title: Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques.
abstract: BACKGROUND
  Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject.
  
  
  METHODS
  The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress.
  
  
  RESULTS
  The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA.
  
  
  CONCLUSIONS
  While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.
authors.affiliation: Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy, University of Melbourne, Parkville, Victoria, Australia.
authors.forename: George F
authors.initials: GF
authors.lastname: Pratt
authors.forename: Warren M
authors.initials: WM
authors.lastname: Rozen
authors.forename: Daniel
authors.initials: D
authors.lastname: Chubb
authors.forename: Mark W
authors.initials: MW
authors.lastname: Ashton
authors.forename: Alberto
authors.initials: A
authors.lastname: Alonso-Burgos
authors.forename: Iain S
authors.initials: IS
authors.lastname: Whitaker
mesh_terms: D000792:Angiography / Q000379:methods; D006801:Humans; D018810:Magnetic Resonance Angiography; D008866:Microsurgery / Q000379:methods*; D011300:Preoperative Care / Q000379:methods*; D019651:Plastic Surgery Procedures / Q000379:methods*; D013524:Surgical Flaps / Q000098:blood supply*; D014057:Tomography, X-Ray Computed; D018615:Ultrasonography, Doppler, Color