Laser-Assisted Indocyanine Green Angiography and DIEP Breast Reconstruction

Sir: Deep inferior epigastric perforator (DIEP) flap breast reconstruction can be technically challenging and has a steep learning curve. Nevertheless, DIEP breast reconstruction decreases both donor-site morbidity and recovery time.1,2 When elevating DIEP flaps, it is necessary for the surgeon to determine whether the perforators used to supply the flap will be sufficient to ensure maximal flap survival. Laser-assisted indocyanine green angiography is a technology that gives the surgeon real-time information on vessel patency and flap perfusion.3–5 We present our experience using laser-assisted indocyanine green angiography in DIEP flap breast reconstruction. The SPY imaging system (Novadaq Technologies, Inc., Toronto, Ontario, Canada) relies on the fluorescent properties of indocyanine green (IC-Green; Akorn, Buffalo Grove, Ill.) to generate real-time blood flow visualization of the macrovasculature and microvasculature. The SPY imaging system captures visible fluorescence of indocyanine green as it perfuses blood vessels in an area 7.5 × 7.5 cm2 and 2 to 4 mm deep and displays the images on a monitor. During DIEP breast reconstruction, laser-assisted indocyanine green angiography was used at four points to assess the following: To isolate perforators on the abdominal wall preoperatively. The abdominal flap was elevated based on one or two deep inferior epigastric perforators and the superficial inferior epigastric artery (SIEA). Each was sequentially clamped to determine which system provided optimal flow to the overlying tissue. To assess patency of arterial and venous anastomoses after flap transfer. To determine which areas of the flap should be discarded during flap insetting by evaluating flap perfusion. Laser-assisted indocyanine green angiography was used in five DIEP breast reconstruction flaps. Laser-assisted indocyanine green angiography was able to verify the position of the perforators on the abdominal wall (Fig. 1, above). Laser-assisted indocyanine green angiography indicated which vessel, DIEP or SIEA (Fig. 1, below), provided the most robust perfusion to the flap. The patencies of the arterial and venous anastomoses were confirmed following anastomosis (Fig. 2, above). Once the flap was inset, the margins of inadequate tissue perfusion were visualized and the best-perfused portion of the flap was selected (Fig. 2, below).Fig. 1.: (Above) Deep inferior epigastric perforators on the abdominal wall confirmed by laser-assisted indocyanine green angiography. (Below) The yellow arrow indicates the cut inferior edge of the flap. The red arrow indicates the SIEA as it courses cephalad to perfuse the flap.Fig. 2.: (Above) View of the vessel anastomoses and patency of vessels on the chest wall. The red arrow indicates the anastomosis between the deep inferior epigastric artery and the internal mammary artery. The yellow arrow indicates the anastomosis between the deep inferior epigastric vena comitans and internal mammary vein. The filling defect is the site of the venous coupling device. (Below) The red arrow indicates the cut edge of the flap. The yellow arrow indicates the margin between well-perfused and marginally perfused tissue.There were no adverse reactions to indocyanine green perioperatively. There has been no whole or partial flap loss, no fat necrosis, and no take- backs. Identification of adequate perforators, sufficient flap perfusion, and vessel patency are vital for successful DIEP breast reconstruction. A handheld Doppler device is a valuable resource for identifying perforating vessels; however, it does not always pinpoint their exact locations, indicate flap perfusion, determine vessel caliber, or distinguish between SIEA and DIEP dominance. Laser-assisted indocyanine green angiography ameliorates these concerns by providing real-time visualization of both macrovasculature and microvasculature. Laser-assisted indocyanine green angiography is a valuable resource to the surgeon performing DIEP breast reconstruction. It offers many advantages over traditional handheld Doppler and computed tomographic angiography by supplying real-time information that can be used to reduce operative time, reduce complications, and maximize flap perfusion. The novice microsurgeon may find utility in this technology at all four of the points described. More experienced microsurgeons might also find this technology helpful, particularly when deciding to use the SIEA versus the DIEP systems. Ben S. Francisco, B.A. University of Texas Health Science Center at San Antonio, School of Medicine San Antonio, Texas Mahlon A. Kerr-Valentic, M.D. Jayant P. Agarwal, M.D. Division of Plastic Surgery Department of Surgery University of Utah Health Science Center Salt Lake City, Utah DISCLOSURE Dr. Agarwal is a consultant for Novadaq.

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