The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial☆
Section snippets
Background
Breast reconstruction is a common procedure that can dramatically improve the quality of life and satisfaction for women who have undergone mastectomy, with over 91,000 procedures performed in 2012.1 The success of the procedure, however, is limited by its complications, including mastectomy skin flap necrosis, which occurs at a rate of 10–15% but has been reported as high as 52% in some studies.2, 3, 4 Postoperative necrosis can have significant consequences including major morbidity, delays
Patients and methods
A prospective clinical trial was designed to evaluate the ICG angiography perfusion values associated with mastectomy skin flap necrosis. Institutional Review Board approval was obtained from the Columbia University Medical Center prior to patient enrolment. Patients presenting for tissue expander, direct-to-implant or autologous reconstruction between June 2011 and January 2013 were considered for enrolment. Verbal and written informed consent was obtained from each patient preoperatively.
Results
A total of 62 breast reconstructions were completed in 42 patients, including 48 tissue expander reconstructions, six pedicled transverse rectus abdominis myocutaneous (TRAM) flaps, six deep inferior epigastric perforator (DIEP) flaps and two direct-to-implant reconstructions. The average patient age was 53.2 years with an average follow-up of 8.8 months (a range of 3.9–22.2 months). Seven patients, comprising 11 of the 62 breasts, were active smokers at the time of surgery. Demographics and
Discussion
Currently, the standard approach to evaluating mastectomy skin flap viability is via clinician assessment intra-operatively. Prior to closure, the surgeon must assess tissue quality and excise skin based on the likelihood of necrosis in the postoperative period. With this clinically guided approach, the literature reports mastectomy skin flap necrosis rates of approximately 10–15%.7, 8 Our current study yielded a 13% rate of necrosis, consistent with the literature, with two out of eight cases
Conflict of interest statement
All of the authors have no financial interests to disclose.
Acknowledgement
We would like to thank Dr. Fatih Balci for his assistance in performing the SPY recordings in many of our patients. Additionally, we thank LifeCell Corporation and the Department of Surgery at Columbia University, who both generously sponsored our research. LifeCell Corporation assisted the authors with data collection. Neither sponsor, however, was involved in study design, interpretation of data, writing of the manuscript or the decision to submit the manuscript for publication.
References (20)
- et al.
Novadaq SPY: intraoperative quality assessment in off-pump coronary artery bypass grafting
Chest
(2004) - et al.
Improving the quality of coronary bypass surgery with intraoperative angiography: validation of a new technique
J Am Coll Cardiol
(2005) - American Society of Plastic Surgeons. 2012 Reconstructive plastic surgery statistics: ASPS national clearinghouse of...
- et al.
Management of massive mastectomy skin flap necrosis following autologous breast reconstruction
Ann Plast Surg
(2012) - et al.
Complications in postmastectomy breast reconstruction: two-year results of the Michigan breast reconstruction outcome study
Plast Reconstr Surg
(2012) - et al.
Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction
Plast Reconstr Surg
(2010) - et al.
Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial
Plast Reconstr Surg
(2012) - et al.
Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined
Plast Reconstr Surg
(2012) - et al.
Flap survival of skin-sparing mastectomy type IV: a retrospective cohort study of 75 consecutive cases
Ann Surg Oncol
(2013) - et al.
Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk
Plast Reconstr Surg
(2008)
Cited by (137)
Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose?
2023, Surgical Oncology Clinics of North AmericaEvaluation of the Angiosome Concept Using Near-Infrared Fluorescence Imaging with Indocyanine Green
2023, Annals of Vascular SurgeryNear-infrared fluorescence angiography with indocyanine green for perfusion assessment of DIEP and msTRAM flaps: A Dutch multicenter randomized controlled trial
2023, Contemporary Clinical Trials CommunicationsImmediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates
2022, Annales de Chirurgie Plastique EsthetiqueCitation Excerpt :One useful tool for future studies on the subject is the BREAST-Q, a validated patient-reported outcome measure that would provide data on patient satisfaction on both traditional and Wise pattern mastectomy results [21]. There may also be a role for blood supply-quantifying modalities such as SPY Intraoperative Perfusion Assessment System (Novadaq Technologies Inc., Richmond, British Columbia, Canada) and thermal imaging in evaluating blood supply of the mastectomy flaps to improve the safety of the technique and minimize mastectomy flap necrosis and wound complications [22–25]. Another avenue of research that may be followed with this operative technique is whether incisional negative pressure wound therapy placed intraoperatively after wound closure would improve flap perfusion/survival [26–28].
- ☆
Abstract presentations: 1) Northeastern Society of Plastic Surgeons Annual Meeting, Washington D.C., Sept. 19–21, 2013. 2) American Society of Plastic Surgery Annual Meeting, San Diego, CA, Oct. 12–14, 2013.