Use of a Three-Dimensional Virtual Reality Model for Preoperative Imaging in DIEP Flap Breast Reconstruction 1 Purificacio ´n Gacto-Sa ´nchez, M.D.,* ,2 Domingo Sicilia-Castro, M.D., Ph.D.,* Toma ´s Go ´mez-Cı ´a, M.D., Ph.D.,* Araceli Lagares, M.D.,* Teresa Collell, M.D.,* Cristina Sua ´rez, D.B.D.I.,† Carlos Parra, D.B.D.I.,† Pedro Infante-Cossı ´o, M.D., Ph.D.,* and Jose Marı ´a De La Higuera, M.B.B.S.† *Plastic and Reconstructive Surgery Department, University Hospitals Virgen del Rocı´o, Sevilla, Spain; and †Technological Development and Investigation Group, Project Direction, University Hospitals Virgen del Rocı´o, Sevilla, Spain Submitted for publication November 12, 2008 Background. The significant variation in the vascu- lar anatomy of the abdominal wall makes preoperative imaging essential when raising a deep inferior epigas- tric artery perforator (DIEP) flap due to the potential for maximizing operative success, reducing intraopera- tive error and minimizing operative complications. Computerized models and virtual reality applications are being used to facilitate teaching and preoperative evaluation in a number of other complex anatomical regions. The variability in perforator anatomy makes DIEP flap surgery a suitable candidate for application of such technology. In this context, a study was undertaken to determine the feasibility of computed tomography angiography (CTA)-guided VirSSPA three- dimensional (3D) software for virtual reality navigation in DIEP flap surgery and to compare findings with oper- ative measurements. Materials and Methods. We recruited 12 consecutive patients planned for an elective DIEP flap for breast reconstruction. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and VirSSPA 3D recon- struction. Imaging findings were compared with oper- ative findings. Results. In all cases, the major perforators were accurately localized using both methods. 3D recon- struction of the abdominal wall with VirSSPA demon- strated a significant good correlation with perforator location compared with operative findings, showing an average error rate of 0.23 cm (95% CI, 0.17–0.30). Conclusion. In short, the main advantage of VirSSPA, when used in conjunction with an image assessment such as CTA, is to provide additional and potentially more accurate data over conventional CTA with regard to the site of the best perforators and its course through the muscle. Ó 2010 Elsevier Inc. All rights reserved. Key Words: computer assisted surgery; reconstruc- tive surgical procedures; microsurgery. INTRODUCTION The increased use of perforator flaps has raised the need for preoperative familiarity with an individual’s particular anatomical features of the deep inferior epigastric artery and its perforating branches, espe- cially when there is such a significant variation in the anatomy of the vascular supply to the abdominal wall [1–3]. Plastic and reconstructive surgery is well suited for image-guided techniques, particularly in the domain of perforator flaps, since preoperative awareness of per- forator location and course can permit improved flap design and reliability, operative safety, and planning of the incision. Furthermore, it might reduce intraoper- ative decision-making (such as deciding which perfora- tor to use), thus potentially contributing to a significant reduction in operative time. Ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA) have been described in the literature as showing benefit for perforator mapping [4–12]. Unidirectional Doppler sonography is the most common instrument for preop- erative location of individual vessels because it is 1 Part of this study was presented at the 43rd Annual Meeting of the Spanish Association of Plastic Surgeons (SECPRE), Zaragoza, Spain, June 2008. 2 To whom correspondence and reprint requests should be addressed at Plastic and Reconstructive Surgery Department, Univer- sity Hospitals Virgen del Rocı ´o, Avenida Manuel Siurot s/n. 41013, Sevilla, Spain. E-mail: purigacto@gmail.com. 0022-4804/$36.00 Ó 2010 Elsevier Inc. All rights reserved. 140 Journal of Surgical Research 162, 140–147 (2010) doi:10.1016/j.jss.2009.01.025