Fluorescent Intraoperative Tissue Angiography with Indocyanine Green: Evaluation of Nipple-Areola Vascularity during Breast Reduction Surgery

Sir: Intraoperative evaluation of the nipple-areola complex during breast reduction surgery can be difficult. Nipple-areola complexes that preoperatively are very pale or very dark may present the greatest challenge in this clinical evaluation, either during dissection of the pedicle or after inset of the nipple-areola complex. However, fluorescent intraoperative tissue angiography with indocyanine green assists the surgeon in evaluating nipple vascularity. All women who were to undergo breast reduction surgery were candidates for this study. Women with an allergy to iodinated contrast dye were excluded. All breasts underwent reduction using a superior, superomedial, or inferior pedicle. Immediately after dissection of the pedicle, 4 ml (2.5 mg/ml) of indocyanine green (Akorn, Inc., Buffalo Grove, Ill.) was infused through a peripheral intravenous catheter by the anesthesia personnel, followed by a 10-ml saline flush. Eight seconds after infusion, real-time fluorescent videoangiography of the nipple-areola complex was captured for 1 minute using the Novadaq Spy SP2001 imaging laser (Mississauga, Ontario, Canada). Arterial phase imaging was initially completed, before inset of the nipple-areola complex. If nipple-areola complex perfusion proved acceptable, the nipple-areola complex was then inset. After being inset, the nipple-areola complex was once again imaged in arterial phase using the same technique (Fig. 1). If perfusion once again appeared acceptable, the nipple-areola complex was imaged 10 minutes later without indocyanine green injection, to examine venous outflow (Fig. 2). If nipple-areola complex outflow was compromised, as seen with a persistently bright fluorescence, the pedicle or skin flaps would be revised or the nipple-areola complex would be grafted.Fig. 1.: Fluorescence of the nipple-areola complex after inset, 1 minute after indocyanine green infusion, showing excellent arterial perfusion.Fig. 2.: Indocyanine green fluorescence of the same nipple-areola complex 10 minutes after indocyanine green infusion, representative of the venous phase. Note the minimal fluorescence of the nipple-areola complex, consistent with excellent venous outflow.In 12 women, we completed 22 reduction mammaplasties. The average notch-to-nipple distance was 33 cm and the average resection weight was a 635 g. Preoperatively, three nipples were very pale, eight nipples were cream colored, seven were tan, two were light brown, and two were dark brown. All nipple-areola complexes exhibited healthy arterial and venous phases after inset. All breasts healed without complication and with acceptable cosmetic appearance. Although intraoperative surgical decisions were not altered based on these images, they nonetheless supported the surgeon's operative evaluation. Fluorescent tissue imaging has been widely used for many years, especially with fluorescein.1 However, fluorescein can only be injected once during an operation because of its long half-life, typically fading over 24 hours after injection. However, as indocyanine green is hepatically metabolized, its half-life is 2.5 to 3 minutes. Indocyanine green may be injected multiple times during an operation to evaluate potentially ischemic or congested tissues.2 In addition, indocyanine green binds to albumin, allowing it to remain intravascular. As indocyanine green remains in congested tissues, it will remain highly luminescent. Indocyanine green has proven helpful to evaluate perfusion of soft tissue in many clinical settings, to include open heart surgery, burn surgery, free tissue transfer, mastectomy, and breast reconstruction.3–5 Intraoperative fluorescence of the nipple-areola complex with indocyanine green during reduction mammaplasty helps to evaluate the nipple-areola complex for vascular compromise. Indocyanine green videofluorography may be used repeatedly during the same operation and helps to evaluate both the arterial microcirculatory inflow and venous outflow. DISCLOSURE The authors have no financial interest to disclose in relation to the content of this article. John D. Murray, M.D. Glyn E. Jones, M.D. Eric T. Elwood, M.D. Lisa A. Whitty, M.D. Chris Garcia, B.S. University of Illinois College of Medicine at Peoria Peoria, Ill.

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