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13.1 Introduction

The art of breast reconstruction has undergone immense evolution throughout the last 30 years. This progress has resulted in techniques that help plastic surgeons attain their goal of an ideal method. A model reconstructive technique should be safe, reliable, and reproducible, with limited or no resultant long-term morbidity. Such a technique should replace the breast with tissue of similar texture, producing an aesthetic result indistinguishable from the natural breast. Before 1980, plastic surgeons were limited to the insertion of a silicone implant beneath the skin and a latissimus flap. With increased use of the transverse rectus abdominis myocutaneous (TRAM) flap after 1980, first described as a pedicled flap by Hartrampf, Scheflan, and Black in 1982, the field of breast autologous reconstruction became established.

Autologous breast reconstruction can be achieved from a range of donor sites, with the abdominal wall integument increasingly being selected as the donor tissue of choice. The use of excess fatty tissue in the lower abdomen to reconstruct the breast allows for a final result that is living and durable, and which eliminates the concerns of artificial materials.

Currently, free flaps and perforator flaps, originally introduced by Koshima and Soeda in 1989, represent the next significant step toward an ideal reconstruction method, providing autologous tissue reconstruction techniques with reduced donor-site morbidity. These techniques allow for the harvest of the same well-suited tissues used in the conventional pedicled/free TRAM flap and gluteal myocutaneous flaps, but without the sacrifice of underlying muscle tissue.

An accurate preoperative evaluation of the vascular anatomy of the abdominal wall is highly desirable to improve results in breast reconstruction using abdominal flaps, reduce the risk of flap necrosis, and help the plastic surgeon design the flap in the most opportune way, avoiding a useless large transfer of tissue. The pedicled TRAM (pTRAM) requires data on the location, course, and anatomical variations of the deep superior epigastric artery (DSEA) and dominant perforators for preoperative planning. Reconstruction with deep inferior epigastric perforator (DIEP) and superior gluteal artery perforator (SGAP) flaps requires a precise location and evaluation of perforating vessels to select preoperatively between homolateral and contralateral sides. Previous reports using color duplex scanning identified several pitfalls, such as operator dependence and questionable results. Currently, multidetector-row computer tomographic angiography, also called angioCT, and magnetic resonance angiography (angioMR), offer thin-slice coverage of extended volumes with extremely high spatial resolutions, which are very useful in surgery planning.

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