Doppler ultrasound versus computed tomography angiography prior to deep inferior epigastric perforator flap breast reconstruction: An updated systematic review and meta-analysis.

Abstract

Preoperative perforator mapping is essential for optimizing outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction. Computed tomography angiography (CTA) and Doppler ultrasound (US) are widely used, but their relative effectiveness remains uncertain. Previous reviews were limited by small numbers of randomized trials and inconsistent outcome reporting. PubMed, Embase, and Cochrane Library were searched through May 2025. Eligible studies compared CTA imaging with Doppler US, reporting flap loss, reoperation, or operative time. Risk of bias was assessed using RoB 2 and ROBINS-I. Subgroup and sensitivity analyses explored heterogeneity and study design effects. Twelve studies involving 1784 patients were included, incorporating two additional RCTs in comparison with previous meta-analyses. CTA was associated with lower flap loss (RR 0.37; 95% CI 0.18-0.78) and reoperation rates (RR 0.55; 95% CI 0.33-0.89), and shorter operative time (MD -65 min; 95% CI -101 to -29) compared to Doppler US. This review is the first to meta-analyze reoperation as an endpoint and provide comprehensive sensitivity analyses, confirming the robustness of the findings. Subgroup analyses revealed that observed benefits were driven largely by observational studies, whereas pooled RCTs did not show significant differences. This expanded review strengthens prior evidence by including additional RCTs, analyzing reoperation as a key outcome, and applying more rigorous subgroup and sensitivity approaches. CTA appears to improve efficiency and reduce complications, but randomized evidence remains limited. CTA and Doppler US may be appropriate depending on surgeon expertise and institutional resources, highlighting the need for larger, high-quality RCTs.