Influence of Preoperative Perforator Mapping Modality on Outcomes in DIEP Flap Breast Reconstruction: A Multicenter Registry Analysis

Background: Preoperative perforator mapping is widely used to guide perforator selection in deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, the impact of different imaging modalities on operative variables and postoperative outcomes remains unclear. Methods: We performed a retrospective analysis of a multicenter breast reconstruction registry including patients who underwent autologous DIEP flap breast reconstruction between 2011 and 2018. Mapping modalities included computed tomography angiography (CTA), magnetic resonance angiography (MRA), color-coded duplex sonography (CCDS), hand-held Doppler sonography (HHDS) or no preoperative mapping. Outcomes included operative time, number of included perforators, and major flap-related complications. Subgroup analyses were performed for unilateral procedures and Holm zone classifications. Associations between perforator number, body mass index (BMI), and complication risk were evaluated. Results: A total of 4283 DIEP flaps were included for analysis. CTA was associated with fewer included perforators and a lower rate of major complications in unilateral reconstructions compared with other modalities. CCDS was associated with the highest number of included perforators. An increasing perforator number was not associated with reduced major complication rates. Higher BMI was associated with increased complication risk, particularly in flaps including Holm zone 4. Conclusions: Preoperative CTA-based perforator mapping was associated with fewer selected perforators and lower major complication rates in unilateral DIEP reconstruction. The number of included perforators alone did not predict complications, while obesity appeared to increase risk in extended perfusion territories. These findings support individualized preoperative planning and careful consideration of patient risk factors.