When Washington University plastic and reconstructive surgeon Rachel Anolik, MD, is planning a DIEP flap surgery, she looks for blood vessels that meet a very strict set of criteria. The vessels need to have a direct path through the muscle and a branching pattern that will perfuse the area of tissue with a healthy blood supply. Choosing the right blood vessels improves the patient’s ability to heal after surgery. An innovative new technology being tested at Washington University School of Medicine in St. Louis, which uses virtual reality to create three-dimensional images, promises to make this aspect of surgical planning more efficient.
DIEP (deep inferior epigastric perforator) flap surgery is a newer type of tissue reconstruction used to rebuild a person’s breast after mastectomy. Like TRAM flap surgery and other forms of tissue reconstruction, a DIEP flap uses skin, fat and blood vessels from the abdomen. Unlike other flap procedures, DIEP flap surgery does not take any abdominal muscle. This reduces the risk of incisional hernias, can lead to shorter recovery times than other flap procedures, and creates a more natural looking breast. For these reasons, DIEP flap surgery is considered a state-of-the-art surgical option for breast reconstruction. Anolik notes that this type of surgery requires a high level of preparation and a clear surgical plan to ensure the best outcomes.
Read more: What is DIEP flap surgery?
“Because we are not taking any muscle, it is important for us to select blood vessels with good perfusion and a direct muscular course through the rectus abdominis,” Anolik says. The perfusion will help carry blood supply throughout the tissue when it is transplanted to the chest, improving healing. A direct muscular course reduces the impact of surgery on the muscles of the abdominal wall.
The View from Inside
Before DIEP flap surgery, patients typically have a CT scan. This allows the surgeon to plan for the procedure by viewing images of the blood vessels, muscle and other tissue in the area. While helpful, CT scans are two-dimensional images of 3D spaces. This means that, traditionally, the surgeon has to imagine what the anatomy would look like in three dimensions. The Division of Plastic and Reconstructive Surgery is pilot testing a new technology that uses virtual reality to create 3D versions of CT scans.
“We are able to color code different types of tissue in this 3D visualization,” says Anolik, who is leading the trial. “For instance, we don’t need to see inside the abdominal cavity, so we can ‘delete’ those organs from our view. What we do want is: skin, fat, muscle, blood vessels. This technology allows us to shade those things in different colors and make them semitransparent, so we can see the path of blood vessels through the muscle.”
If CT scans provide a roadmap for intraoperative planning, VR headsets create a “street view,” putting you directly inside the anatomy. The surgeon can put on a VR headset and “step inside” the imaging, rotating their view, looking at the anatomy from different angles. This 3D view is created using the CT scans a patient usually has before flap surgery, meaning no additional tests or appointments are necessary to equip surgeons with this powerful tool.
“Originally, before imaging was available, we relied strictly on surgical judgment to determine the best perforating vessels to take,” says Division Chief of Plastic and Reconstructive Surgery Justin Sacks, MD, MBA. “CT scans gave us a picture of the abdomen, but that’s not the same as operating in three dimensions. With this technology, we are inside the abdominal wall, developing a game plan in the metaverse. It helps you make these decisions before you make an incision. This truly takes surgery to a more sophisticated level.”
The Future of Reconstruction
The benefits of this immersive visualization extend to the entire surgical team. When operating room staff, including scrub technicians and nurses, can see precisely what the surgeon sees, before the surgery even begins, everyone involved knows what to expect. This can improve the efficiency of DIEP flap surgery, which tends to be a long operation.
“In addition to its patient benefits, this innovative technology has potential as a training tool,” says Anolik, who mentors trainees in the Plastic Surgery Residency Program. “If everyone puts on the headset, everyone is armed with the same information. Medical students, residents, fellows: they can all see the same thing I am seeing as the surgeon leading the case. We are all sharing the same information.”
Sacks anticipates this technology will extend to other procedures and surgical specialties. In the future, surgeons may be able to “step inside” the body with 3D VR imaging to examine tumors and prepare for oncologic surgeries. For Sacks and Anolik, it seems only natural that plastic and reconstructive surgeons lead the way in piloting this technology.
“Plastic surgery is a very innovative field,” says Sacks, who is the Sydney M. Shoenberg, Jr. and Robert H. Shoenberg Endowed Chair in Plastic and Reconstructive Surgery. “Innovation is about more than doing a surgery faster. Innovation means a complete shift in thinking, a shift in how you approach a surgery. This technology is an innovation we are using to improve outcomes for our patients, enhance our training programs and conduct new research in the area of breast reconstruction.”