Combining CTA and US reduces complication rates in DIEP flap reconstruction compared to US aloneCombining imaging tests may lower complications in breast reconstruction

Microsurgery Published July 27, 2026 Study authors: Brooks Athena, Lemke Jessica, Hornbach Anna, Keller Nathan, Foppiani Jose, Escobar-Domingo Maria J, … PubMed ↗ DOI ↗ Editorial oversight: Dr. Lars van Dijk, PhD · Surgical, Procedural & Diagnostic

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Key Takeaway

Consider combined CTA and US imaging to potentially reduce complication rates in DIEP flap reconstruction.

This meta-analysis evaluates various preoperative imaging modalities, including CTA, US, MRA, SPY/ICG, and DIRT, for patients undergoing DIEP flap reconstruction. The analysis synthesizes data from 3238 patients to compare outcomes such as perforator utilization and complication rates across different imaging combinations.

Key findings indicate that MRA showed the highest perforator utilization at 92%, followed by CTA (87%) and US (85%). Regarding safety, the combination of CTA and US was associated with a complication rate of 10.8%. In contrast, US alone had a higher complication rate of 17.3% (410/2967), while CTA alone had a rate of 13.9% (410/2967). The risk of complications for US alone versus the combination of CTA and US was significantly lower (RR = 0.63; p=0.0123). Comparisons between CTA alone and other modalities did not reach statistical significance.

Clinical practice relevance suggests that while CTA is a well-studied modality with high perforator utilization, combining it with US may improve outcomes by reducing complication rates. However, as the underlying data are from observational studies, these results reflect associations rather than direct causation.

When a patient undergoes a DIEP flap reconstruction, surgeons must identify tiny blood vessels called perforators to ensure the tissue survives. Choosing the right imaging tool before surgery is vital for a successful outcome. This study looked at how different imaging methods impact these results.

Researchers analyzed data from over 3,000 patients to compare several tools. They found that using both CT scans (CTA) and ultrasounds (US) resulted in the lowest complication rate of 10.8%. In contrast, using ultrasound alone had a higher complication rate of 17.3%. While CTA alone showed a lower rate than ultrasound alone, combining the two methods showed a promising trend for patient safety.

While these findings suggest that combined imaging helps surgeons find more blood vessels and reduces risks like fat necrosis or flap loss, it is important to remember these results come from observational data. This means the study shows a link between the tools used and the outcomes, but doesn't prove one causes the other directly. Talk to your surgical team about which imaging path is best for your specific needs.

What this means for you:

Combining CT scans and ultrasounds before surgery may lower complication rates in DIEP flap reconstructions.

Common questions

What are the risks of using only an ultrasound before surgery?

The study found that using ultrasound alone resulted in a complication rate of 17.3%. This was higher than the rates seen when surgeons used CT scans alone (13.9%) or a combination of both CT scans and ultrasounds (10.8%). You should discuss these specific risks with your surgeon to decide on the best imaging plan.

How does combining different imaging tools help my surgery?

Combining CTA (CT scans) and US (ultrasound) may improve outcomes by helping surgeons identify more blood vessels, known as perforators. The data showed that this combined approach had the lowest complication rate of 10.8% compared to other methods. This helps ensure the reconstructed tissue has a better chance of success.

What kind of complications can occur during these reconstructions?

Common issues include fat necrosis, which occurred in 19% of cases, and partial flap loss, which happened in 14% of cases. Total flap loss was seen in 8% of complications. These risks are monitored closely by your surgical team to ensure the best possible outcome.

Study Details

Study typeMeta analysis

Sample sizen = 3,238

EvidenceLevel 1

PublishedJul 2026

PMID42304573

View Original Abstract ↓

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flaps are widely used in autologous breast reconstruction and increasingly favored due to superior patient-reported outcomes. Preoperative imaging is central to efficient and safe DIEP flap planning, yet the optimal modality remains debated. While computed tomography angiography (CTA) is recommended by ERAS protocols, concerns over radiation exposure and cost have prompted interest in alternatives such as ultrasound (US) and magnetic resonance angiography (MRA). METHODS: A systematic review following PRISMA guidelines was conducted across five major databases, including clinical trials and observational studies published through 2025. Studies included patients undergoing DIEP flap reconstruction with preoperative imaging using CTA, US, MRA, or other modalities. Data extracted included imaging-to-surgical perforator correlation, operative time, complication rates, and flap outcomes. Meta-analyses and heterogeneity assessments were performed using STATA. RESULTS: Thirty-two studies encompassing 3238 patients were included. CTA was used in nearly all studies; US, MRA, SPY/ICG, and DIRT were evaluated in a subset. Pooled perforator utilization was highest with MRA (92%), followed by CTA (87%) and US (85%). Among 2967 patients with complication data, 410 (13.8%) experienced adverse outcomes. Complication rates differed significantly across strategies. Patients utilizing US alone experienced the highest complication rates (17.3%), compared to CTA alone (13.9%) and CTA and US (10.8%). The complication rate difference between US alone patients and CTA and US alone patients was statistically greater (RR = 0.63, p = 0.0123). The complication rates between CTA alone and US alone or CTA and US were not statistically different (US alone: RR = 0.81, p = 0.1040; CTA and US: RR = 0.78, p = 0.11). Complete flap loss occurred in 8.0% of complications, partial flap loss in 14%, and fat necrosis in 19%. CONCLUSION: CTA remains the most studied imaging modality for DIEP flap surgical planning, demonstrating high perforator utilization and low complication rates. Combining CTA with US may further improve outcomes by integrating anatomical precision with dynamic feedback. As newer, lower-risk imaging technologies emerge, comparative studies are needed to determine whether they can match or exceed the performance of CTA in DIEP reconstruction.

Combining CTA and US reduces complication rates in DIEP flap reconstruction compared to US aloneCombining imaging tests may lower complications in breast reconstruction

Common questions

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Combining CTA and US reduces complication rates in DIEP flap reconstruction compared to US aloneCombining imaging tests may lower complications in breast reconstruction

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