PERFORATÖR HARİTALAMADA GÜNCEL YÖNTEMLER

Deri perforatörlerinin yerleşiminde, doku planları arasındaki seyrinde ve dallanmalarında görülen farklılıklar nedeniyle perforatör flep cerrahisi öncesi vasküler haritalandırmaya ihtiyaç vardır. Bu makalede amaç, perforatör flep cerrahisinin planlanmasında perforatör damar haritalamasının önemini vurgulamak ve kullanılan yöntemleri tartışmaktır. Taşınabilir akustik dopler sonografi, renki dopler ultrasonografi, multi-detektör bilgisayarlı tomografik-anjiografi (MDBT-ANJ) ve manyetik rezonans anjiografi (MR-ANJ) karşılaştırılmıştır. Taşınabilir akustik dopler sonografi ucuz ve kolay uygulanabilir bir yöntemdir. Ancak yanlış pozitiflik yüksektir ve çoğu zaman tek başına yeterli olmamaktadır. Renkli dopler ultrasonografi akım hızını, damar çapını ve dallanmaları değerlendirir. Ancak deneyimli bir radyolog gerekliliği ve incelemenin uzun sürmesi zayıf yönleridir. MDBT-ANJ ile damar haritalaması, perforatör flep cerrahi planlanmasında en iyi yöntemlerden birisidir. Hassasiyeti yüksektir, hızlı uygulanır ve üç boyutlu detaylı anatomik bilgi verir. Ancak cihazın kendisinin ve uygulamasının maliyeti yüksektir, iyonizan radyasyonun ve kontrast maddelerin zararlı etkileri bu görüntüleme yönteminin dezavantajlarıdır. MR-ANJ ise radyasyon ve kontrast madde kullanılmayan bir görüntüleme yöntemi olması nedeniyle MDBT-ANJ’den üstündür. Ancak görüntü kalitesi halen MDBT-ANJ kadar iyi değildir. Sonuç olarak, perforatör flep cerrahi planlamasında seçilecek yöntemi, çalışılan merkezin olanakları ile kişisel deneyim ve tercih belirlemektedir. MDBT-ANJ veya MR-ANJ bu amaç için kullanılabilecek en ileri tekniklerdir. MDBT-ANJ yüksek kalitede, detaylı görüntü sunarken, MR-ANJ radyasyon vermeksizin buna yakın kalitede görüntü sağlamaktadır. Ameliyat planlamasında tercih edilen görüntüleme yöntemine, akustik dopler sonografi ve ameliyat sırasında görsel değerlendirmenin eklenmesi ile doğru perforatör damar seçiminde hata payı sıfırlanabilir.

Anahtar Kelimeler:

Perforatör flep, perforatör haritalama, dopler, multidetektör BT anjiyografi, MR anjiyografi

CURRENT TRENDS IN PERFORATOR MAPPING

Due to variations in location, course between tissue planes and branching of the skin perforators, a preoperative vascular mapping is mandatory during perforator flap surgery. The aim of this article is to emphasize the importance of perforator mapping in preoperative planning of the perforator flaps and discuss each method used. Hand held acoustic doppler sonography, color doppler ultrasonography, multi-detector computed tomographic angiogram (MDCT-ANG) and magnetic resonance angiography (MR-ANG) were compared. Hand held acoustic doppler sonography is a cheap and simple method, but it has a high rate of false positivity and most of the time it is inadequate when used alone. Color doppler ultrasonography evaluates the flow rates, vessel diameters and branching. But an experienced radiologist is needed and the examination takes long time. Vascular mapping with MDCT-ANG is one of the most valuable methods in preoperative planning of perforator flaps. It has high sensitivity, can be applied fast and gives detailed three-dimensional anatomical information. But the expensive cost of the machine itself and its application, and unwanted effects of ionizing radiation and radio-opaque are the disadvantages. MR-ANG is a radiation and contrast free imaging technique, however the quality of the images is not as good as MDCT-ANG. In conclusion, the facilities of the center, experiences and personal preferences determine the method chosen for surgical planning of the perforator flaps. MDCT-ANG and MR-ANG are the most advanced and powerful tools for this purpose. MDCT-ANG provides high quality detailed images; MR-ANG gives moderate quality images without the need of radiation. If verification with acoustic doppler sonography and intraoperative visual evaluation is added to the chosen imaging technique during preoperative planning, possibility of errors in correct perforator selection can be minimized.

Keywords:

Perforator flap, perforator mapping, doppler, multidetector CT angiography, MR angiography,

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