DIEP flap breast reconstructions: thermographic assistance as a possibility for perforator mapping and improvement of DIEP flap quality.

In the modern world, one-third or more of breast cancer patients still undergo uni- or bilateral mastectomy. Breast cancer patients, in general, have a good prognosis and long-term survival. Therefore, the treatment must not only focus on survival but also on the quality of life. Breast reconstruction with an autologous free deep inferior epigastric artery perforator (DIEP) flap is one of the preferred options after mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap to prevent necrosis after anastomosis. In this pilot study, the possibilities for dynamic infrared thermography (DIRT) are investigated to select the best suitable perforator. The measurements are done with external cooling in the preoperative stage to accurately predict the location of the dominant perforators. During the surgery, in the peroperative stage, measurements are done for mapping the influence of a specific perforator on the perfused areas of the abdominal flap. Perforators are sequentially closed and opened again to map the influence of that perforator on the vascularization of the flap, visualized with the help of the thermographic camera. The acquired steady-state thermal images could help decide which parts of the abdominal flap to use for the reconstruction so that the chance of (partial) necrosis is reduced. In the postoperative stage, DIRT could visualize the arterial and or venous thrombosis before they become clinically obvious as (partial) necrosis. At present DIRT seems to be a valuable investigation for the pre-, per-, and postoperative phases of DIEP-flap reconstructions. Large, high-quality clinical studies are needed to determine its definitive role.

Dynamic InfraRed Thermography (DIRT) in DIEP-flap breast reconstruction: A review of the literature.

In the industrialised world still 34% of the breast cancer patients are surgically treated by a mastectomy. Breast cancer patients in general have a good prognosis and a long-term survival. Therefore, it is important that the treatment doesn't focus only on survival but also on the quality of life. Breast reconstruction improves the quality of life. A breast reconstruction with an autologous free DIEP (Deep Inferior Epigastric artery Perforator) flap is one of the preferred options after mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. Current techniques to locate the perforator vessels include handheld Doppler, colour Doppler ultrasound (CDU), Magnetic resonance angiography (MRA), computer tomographic angiography (CTA) and dynamic infrared thermography (DIRT). At present CTA is the golden standard and DIRT a new option. The objective of this article is to document whether DIRT can accurately map the position of the perforators and measure their influence on the perfusion of the flap in order to select the best perforators to improve the outcome of breast reconstructions with free DIEP flaps. A systematic review of the literature published between January 1998 and November 23th 2018 was conducted regarding the possible benefit of dynamic infrared thermography (DIRT) in DIEP-flap breast reconstructions. The databases PubMed and Web of Science were used to search for qualified articles. Inclusion criteria were women who underwent a breast reconstruction by means of a DIEP flap where DIRT was used to analyse the blood supply of the flap. The search yielded a total of fourteen suitable articles: six articles being descriptive clinical studies, three case reports, three expert opinions/Overview articles and two systematic reviews. There are only a limited number of studies looking at the use of DIRT in breast reconstruction with DIEP-flaps. Adequate identification of the dominate vessel(s) in DIEP reconstruction is essential for a successful outcome. DIRT appears to be an ideal alternative technique for the identification of the dominant perforators of the flap. With the use of DIRT it is possible to identify the dominant vessel(s) preoperatively. The use of DIRT during the operation allows the tailoring of the surgery and postoperative use may identify vascularisation problems in an early stage. Additional high-quality studies are needed, but DIRT seems to be a valuable investigation for the pre-, per- and postoperative phase of DIEP-flap reconstructions.

Dynamic infrared thermography (DIRT) in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: standardization of the measurement set-up.

Breast reconstruction with an autologous free Deep Inferior Epigastric Perforator (DIEP) flap is one of the preferred options following mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. The current golden standard for perforator mapping is computed tomography angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, dynamic infrared thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion. Multiple studies have been performed with the use of DIRT, unfortunately without standardisation of the measurement set-up. In this technical note we propose a standardised and reproducible measurement set-up for the use of DIRT during breast reconstructions with a free DIEP flap. This set-up can be used pre-, intra- and postoperatively. A standardised measurement set-up will improve the quality of measured data and ensure reproducibility.