The role of cinematic rendering in pre-operative planning of a thoracodorsal artery perforator flap (TDAP) phalloplasty: a case study

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Abstract

The thoracodorsal artery perforator (TDAP) flap is a muscle-sparing skin and fat flap that requires precise intramuscular dissection of the thoracodorsal artery perforators in the axillary region. Pre-operative image-based treatment planning is a crucial part of flap design. In this article, we discuss the first-ever reported use of the cinematic volume rendering technique (CVRT) to evaluate the thoracodorsal artery for a TDAP flap phalloplasty in a 49-year-old transgender patient. Cinematic volume rendering technique uses light maps to generate photo-realistic three-dimensional images of the thoracodorsal artery and its perforators. These images aid the surgeon in evaluating optimal perforators and latissimus dorsi muscle involvement for more efficient flap design.

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Most cited references 14

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Pedicled perforator flaps in breast reconstruction: a new concept.

Moustapha Hamdi, Koenraad Van Hoorde, P Blondeel … (2004)

Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.

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Doppler flowmetry in the planning of perforator flaps.

Phillip N V Blondeel, Guy Beyens, Raymond Verhaeghe … (1998)

Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.

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Cinematic Rendering in CT: A Novel, Lifelike 3D Visualization Technique.

Marwen Eid, Carlo N. De Cecco, John W Nance … (2017)

The purpose of this article is to present an overview of cinematic rendering, illustrating its potential advantages and applications.

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Author and article information

Contributors

Carolina Lugo-Fagundo

Hannah Ahn

Devin O’Brien-Coon

Elliot K. Fishman

Journal

Journal ID (nlm-ta): BJR Case Rep

Journal ID (iso-abbrev): British Institute of Radiology

Journal ID (publisher-id): bjrcr

Title: BJR | case reports

Publisher: The British Institute of Radiology.

ISSN (Electronic): 2055-7159

Publication date Collection: June 2019

Publication date (Electronic): 22 November 2018

Volume: 5

Issue: 2

Electronic Location Identifier: 20180084

Affiliations

[1 ] org-divisionThe Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins School of Medicine , Baltimore, MD, USA

Author notes

Address correspondence to: Dr Elliot K. Fishman. E-mail: efishman@ 123456jhmi.edu

Article

Publisher-manuscript ID: BJRCR-D-18-00084

DOI: 10.1259/bjrcr.20180084

PMC ID: 6726175

SO-VID: cf20beea-75ce-4a5a-9357-39ab57035e96

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 20 July 2018

Date revision received : 24 October 2018

Date accepted : 12 November 2018

Page count

Figures: 0, Tables: 0, Equations: 0, References: 15, Words: 2398

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A novel computed tomography angiography technique: guided preoperative localization and design of anterolateral thigh perforator flap
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