Duplex ultrasound-based step-by-step perforator mapping by a microsurgeon for DIEP flap planning: A prospective case series

BACKGROUND: Precise preoperative assessment and selection of optimal perforators are critical to optimize outcomes in DIEP flap microsurgical breast reconstruction (BR). Although CTA is widely used, color-coded duplex sonography (CCDS) offers a radiation-free and cost-effective alternative. This study presents a standardized step-by-step protocol for duplex-based perforator mapping and evaluates its application in a prospective case series. METHODS: We prospectively enrolled patients who underwent unilateral or bilateral DIEP flaps BR between January 2022 and January 2025. All patients received preoperative CCDS mapping to identify the dominant perforator. Variables recorded included number, location, size, and flow characteristics of perforators, flap weight, and flap-related complications. RESULTS: A total of 62 flaps were performed. The average number of perforators identified per flap was 3.19 (SD: 1.39), with a mean of 1.35 (SD: 0.54) perforators harvested. The mapped dominant perforator matched the intraoperative finding in 50/62 cases (80.64%), with agreement being statistically higher in unilateral flaps than in bilateral flaps (88.63% vs. 61.11%; p=0.018). The choice of perforator row was statistically different between the unilateral and bilateral flaps (p=0.045), with 70.4% of medial row in unilateral and 55.5% of lateral row in bilateral flaps. Postoperative complications occurred in 6 flaps (9.68%): fat necrosis (n=3), partial flap necrosis (n=2), and total flap loss (n=1). CONCLUSION: Using our step-by-step approach, preoperative CCDS is known to be a reliable, reproducible, and non-invasive tool for assessing perforators in DIEP flap reconstruction. This examination may represent a feasible, radiation-free adjunct that can be performed directly by the microsurgeon preoperatively. LEVEL OF EVIDENCE: IV.