{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T13:04:39Z","timestamp":1790687079640,"version":"4.1.0"},"reference-count":34,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"German Society of Plastic, Reconstructive and Aesthetic Surgeons"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Preoperative perforator mapping is widely used to guide perforator selection in deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, the impact of different imaging modalities on operative variables and postoperative outcomes remains unclear. Methods: We performed a retrospective analysis of a multicenter breast reconstruction registry including patients who underwent autologous DIEP flap breast reconstruction between 2011 and 2018. Mapping modalities included computed tomography angiography (CTA), magnetic resonance angiography (MRA), color-coded duplex sonography (CCDS), hand-held Doppler sonography (HHDS) or no preoperative mapping. Outcomes included operative time, number of included perforators, and major flap-related complications. Subgroup analyses were performed for unilateral procedures and Holm zone classifications. Associations between perforator number, body mass index (BMI), and complication risk were evaluated. Results: A total of 4283 DIEP flaps were included for analysis. CTA was associated with fewer included perforators and a lower rate of major complications in unilateral reconstructions compared with other modalities. CCDS was associated with the highest number of included perforators. An increasing perforator number was not associated with reduced major complication rates. Higher BMI was associated with increased complication risk, particularly in flaps including Holm zone 4. Conclusions: Preoperative CTA-based perforator mapping was associated with fewer selected perforators and lower major complication rates in unilateral DIEP reconstruction. The number of included perforators alone did not predict complications, while obesity appeared to increase risk in extended perfusion territories. These findings support individualized preoperative planning and careful consideration of patient risk factors.<\/jats:p>","DOI":"10.3390\/jcm15197562","type":"journal-article","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T12:09:25Z","timestamp":1790683765000},"page":"7562","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Influence of Preoperative Perforator Mapping Modality on Outcomes in DIEP Flap Breast Reconstruction: A Multicenter Registry Analysis"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3415-3051","authenticated-orcid":false,"given":"Uwe von","family":"Fritschen","sequence":"first","affiliation":[{"name":"Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Walterh\u00f6ferstra\u00dfe 11, 14165 Berlin, Germany"},{"name":"Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2473-5816","authenticated-orcid":false,"given":"Andreas","family":"Arkudas","sequence":"additional","affiliation":[{"name":"Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-N\u00fcrnberg (FAU), 91054 Erlangen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Maike","family":"Keck","sequence":"additional","affiliation":[{"name":"Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, 20259 Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4906-6062","authenticated-orcid":false,"given":"Sonia","family":"Fertsch","sequence":"additional","affiliation":[{"name":"Department of Plastic and Aesthetic Surgery, Interdisciplinary Breast Center, Sana Kliniken D\u00fcsseldorf GmbH, 40625 D\u00fcsseldorf, Germany"},{"name":"Faculty of Health, University of Witten-Herdecke, 58455 Witten, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"data-curation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2826-2793","authenticated-orcid":false,"given":"Emre","family":"Gazyakan","sequence":"additional","affiliation":[{"name":"Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Klinik Ludwigshafen, Heidelberg University, 67071 Ludwigshafen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1096-9336","authenticated-orcid":false,"given":"Daniel","family":"Schiltz","sequence":"additional","affiliation":[{"name":"Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Walterh\u00f6ferstra\u00dfe 11, 14165 Berlin, Germany"},{"name":"Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,29]]},"reference":[{"key":"ref_1","unstructured":"Robert Koch-Institute (2023). Brustdr\u00fcse. Krebs in Deutschland, Robert Koch-Institute."},{"key":"ref_2","first-page":"593","article-title":"Breast Reconstruction Following Cancer Treatment","volume":"112","author":"Gerber","year":"2015","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1002\/jso.23365","article-title":"Trends in post-mastectomy reconstruction: A SEER database analysis","volume":"108","author":"Lang","year":"2013","journal-title":"J. Surg. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1097\/PRS.0b013e3182729cde","article-title":"A paradigm shift in U.S. breast reconstruction: Increasing implant rates","volume":"131","author":"Albornoz","year":"2013","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1748","DOI":"10.1245\/s10434-010-1509-y","article-title":"Receipt of delayed breast reconstruction after mastectomy: Do women revisit the decision?","volume":"18","author":"Alderman","year":"2011","journal-title":"Ann. Surg. Oncol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.breast.2017.12.003","article-title":"Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps","volume":"38","author":"Jeong","year":"2018","journal-title":"Breast"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1097\/PRS.0000000000001747","article-title":"Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review","volume":"138","author":"Knox","year":"2016","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1054\/bjps.1998.3033","article-title":"One hundred free DIEP flap breast reconstructions: A personal experience","volume":"52","author":"Blondeel","year":"1999","journal-title":"Br. J. Plast. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1016\/0007-1226(89)90075-1","article-title":"Inferior epigastric artery skin flaps without rectus abdominis muscle","volume":"42","author":"Koshima","year":"1989","journal-title":"Br. J. Plast. Surg."},{"key":"ref_10","first-page":"248","article-title":"Breast reconstruction with the free TRAM or DIEP flap\u2014What is the current standard? Consensus Statement of the German Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels","volume":"50","author":"Eisenhardt","year":"2018","journal-title":"Handchir. Mikrochir. Plast. Chir."