Preoperative Flap Volume Prediction in Autologous Abdominal Breast Reconstruction : Plastic and Reconstructive Surgery

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Preoperative Flap Volume Prediction in Autologous Abdominal Breast Reconstruction

Eder, Maximilian M.D.; Raith, Stefan Dipl.-Ing.; Jalali, Jalil M.Sc.; Kovacs, Laszlo Ph.D., F.A.C.S.

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Plastic and Reconstructive Surgery: March 2013 - Volume 131 - Issue 3 - p 437e-438e
doi: 10.1097/PRS.0b013e31827c70c8
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We read with great interest the Viewpoint entitled “A Method of Preoperatively Assessing the Volume of Abdominal Tissue Available for an Autologous Breast Reconstruction” published recently in Plastic and Reconstructive Surgery and would like to congratulate the authors on their interesting work.1 We agree that preoperative flap volume estimation will support surgical planning for adequate breast volume replacement and facilitate the intraoperative flap trimming and final breast shaping, resulting in reduced operative time, and may be helpful in preoperative patient consultation.

Current approaches for flap volume/weight determination include intraoperative water displacement or ordinary weight measurements, preoperative ultrasound, and three-dimensional computed tomographic angiography–based calculations.2,3 In particular, computed tomographic angiography has proven clinical utility in the accurate vascular perforator supply determination and preoperative preparation in abdominal free flap breast reconstruction. Furthermore, the diagnostic application of computed tomographic angiography can be easily expanded to flap volume assessment before surgery with potential clinical benefit.3 According to the surgeon's preoperative flap markings, a virtual three-dimensional model of the abdominal flap can be reconstructed based on preoperative computed tomographic angiography with the resulting flap dimension (in centimeters), surface (in square centimeters), and volume (in cubic centimeters) (Fig. 1). As harvested flap dimensions are subject to intraoperative soft-tissue changes,3 three-dimensional surface scans of the harvested flap were obtained for comparison of the intraoperative flap geometry and volume (three-dimensional scan volume, 534 cc) to the preoperative three-dimensional computed tomographic estimations (three-dimensional computed tomographic scan volume, 549 cc) and to the actual measured flap weight (flap weight, 550 g). Flap dimensions changed significantly with reduction in the horizontal plane and flap enlargement in the vertical plane combined with a flap thickness increase (Fig. 1). The skin surface (in square centimeters) showed a valuable decrease by 15 percent. Although flap geometry has changed, the predicted preoperative (three-dimensional computed tomography) and intraoperative (three-dimensional scan) flap volumes showed no relative differences compared with the actual measured flap weight, assuming that adipose tissue density is approximately 1.0 to 1.1 g/ml.35

Fig. 1:
Virtual three-dimensional (3-D) model of the deep inferior epigastric artery perforator flap reconstruction of the preoperative computed tomographic angiography scan (left) according to the surgeon's markings and resulting flap dimensions (in centimeters), surface (in square centimeters), and volume calculations (in cubic centimeters). Intraoperative three-dimensional surface scan model of the harvested deep inferior epigastric artery perforator flap and the corresponding flap geometry changes (right) compared with the actual intraoperative flap weight (in grams). CT, computed tomography.

Modern three-dimensional imaging techniques offer significant benefit for the surgeon, especially in the field of breast volume assessment for preoperative planning purposes using noninvasive three-dimensional surface imaging.5 However, three-dimensional computed tomographic angiography–based preoperative flap volume prediction is limited because of the patient's exposure to radiation and contrast medium application, and should be used solely as an expanded assessment method if computed tomographic angiography is indicated for perforator mapping in autologous abdominal breast reconstruction planning.

Therefore, we highly appreciate the approach presented by the authors based on simple distance measurements and applied formula calculations. Although the predefined geometric shape of a triangle is imposed on the abdomen, which does not necessarily correspond to the individual marked flap dimensions and may cause the presented average measurement error, clinical implementation can be performed quickly and is relatively feasible, cheap, patient-friendly, noninvasive without radiation exposure, and obviously able to deliver reliable results. We believe that a combination of noninvasive three-dimensional surface imaging with simple predictive calculation approaches like the one presented by the authors1 will open up very promising perspectives in many areas of reconstructive microsurgery.

Maximilian Eder, M.D.

Stefan Raith, Dipl.-Ing.

Research Group Computer Aided Plastic Surgery, Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany

Jalil Jalali, M.Sc.

Research Group Computer Aided Plastic Surgery, Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany, Institute of Medical Engineering, Technische Universität München, Garching, Germany

Laszlo Kovacs, Ph.D., F.A.C.S.

Research Group Computer Aided Plastic Surgery, Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany


Funding for the study was received from the Federal Ministry of Economics and Technology (BMWi funding no. KF2061601KJ1).


The authors have no financial interest to declare in relation to the content of this communication.


1. Mohanna PN, Farhadi J. A method of preoperatively assessing the volume of abdominal tissue available for an autologous breast reconstruction. Plast Reconstr Surg. 2012;129:756e–757e.
2. Minn KW, Hong KY, Lee SW. Preoperative TRAM free flap volume estimation for breast reconstruction in lean patients. Ann Plast Surg. 2010;64:397–401.
3. Rosson GD, Shridharani SM, Magarakis M, et al.. Three-dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction. Microsurgery 2011;31:510–516.
4. van der Pot WJ, Kreulen M, Melis P, Hage JJ. Specific volume of female subcutaneous abdominal tissue as a reference in autologous breast reconstruction. J Reconstr Microsurg. 2010;26:185–188.
5. Kovacs L, Eder M, Hollweck R, et al.. Comparison between breast volume measurement using 3D surface imaging and classical techniques. Breast 2007;16:137–145.


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