Viewpoints Image Overlay of Deep Inferior Epigastric Artery in Breast Reconstruction Yohei Sotsuka, MD Department of Plastic Surgery Hyogo College of Medicine Hyogo, Japan Ken Matsuda, MD, PhD Division of Plastic and Reconstructive Surgery Niigata University Graduate School of Medicine Niigata, Japan Kazutoshi Fujita, MD Toshihiro Fujiwara, MD, PhD Masao Kakibuchi, MD, PhD Department of Plastic Surgery Hyogo College of Medicine Hyogo, Japan
Sir: he use of computer tomography angiography (CTA) is combined with ultrasound duplex scanning to identify perforating arteries preoperatively for abdominal free flap breast reconstruction.1 CTA shows the course of the blood vessels on the computer’s display, whereas duplex scan takes much time for perforator mapping on real patient’s abdominal wall. Augmented reality and image overlay navigation with computer in laparoscopic and robotic surgery are now rapidly developing.2 We applied those technologies to preoperative planning of breast reconstruction and describe a quicker-to-perform method of marking perforators on real patient’s abdominal skin before surgery by using image overlay technique. CTA studies were prospectively performed in patients before undergoing breast reconstructive surgery, using 64-multidetector computed tomography scanner (Siemens Healthcare SOMATOM Definition AS+, Siemens Japan, Japan). A MacBook Air 1.7 GHz dual-core Intel Core i7 Processor was used, and axial source DICOM data were transferred to OsiriX (Pixmeo, Geneva, Switzerland), a free, open-source medical application (available for only MacOS X) to convert into maximum intensity projection image in coronal plane (Fig. 1). The
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Copyright © 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2014;2:e235; doi:10.1097/ GOX.0000000000000210; Published online 21 October 2014.
Fig. 1. A 50-mm-thick maximum intensity projection reconstruction in coronal plane including the deep inferior epigastric arteries course from the iliac arteries to the middle abdomen. Umbilicus is marked white as a landmark.
Fig. 2. Tracing the arteries and perforators on patient’s abdominal body surface. Deep inferior epigastric arteries are marked with red marker (red arrows). Perforators are marked with black marker (black arrow). Umbilicus is used as one of the fixed points (white arrow).
images were directly projected on the patient’s abdominal skin by a portable projector (PRJ-5, Sanwa Supply, Japan) fixed to a hand-built stand and were superimposed on the patient’s body surface to match the visual landmarks; umbilicus, iliac crest, and symphysis pubis
www.PRSGlobalOpen.com 1
PRS Global Open • 2014 were set as fixed points. Then, the deep inferior epigastric arteries and those perforators were traced by a permanent marker (Fig. 2). The whole procedure took about 10 minutes. Intraoperative findings of the deep inferior epigastric arteries and the perforators were exactly matched with the preoperative surface markings. Although methods for identifying perforator arteries have been described, both CTA and ultrasound scanning have good and bad points1,3; a time-consuming task. We have described a new, precise, quick, and easy way to mark the perforators in the real patient. Correspondence to Dr. Sotsuka Department of Plastic Surgery Hyogo College of Medicine 1-1 Mukogawa, Nishinomiya Hyogo 663–8501, Japan [email protected]
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DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES
1. Rozen WM, Phillips TJ, Ashton MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008;121:9–16. 2. Volonté F, Pugin F, Bucher P, et al. Augmented reality and image overlay navigation with OsiriX in laparoscopic and robotic surgery: not only a matter of fashion. J Hepatobiliary Pancreat Sci. 2011;18:506–509. 3. Teunis T, Heerma van Voss MR, Kon M, et al. CT angiography prior to DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery 2013;33:496–502.
Sir: he use of computer tomography angiography (CTA) is combined with ultrasound duplex scanning to identify perforating arteries preoperatively for abdominal free flap breast reconstruction.1 CTA shows the course of the blood vessels on the computer’s display, whereas duplex scan takes much time for perforator mapping on real patient’s abdominal wall. Augmented reality and image overlay navigation with computer in laparoscopic and robotic surgery are now rapidly developing.2 We applied those technologies to preoperative planning of breast reconstruction and describe a quicker-to-perform method of marking perforators on real patient’s abdominal skin before surgery by using image overlay technique. CTA studies were prospectively performed in patients before undergoing breast reconstructive surgery, using 64-multidetector computed tomography scanner (Siemens Healthcare SOMATOM Definition AS+, Siemens Japan, Japan). A MacBook Air 1.7 GHz dual-core Intel Core i7 Processor was used, and axial source DICOM data were transferred to OsiriX (Pixmeo, Geneva, Switzerland), a free, open-source medical application (available for only MacOS X) to convert into maximum intensity projection image in coronal plane (Fig. 1). The
T
Copyright © 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercialNoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2014;2:e235; doi:10.1097/ GOX.0000000000000210; Published online 21 October 2014.
Fig. 1. A 50-mm-thick maximum intensity projection reconstruction in coronal plane including the deep inferior epigastric arteries course from the iliac arteries to the middle abdomen. Umbilicus is marked white as a landmark.
Fig. 2. Tracing the arteries and perforators on patient’s abdominal body surface. Deep inferior epigastric arteries are marked with red marker (red arrows). Perforators are marked with black marker (black arrow). Umbilicus is used as one of the fixed points (white arrow).
images were directly projected on the patient’s abdominal skin by a portable projector (PRJ-5, Sanwa Supply, Japan) fixed to a hand-built stand and were superimposed on the patient’s body surface to match the visual landmarks; umbilicus, iliac crest, and symphysis pubis
www.PRSGlobalOpen.com 1
PRS Global Open • 2014 were set as fixed points. Then, the deep inferior epigastric arteries and those perforators were traced by a permanent marker (Fig. 2). The whole procedure took about 10 minutes. Intraoperative findings of the deep inferior epigastric arteries and the perforators were exactly matched with the preoperative surface markings. Although methods for identifying perforator arteries have been described, both CTA and ultrasound scanning have good and bad points1,3; a time-consuming task. We have described a new, precise, quick, and easy way to mark the perforators in the real patient. Correspondence to Dr. Sotsuka Department of Plastic Surgery Hyogo College of Medicine 1-1 Mukogawa, Nishinomiya Hyogo 663–8501, Japan [email protected]
2
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES
1. Rozen WM, Phillips TJ, Ashton MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008;121:9–16. 2. Volonté F, Pugin F, Bucher P, et al. Augmented reality and image overlay navigation with OsiriX in laparoscopic and robotic surgery: not only a matter of fashion. J Hepatobiliary Pancreat Sci. 2011;18:506–509. 3. Teunis T, Heerma van Voss MR, Kon M, et al. CT angiography prior to DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery 2013;33:496–502.
