title: A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study.
abstract: BACKGROUND
  Skin-sparing mastectomy with immediate reconstruction can yield excellent aesthetic results, but high rates of mastectomy flap necrosis have been reported. A prospective cohort study was undertaken to compare three methods of assessing mastectomy flap viability following skin-sparing mastectomy and immediate reconstruction to determine which is most effective in reducing mastectomy flap necrosis.
  
  
  METHODS
  The study group included 60 consecutive patients (99 breasts) undergoing skin-sparing mastectomy and immediate reconstruction with either tissue expanders (n = 39) or transverse rectus abdominis musculocutaneous flaps (n = 21). Mastectomy flap viability was assessed either visually (n = 20), with fluorescein dye and Wood's lamp imaging (n = 20), or by indocyanine green angiography (n = 20). Variation across groups was analyzed using analysis of variance for continuous variables and chi-square test for dichotomous variables.
  
  
  RESULTS
  The mean follow-up was 10 months. There were no significant differences in mean age, body mass index, medical history, smoking history, pathologic diagnosis, chemotherapy, or reconstruction type. Mastectomy flap necrosis was observed in eight of 30 breasts in the direct visualization group (27 percent), compared with 14 percent in the indocyanine green angiography group and 3 percent in the fluorescein group (p = 0.03). The reoperation rate in the direct visualization group was 20 percent, compared with 15 percent in the indocyanine green angiography group and 0 percent in the fluorescein group.
  
  
  CONCLUSIONS
  Fluorescein dye was associated with the lowest rate of complications after skin-sparing mastectomy, but indocyanine green angiography was also shown to reduce mastectomy flap necrosis compared with direct visualization. Routine imaging of mastectomy flap perfusion seems to be beneficial in skin-sparing mastectomy, but intravenous fluorescein may be as effective as more expensive modalities.
  
