Incidence of ‘Incidentalomas’ in over 100 consecutive CT angiograms for preoperative DIEP flap planning

Published:December 01, 2008DOI:


      The gold standard in breast reconstruction is the deep inferior epigastric perforator (DIEP) flaps, although muscle-sparing tranverse rectus abdominis myocutaneous (TRAM) flaps are still being performed due to variations in the abdominal vasculature and to reduce flap complications. Recently, there has been a rise in interest in preoperative imaging, in particular, by means of computer tomography angiogram (CTA). CTA has been shown to delineate the vascular anatomy, improve preoperative decision making and possibly reduce operating time and constitutes a routine preoperative investigation in our unit.
      Of the 104 consecutive patients who had undergone CTA prior to breast reconstruction, we have found a 13% incidence of unexpected findings or ‘incidentalomas’ in otherwise asymptomatic women. None were malignant, but changes to the initial operative plan included deferring immediate breast reconstruction, further surgery and further investigations for these incidentalomas.
      We recommend that all women are counselled of the possibilities of incidentalomas prior to CTA. Furthermore, clinicians need to be receptive to the possibility of a delayed or alternative reconstruction, and closely liaise with other specialties to avoid damage to the deep inferior epigastric vasculature.


      To read this article in full you will need to make a payment


        • Granzow J.W.
        • Levine J.L.
        • Chiu E.S.
        • et al.
        Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique.
        J Plast Reconstr Aesthet Surg. 2006; 59: 571-579
        • Blondeel P.N.
        One hundred free DIEP flap breast reconstructions: a personal experience.
        Br J Plast Surg. 1999; 52: 104-111
        • Blondeel P.N.
        • Boeckx W.D.
        Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery.
        Br J Plast Surg. 1994; 47: 495-501
        • Allen R.J.
        • Treece P.
        Deep inferior epigastric perforator flap for breast reconstruction.
        Ann Plast Surg. 1994; 32: 32-38
        • Nahabedian M.Y.
        • Momen B.
        • Galdino G.
        • et al.
        Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome.
        Plast Reconstr Surg. 2002; 110 (discussion 476–7): 466-475
        • Blondeel P.N.
        • Beyens G.
        • Verhaeghe R.
        • et al.
        Doppler flowmetry in the planning of perforator flaps.
        Br J Plast Surg. 1998; 51: 202-209
        • Pacifico M.D.
        • See M.S.
        • Cavale N.
        • et al.
        Pre-operative planning for DIEP breast reconstruction: early experience of the use of CT-angiography with VoNavix 3D software for perforator navigation.
        J Plast Reconstr Aesthet Surg. 2009; 62: 1464-1469
        • Rozen W.M.
        • Palmer K.P.
        • Suami H.
        • et al.
        The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps.
        Plast Reconstr Surg. 2008; 121: 367-373
        • Masia J.
        • Clavero J.A.
        • Larranaga J.R.
        • et al.
        Multidetector-row computed tomography in the planning of abdominal perforator flaps.
        J Plast Reconstr Aesthet Surg. 2006; 59: 594-599
        • Alonso-Burgos A.
        • Garcia-Tutor E.
        • Bastarrika G.
        • et al.
        Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience.
        J Plast Reconstr Aesthet Surg. 2006; 59: 585-593
        • Hamdi M.
        • Van Landuyt K.
        • Van Hedent E.
        • et al.
        Advances in autogenous breast reconstruction: the role of preoperative perforator mapping.
        Ann Plast Surg. 2007; 58: 18-26
        • Kronowitz S.J.
        • Hunt K.K.
        • Kuerer H.M.
        • et al.
        Delayed-immediate breast reconstruction.
        Plast Reconstr Surg. 2004; 113: 1617-1628
        • Rozen W.M.
        • Stella D.L.
        • Ashton M.W.
        • et al.
        The cutaneous arteries of the anterior abdominal wall: a three-dimensional study.
        Plast Reconstr Surg. 2008; 121 (author reply 1512): 1510-1512
        • Rozen W.M.
        • Phillips T.J.
        • Ashton M.W.
        • et al.
        Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and doppler ultrasound.
        Plast Reconstr Surg. 2008; 121: 1-8
        • Paluska T.R.
        • Sise M.J.
        • Sack D.I.
        • et al.
        Incidental CT findings in trauma patients: incidence and implications for care of the injured.
        J Trauma. 2007; 62: 157-161
        • Mehta V.K.
        • Goffinet D.R.
        Unsuspected abnormalities noted on CT treatment-planning scans obtained for breast and chest wall irradiation.
        Int J Radiat Oncol Biol Phys. 2001; 49: 723-725
        • Messersmith W.A.
        • Brown D.F.
        • Barry M.J.
        The prevalence and implications of incidental findings on ED abdominal CT scans.
        Am J Emerg Med. 2001; 19: 479-481
        • Xiong T.
        • Richardson M.
        • Woodroffe R.
        • et al.
        Incidental lesions found on CT colonography: their nature and frequency.
        Br J Radiol. 2005; 78: 22-29
        • Berrington de Gonzalez A.
        • Darby S.
        Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries.
        Lancet. 2004; 363: 345-351
        • Brenner D.J.
        • Hall E.J.
        Computed tomography–an increasing source of radiation exposure.
        N Engl J Med. 2007; 357: 2277-2284