title: Displaying inguinal lymph nodes before transplantation in a deep inferior epigastric perforator flap breast reconstruction using an innovative projection method.
abstract: BACKGROUND
  Lymphedema of the arm is a common postoperative complication as a result of breast cancer surgery. One of the surgical treatments comprises modification of a deep inferior epigastric perforator (DIEP) flap breast reconstruction to facilitate additional lymph node transplantation from the inguinal area. Using computed tomography angiography (CTA), the distribution of these lymph nodes can be assessed. A virtual planning based on this CTA created for the DIEP flap is presented, with the inguinal lymph nodes included, followed by preoperatively projecting this information on the patient's abdomen.
  
  
  METHODS
  A total of 10 patients underwent the standard imaging protocol: A preoperative CTA to assess the vascular anatomy of the lower abdomen. A three-dimensional (3D) model of the blood vessels was produced, and the inguinal lymph nodes in this reconstruction were included. Preoperative projection of the 3D model onto the patients' abdomen and inguinal area was performed, followed by tracing of this image. Intraoperatively found lymph nodes were identified by touch and compared with the markings on the skin.
  
  
  RESULTS
  In all 10 patients, all lymph nodes located preoperatively were found intraoperatively within a 1-cm radius of the marking on the skin; and these were more easily located by two operating surgeons.
  
  
  CONCLUSIONS
  Virtual planning of lymph node transplantations in a deep inferior epigastric artery perforator flap breast reconstruction seems feasible and can be performed quickly. This additional visual support aids the surgeon in locating the lymph nodes in the inguinal area.
authors.affiliation: Department of Plastic Surgery, Radboudumc, Nijmegen, The Netherlands; Department of Interventional Radiology, Radboudumc, Nijmegen, The Netherlands. Electronic address: stefan.hummelink@radboudumc.nl.
authors.forename: S
authors.initials: S
authors.lastname: Hummelink
authors.affiliation: Department of Interventional Radiology, Radboudumc, Nijmegen, The Netherlands.
authors.forename: L J
authors.initials: LJ
authors.lastname: Schultze Kool
authors.affiliation: Department of Plastic Surgery, Radboudumc, Nijmegen, The Netherlands.
authors.forename: D J
authors.initials: DJ
authors.lastname: Ulrich
mesh_terms: D034861:Abdominal Wall / Q000098:blood supply / Q000601:surgery; D000328:Adult; D000792:Angiography / Q000379:methods*; D001132:Arm; D001943:Breast Neoplasms / Q000601:surgery; D015331:Cohort Studies; D019074:Epigastric Arteries / Q000637:transplantation; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D007264:Inguinal Canal; D008198:Lymph Nodes / Q000098:blood supply / Q000000981:diagnostic imaging* / Q000601:surgery; D008209:Lymphedema / Q000517:prevention & control*; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply* / Q000637:transplantation; D011300:Preoperative Care / Q000379:methods; D011379:Prognosis; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome
keywords: Breast reconstruction; CTA; DIEP flap; Deep inferior epigastric perforator flap; Pico video projector; Vascularized lymph node transfer