  
  METHODS
  Therapeutic, II.
authors.affiliation: Lexington, Ky. From the Department of Surgery, Division of Plastic Surgery, University of Kentucky.
authors.forename: Brian
authors.initials: B
authors.lastname: Rinker
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000098:blood supply / Q000601:surgery*; D005260:Female; D005451:Fluorescein Angiography; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy / Q000379:methods*; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control; D011446:Prospective Studies; D017568:Rectus Abdominis / Q000637:transplantation*; D016038:Skin Transplantation / Q000379:methods*; D013524:Surgical Flaps / Q000098:blood supply*; D013997:Time Factors
references.citation: Yi M, Kronowitz SJ, Meric-Bernstam F, et al. Local, regional, and systemic recurrence rates in patients undergoing skin-sparing mastectomy compared with conventional mastectomy. Cancer. 2011;117:916–924
references.citation: Lim W, Ko BS, Kim HJ, et al. Oncological safety of skin sparing mastectomy followed by immediate reconstruction for locally advanced breast cancer. J Surg Oncol. 2010;102:39–42
references.citation: Salhab M, Al Sarakbi W, Joseph A. Skin-sparing mastectomy and immediate breast reconstruction: Patient satisfaction and clinical outcome. Int J Clin Oncol. 2006;11:51–54
references.citation: Downes KJ, Glatt BS, Kanchwala SK, et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma. Cancer. 2005;103:906–913
references.citation: Sultan MR, Smith ML, Estabrook A. Immediate breast reconstruction in patients with locally advanced disease. Ann Plast Surg. 1997;38:345–349
references.citation: Foster RD, Esserman LJ, Anthony JP, Hwang ES, Do H. Skin-sparing mastectomy and immediate breast reconstruction: A prospective cohort study for the treatment of advanced stages of breast carcinoma. Ann Surg Oncol. 2002;9:462–466
references.citation: Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: Oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg. 1998;102:49–62
references.citation: Woerdeman LA, Hage JJ, Smeulders MJ, Rutgers EJ, van der Horst CM. Skin-sparing mastectomy and immediate breast reconstruction by use of implants: An assessment of risk factors for complications and cancer control in 120 patients. Plast Reconstr Surg. 2006;118:321–330
references.citation: Woerdeman LA, Hage JJ, Hofland MM, Rutgers EJ. A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria. Plast Reconstr Surg. 2007;119:455–463
references.citation: Hultman CS, Daiza S. Skin-sparing mastectomy flap complications after breast reconstruction: Review of incidence, management, and outcome. Ann Plast Surg. 2003;50:249–255
references.citation: Kobraei EM, Nimtz J, Wong L, et al. Risk factors for adverse outcome following skin-sparing mastectomy and immediate prosthetic reconstruction. Plast Reconstr Surg. 2012;129:234e–241e
references.citation: Singer R, Lewis CM, Franklin JD, Lynch JB. Fluorescein test for prediction of flap viability during breast reconstructions. Plast Reconstr Surg. 1978;61:371–375
references.citation: Losken A, Styblo TM, Schaefer TG, Carlson GW. The use of fluorescein dye as a predictor of mastectomy skin flap viability following autologous tissue reconstruction. Ann Plast Surg. 2008;61:24–29
references.citation: Desmettre T, Devoisselle JM, Mordon S. Fluorescence properties and metabolic features of indocyanine green (ICG) as related to angiography. Surv Ophthalmol. 2000;45:15–27
references.citation: Chatterjee A, Krishnan NM, Van Vliet MM, Powell SG, Rosen JM, Ridgway EB. A comparison of free autologous breast reconstruction with and without the use of laser-assisted indocyanine green angiography: A cost-effectiveness analysis. Plast Reconstr Surg. 2013;131:693e–701e
references.citation: Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg. 2010;125:1065–1073
references.citation: Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: The gray area defined. Plast Reconstr Surg. 2012;129:1043–1048
references.citation: Holm C, Mayr M, Höfter E, Becker A, Pfeiffer UJ, Mühlbauer W. Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Br J Plast Surg. 2002;55:635–644
references.citation: Toth BA, Lappert P. Modified skin incisions for mastectomy: The need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87:1048–1053
references.citation: Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: A 6-year follow-up. Plast Reconstr Surg. 1999;104:421–425
references.citation: Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol. 1999;6:676–681
references.citation: McCraw JB, Horton CE, Grossman JA, Kaplan I, McMellin A. An early appraisal of the methods of tissue expansion and the transverse rectus abdominis musculocutaneous flap in reconstruction of the breast following mastectomy. Ann Plast Surg. 1987;18:93–113
references.citation: Bailey MH, Smith JW, Casas L, et al. Immediate breast reconstruction: Reducing the risks. Plast Reconstr Surg. 1989;83:845–851
references.citation: Ward J, Cohen IK, Knaysi GA, Brown PW. Immediate breast reconstruction with tissue expansion. Plast Reconstr Surg. 1987;80:559–566
references.citation: Dowden RV. Selection criteria for successful immediate breast reconstruction. Plast Reconstr Surg. 1991;88:628–634
references.citation: Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction. Breast. 2011;20:21–25
references.citation: Meretoja TJ, Rasia S, von Smitten KA, Asko-Seljavaara SL, Kuokkanen HO, Jahkola TA. Late results of skin-sparing mastectomy followed by immediate breast reconstruction. Br J Surg. 2007;94:1220–1225
references.citation: Singer R, Lewis CM, Franklin JD, Lynch JB. Fluorescein test for prediction of flap viability during breast reconstructions. Plast Reconstr Surg. 1978;61:371–375
references.citation: Myers MB. Prediction of skin sloughs at the time of operation with the use of fluorescein dye. Surgery. 1962;51:158–162
references.citation: Myers MB, Brock D, Cohn I Jr. Prevention of skin slough after radical mastectomy by the use of a vital dye to delineate devascularized skin. Ann Surg. 1971;173:920–924
references.citation: Rübben A, Eren S, Krein R, Younossi H, Böhler U, Wienert V. Infrared videoangiofluorography of the skin with indocyanine green: Rat random cutaneous flap model and results in man. Microvasc Res. 1994;47:240–251
references.citation: Holm C, Tegeler J, Mayr M, Becker A, Pfeiffer UJ, Mühlbauer W. Monitoring free flaps using laser-induced fluorescence of indocyanine green: A preliminary experience. Microsurgery. 2002;22:278–287
references.citation: Newman MI, Samson MC, Tamburrino JF, Swartz KA. Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg. 2010;26:487–492
references.citation: Munabi NC, Olorunnipa OB, Goltsman D, Rohde CH, Ascherman JA. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial. J Plast Reconstr Aesthet Surg. 2014;67:449–455
references.citation: Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg. 2014;133:448e–454e
references.citation: Lira RP, Oliveira CL, Marques MV, Silva AR, Pessoa Cde C. Adverse reactions of fluorescein angiography: A prospective study. Arq Bras Oftalmol. 2007;70:615–618
references.citation: Kwiterovich KA, Maguire MG, Murphy RP, et al. Frequency of adverse systemic reactions after fluorescein angiography: Results of a prospective study. Ophthalmology. 1991;98:1139–1142
references.citation: Celik I, Duda D, Stinner B, Kimura K, Gajek H, Lorenz W. Early and late histamine release induced by albumin, hetastarch and polygeline: Some unexpected findings. Inflamm Res. 2003;52:408–416
references.citation: Zografos L. International survey on the incidence of severe or fatal complications which may occur during fluorescein angiography (in French). J Fr Ophtalmol. 1983;6:495–506
references.citation: Hope-Ross M, Yannuzzi LA, Gragoudas ES, et al. Adverse reactions due to indocyanine green. Ophthalmology. 1994;101:529–533