging and its associated costs, the objective of this randomized controlled trial was to evaluate surgical and patient-reported outcomes of patients undergoing DIEP flap breast reconstruction, comparing routine surgery without imaging to either preoperative CTA or MRA.

Methods
Consecutive patients consenting for DIEP breast reconstruction were invited to participate in this REB-approved study. Recruited patients were randomized to no preoperative imaging (Control; n=20), CTA (n=20) or MRA (n=20). Primary outcome was flap dissection time. Power analysis was performed to detect statistical significance for the primary outcome. Secondary outcomes included surgeon stress associated with flap dissection (NASA Task Load Index), postoperative pain using Memorial Pain Assessment Card (MPAC), total inpatient morphine-equivalent narcotic analgesia, patient-reported outcomes (Breast-Q), flap-related complications and donor site morbidities.

Results
Sixty-four patients were enrolled in the study; four withdrew prior to surgery. There was no significant difference in demographics among the groups. Flap dissection time and total operative time in minutes was 85.0 28.7 and 511.7 135.1 for Control, 82.0 24.5 and 491.2 112.8 for CTA, and 76.3 17.9 and 466.8 130.1 for MRA group (no significant difference, no effect of surgeon or flap laterality). There was a significant decrease in Physical Demand subscale of the NASA Task Load Index for MRA compared to Control group and Frustration subscale for MRA compared to CTA group after adjusting for surgeon (ANCOVA; p<0.05). Change in Breast Satisfaction and Satisfaction with Outcomes at 12 months was significantly higher in Control than MRA group (p<0.05). There was no significant difference in MPAC score, total morphine-equivalent narcotic analgesia, flap-related complications or donor site morbidities.

Conclusion
In this first RTC assessing the utility of preoperative CTA and MRA in DIEP flap breast reconstruction, preoperative imaging does not reduce flap dissection or total operative time, post-operative pain, patient-reported outcomes, donor site or flap-related complications. Preoperative MRA may improve surgeon wellbeing, possibly due to superior visualization of the intramuscular perforator course.


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