ARTICLE IN PRESS JID: PRAS [m6+;December 17, 2020;16:6] Journal of Plastic, Reconstructive & Aesthetic Surgery (2020) 000, 1–12 Review The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis John Kiely a,* , Mayank Kumar b , Ryckie G. Wade c,d a Department of Plastic and Reconstructive Surgery, Bradford Teaching Hospitals Trust, Bradford, UK b Department of Trauma & Orthopaedics, Leeds Teaching Hospitals Trust, Leeds, UK c Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK d Leeds Institute for Medical Research, The University of Leeds, Leeds, UK Received 26 April 2020; accepted 2 December 2020 Available online xxx KEYWORDS Breast reconstruction; Computed tomography angiography; Magnetic resonance angiography; Ultrasonography; Free tissue flaps; Systematic review Summary Background: Perforator mapping may be performed prior to deep inferior epigas- tric perforator (DIEP) flap breast reconstruction to guide perforator selection. However, the accuracy of different imaging modalities remains unknown. This review aimed to evaluate the accuracy of different modalities for locating perforators for unipedicled DIEP flap breast recon- struction. Methods: MEDLINE and EMBASE were searched from inception to 24th September 2019 for studies concerning adult women undergoing DIEP flap breast reconstruction with preoperative perforator mapping. The index test was pre-operative imaging and the reference standard was intraoperative identification. Results: 21 articles with 1146 women were included. Six methods were described; handheld doppler, colour doppler (duplex) ultrasonography, computed tomography angiography, mag- netic resonance angiography (MRA), direct infrared thermography with and without doppler. Meta-analysis revealed 94% (95% CI 88–99%) of DIEPs identified as the ‘dominant perforator’ on imaging were chosen as dominant perforators intraoperatively. Colour doppler (Duplex) ultra- sonography had the lowest agreement (mean 74% [95% CI 67–81%]) whilst MRA had the highest agreement (mean 97% [95% CI 86–100%]). There was no statistically significant difference in the performance of different tests. All studies were subject to bias as the operators had knowledge of the index test prior to conducting the reference standard. Abbreviations: FP, false positive; FN, false negative; QUADAS, Quality Assessment of Diagnostic Accuracy Studies; TP, true positive; TN, true negative. ∗ Corresponding author. E-mail address: john.kiely@bthft.nhs.uk (J. Kiely). https://doi.org/10.1016/j.bjps.2020.12.005 1748-6815/© 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Please cite this article as: J. Kiely, M. Kumar and R.G. Wade, The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis, Journal of Plastic, Reconstructive & Aesthetic Surgery, https: //doi.org/10.1016/j.bjps.2020.12.005