title: The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: a prospective trial.
abstract: Mastectomy skin flap ischaemia leading to necrosis is a common occurrence. Laser-assisted indocyanine green (ICG) angiography can assist to locate these poorly perfused areas intra-operatively. Our study aims to identify specific perfusion values produced by ICG angiography that accurately predict mastectomy flap necrosis. A total of 42 patients undergoing autologous or implant-based breast reconstruction had mastectomy flaps imaged using laser-assisted ICG angiography at the completion of reconstruction. Intra-operative perfusion values were correlated with postoperative skin flap outcomes. Risk factors for abnormal perfusion were recorded and analysed. A total of 62 breast reconstructions were imaged, including 48 tissue expander reconstructions, six transverse rectus abdominis myocutaneous (TRAM) flaps, six deep inferior epigastric perforator (DIEP) flaps and two direct-to-implant reconstructions. Eight cases (13%) of full-thickness skin necrosis were identified postoperatively. A SPY Elite(®) value of ≤ 7 accurately predicted the development of flap necrosis at 88% sensitivity and 83% specificity. False-positive cases (those with perfusion values ≤ 7 which did not develop necrosis) were more likely to have a smoking history and/or to have had an epinephrine-containing tumescent solution used during mastectomy. Excluding patients with smoking or epinephrine use, a SPY value of ≤ 7 predicted flap necrosis with a sensitivity of 83% and specificity of 97%. Thus, these data suggest that laser-assisted ICG angiography predicts postoperative outcomes with high accuracy. In our series, a SPY value of ≤ 7 correlated well with mastectomy flap necrosis. Furthermore, smoking and intra-operative injections containing epinephrine should be considered when evaluating low perfusion values as they can lead to false-positive test results.
authors: Division of Plastic Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
authors: Naikhoba C O
authors: NC
authors: Munabi
authors: Division of Plastic Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
authors: Olushola B
authors: OB
authors: Olorunnipa
authors: Division of Plastic Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
authors: David
authors: D
authors: Goltsman
authors: Division of Plastic Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
authors: Christine H
authors: CH
authors: Rohde
authors: Division of Plastic Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA. Electronic address: jaa7@cumc.columbia.edu.
authors: Jeffrey A
authors: JA
authors: Ascherman
mesh_terms: D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods*; D004396:Coloring Agents; D005260:Female; D006801:Humans; D007208:Indocyanine Green; D007430:Intraoperative Care; D007511:Ischemia / Q000000981:diagnostic imaging*; D007834:Lasers; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D009336:Necrosis; D011446:Prospective Studies; D012867:Skin / Q000098:blood supply / Q000473:pathology*; D013524:Surgical Flaps / Q000098:blood supply / Q000473:pathology*
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green
keywords: Indocyanine green angiography; Mastectomy flap necrosis