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"651e","DOI":"10.1097\/PRS.0000000000003768","article-title":"Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps","volume":"140","author":"Lee","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"758","DOI":"10.1097\/01.prs.0000479932.11170.8f","article-title":"Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods","volume":"137","author":"Macadam","year":"2016","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1097\/PRS.0000000000000024","article-title":"Using propensity score analysis to compare major complications between DIEP and free muscle-sparing TRAM flap breast reconstructions","volume":"133","author":"Zhong","year":"2014","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1097\/PRS.0000000000004016","article-title":"Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study","volume":"141","author":"Wilkins","year":"2018","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1097\/SAP.0b013e31816fc372","article-title":"Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction","volume":"60","author":"Andrades","year":"2008","journal-title":"Ann. Plast. Surg."},{"key":"ref_16","first-page":"58","article-title":"Quality assurance in breast reconstruction\u2014Establishment of a prospective national online registry for microsurgical breast reconstructions","volume":"52","author":"Fritschen","year":"2020","journal-title":"Handchir. Mikrochir. Plast. Chir."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1055\/s-0040-1714426","article-title":"Impact of Smoking Status in Free Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: A Multicenter Study","volume":"36","author":"Prantl","year":"2020","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1451","DOI":"10.1007\/s00404-020-05779-w","article-title":"Immediate versus secondary DIEP flap breast reconstruction: A multicenter outcome study","volume":"302","author":"Prantl","year":"2020","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Heidekrueger, P.I., Moellhoff, N., Horch, R.E., Lohmeyer, J.A., Marx, M., Heitmann, C., Fansa, H., Geenen, M., Gabka, C.J., and Handstein, S. (2021). Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany\u2014A Multi-Center Analysis Based on the DGPRAC Prospective National Online Registry for Microsurgical Breast Reconstructions. J. Clin. Med., 10.","DOI":"10.3390\/jcm10051016"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1718","DOI":"10.1016\/j.bjps.2020.12.043","article-title":"Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study","volume":"74","author":"Heidekrueger","year":"2021","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1002\/micr.30686","article-title":"Comparison of venous couplers versus hand-sewn technique in 4577 cases of DIEP-flap breast reconstructions\u2014A multicenter study","volume":"42","author":"Heidekrueger","year":"2022","journal-title":"Microsurgery"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1097\/SAP.0000000000002628","article-title":"Effect of Radiation Therapy on Microsurgical Deep Inferior Epigastric Perforator Flap Breast Reconstructions: A Matched Cohort Analysis of 4577 Cases","volume":"86","author":"Prantl","year":"2021","journal-title":"Ann. Plast. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.bjps.2021.05.050","article-title":"CT angiography prior to DIEP flap breast reconstruction: A randomized controlled trial","volume":"75","author":"Colakoglu","year":"2022","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_24","first-page":"93","article-title":"Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications","volume":"5","author":"Rozen","year":"2016","journal-title":"Gland Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1097\/01.prs.0000298313.28983.f4","article-title":"The DIEA branching pattern and its relationship to perforators: The importance of preoperative computed tomographic angiography for DIEA perforator flaps","volume":"121","author":"Rozen","year":"2008","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.bjps.2022.10.022","article-title":"Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment","volume":"76","author":"Bajus","year":"2023","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/j.bjps.2005.12.011","article-title":"Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: Imaging findings and initial experience","volume":"59","author":"Bastarrika","year":"2006","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1007\/s00266-020-01784-1","article-title":"Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes","volume":"44","author":"Bhullar","year":"2020","journal-title":"Aesthetic Plast. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1016\/j.bjps.2015.02.002","article-title":"Preoperative CT angiography versus Doppler ultrasound mapping of abdominal perforator in DIEP breast reconstructions: A randomized prospective study","volume":"68","author":"Klasson","year":"2015","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1016\/j.crad.2012.06.105","article-title":"CT-guided deep inferior epigastric perforator (DIEP) flap localization\u2014Better for the patient, the surgeon, and the hospital","volume":"68","author":"Malhotra","year":"2013","journal-title":"Clin. Radiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/GOX.0b013e318294e41d","article-title":"Increased Flap Weight and Decreased Perforator Number Predict Fat Necrosis in DIEP Breast Reconstruction","volume":"1","author":"Mulvey","year":"2013","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"772","DOI":"10.1097\/PRS.0b013e3181cb63e0","article-title":"Perforasomes of the DIEP flap: Vascular anatomy of the lateral versus medial row perforators and clinical implications","volume":"125","author":"Wong","year":"2010","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1600476","DOI":"10.3389\/fonc.2025.1600476","article-title":"A systematic review and meta-analysis on computed tomography angiography mapping for deep inferior epigastric perforator flap breast reconstruction","volume":"15","author":"Rupra","year":"2025","journal-title":"Front Oncol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"D\u2019Angelo, A., Cina, A., Macr\u00ec, G., Belli, P., Mercogliano, S., Barbieri, P., Grippo, C., Franceschini, G., D\u2019archi, S., and Mason, E.J. (2021). Conventional CT versus Dedicated CT Angiography in DIEP Flap Planning: A Feasibility Study. J. Pers. Med., 11.","DOI":"10.3390\/jpm11040277"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7562\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T12:46:24Z","timestamp":1790685984000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7562"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,29]]},"references-count":34,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197562"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197562","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,29]]}}}