Imaging: The Ultimate Game-Changer in Reconstructive Microsurgery

Over the years of reconstruction, the tools for diagnosis were limited for reconstructive microsurgeons. For decades, the main tools were the knowledge of anatomy, anecdotal experience, and most of all good judgment [1]. In the modern era, the angiogram and CT angiograms played a key role in providing critical information of the vascular status of the limb or the zone of injury [2, 3]. While the imaging was focused on understanding the overall circulation of the injury, imaging to evaluate the donor site was still difficult. With the introduction of handheld Doppler, it further brought understanding of recipient vessels, donor vessels like perforators and most of all, the simplicity allowed it to be used not only preoperatively but help intraoperative decision-making and postoperative monitoring [4–8]. The handheld Doppler opened the doors to freestyle flaps where the flap can be designed around any perforator [5, 9]. This revolutionized the reconstructive surgery approach and outcome reaching success rate as high as 90–99% [5, 10]. Despite entering the age where reconstructive microsurgery is now practiced routinely, microsurgeons continue the endeavor to make flap reconstruction easier, replicable, reliable, and efficient [1]. Thus, new diagnostic evaluation tools are constantly being introduced to this field. The introduction of thermography and indocyanine green angiography as new tools allows us to have a better understanding of flap surgery, which is even available on your mobile device [11–14]. However, all tools have their pros and cons. When considering the cost, imaging speed, learning curve, perforator imaging, flow physiology, and depth of tissue information, one must determine which imaging modalities are able to provide the best information [15] (Table 1.1). Of course, if the surgeon has the luxury to apply various and multiple imaging, it will provide you with more information that may lead to better understanding of the overall layout prior to and during the reconstruction. In the author’s opinion, color duplex ultrasound (CDU) is the tool that is able to provide the most information with highest efficiency. Early reports of using CDU have shown it efficacy and precision in identifying various anatomical structures including perforators [8, 16–20]. Unfortunately, despite early reports, the CDU did not gain wide usage among reconstructive surgeons due to the lack of accessibility. These are the presently widely used and available imaging modalities for reconstructive surgeons [15]. A brief introduction will be made in this chapter, and the details will be covered by modality and approach in the following chapters.