title: Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction:  results of a prospective trial.
abstract: BACKGROUND
  Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment.
  
  
  METHODS
  The authors conducted a prospective clinical trial of tissue expander-implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis.
  
  
  RESULTS
  Fifty-one tissue expander-implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity.
  
  
  CONCLUSIONS
  Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis.
  
  
  METHODS
  Diagnostic, I.
authors.affiliation: Stony Brook, N.Y. From the Division of Plastic and Reconstructive Surgery, Stony Brook University Medical Center, and the Stony Brook University School of Medicine.
authors.forename: Brett T
authors.initials: BT
authors.lastname: Phillips
authors.forename: Steven T
authors.initials: ST
authors.lastname: Lanier
authors.forename: Nicole
authors.initials: N
authors.lastname: Conkling
authors.forename: Eric D
authors.initials: ED
authors.lastname: Wang
authors.forename: Alexander B
authors.initials: AB
authors.lastname: Dagum
authors.forename: Jason C
authors.initials: JC
authors.lastname: Ganz
authors.forename: Sami U
authors.initials: SU
authors.lastname: Khan
authors.forename: Duc T
authors.initials: DT
authors.lastname: Bui
mesh_terms: D019928:Breast Implantation; D004396:Coloring Agents; D005260:Female; D005451:Fluorescein Angiography; D006801:Humans; D007208:Indocyanine Green; D007430:Intraoperative Care; D008408:Mastectomy; D008875:Middle Aged; D009336:Necrosis; D010477:Perfusion; D011446:Prospective Studies; D013524:Surgical Flaps / Q000098:blood supply* / Q000473:pathology
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green