Equilibrium-phase high spatial resolution contrast-enhanced MR angiography at 1.5T in preoperative imaging for perforator flap breast reconstruction Table 7.3 Number of perforator branches as identified with CE-MRA. DISCUSSION The accuracy and image quality of contrast-enhanced MR angiography at 1.5T using a blood pool contrast agent in identifying the single best DIEA perforator branch, as desired in the preoperative planning of a deep inferior epigastric perforator flap breast reconstruction procedure, was evaluated, both for equilibrium-phase high spatial resolution and first-pass imaging. Equilibrium-phase high spatial resolution imaging proved 100% accurate in identifying the single best perforator branch compared to intra- operative findings, against only 31% (11 out of 36 perforators) in first-pass imaging. Image quality of equilibrium-phase high spatial resolution imaging was significantly higher compared to first pass imaging. Preoperative identification of suitable perforator branches of the DIEA is highly valuable because it can shorten anesthesia duration and it makes surgery easier to perform and less traumatic compared to surgery based on ultrasonography.10 Although it is well known that the best perforators usually lie around the umbilicus, the anatomical variation is very high, which is proven by the results presented in figure 7.1. This also clarifies why pre- operative imaging is really a necessity to decrease dissection time, as blindly localizing the perforator branches with a handheld Doppler device per- operative is quite time consuming, whereas MRA in this study proved 100% accurate in identifying the perforator branches. Moreover the MRA gives in- formations also about the intramuscular course of the perforator and the connections between perforator and superficial epigastric system, which is also relevant information from a surgical point of view. However, pre- operative imaging with CE-MRA is challenging for a number of reasons. First of all, the relatively small caliber of the perforator branches (0.1 to 1 mm when they emerge from the fascia) makes it difficult to find an adequate balance between spatial resolution and acquisition time, especially 124
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