Laser Angiography as a Predictor of Mastectomy Flap Necrosis after Breast Reconstruction

Sir:FigureSkin-sparing mastectomy improves the aesthetic result of the reconstructed breast and broadens the reconstructive options. However, areas of ischemia leading to necrosis can prove difficult to clinically assess. We review our experience with laser angiography as a predictor of mastectomy skin flap necrosis. All women who were to undergo immediate postmastectomy breast reconstruction were candidates for this study. Women with an allergy to iodinated contrast dye were excluded. All mastectomy flaps in patients undergoing immediate breast reconstruction over a 2-year period were studied. The vascularity of each flap was initially assessed clinically, and simultaneous intraoperative images were obtained using infrared fluorescent tissue angiography (SPY SP2001; Novadaq, Mississauga, Ontario, Canada) with indocyanine green (Akorn, Inc., Buffalo Grove, Ill.). For performance of the indocyanine green angiography, 4 ml (2.5 mg/ml) of indocyanine green 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 mastectomy flaps was captured for 1 minute using the Novadaq SPY SP2001 imaging laser. Any portion of the mastectomy flaps that did not appear viable by clinical examination was excised. No tissue was excised based on indocyanine green fluorescence alone. Postoperatively, the amount of fluorescence (fluorescence level) throughout each saved image was calculated (SPY-Q; Novadaq), with relative percentages of fluorescent brightness noted when compared with the most well-perfused area of each respective flap (or brightest, regarded as 100 percent). The fluorescent images and respective postoperative photographs were then compared and areas of ischemic necrosis were correlated. Two hundred twenty-seven mastectomy flaps in 174 patients were studied. Poorly perfused mastectomy flap skin, as determined clinically, was resected. However, mastectomy flap necrosis occurred in 10 breasts (4.41 percent). Four of the 10 (40 percent) developed full-thickness necrosis requiring débridement, and the remaining six breasts (60 percent) developed partial-thickness necrosis and healed with conservative care. However, all areas of necrosis displayed a fluorescence level of 18 percent or less (positive predictive value, 100 percent) (Figs. 1 and 2). All reconstructions were salvaged using the original procedure.Fig. 1: Intraoperative laser image of left mastectomy flaps showing areas with a fluorescence level less than 18 percent (blue circled islands).Fig. 2: Postoperative necrosis correlating to Figure 1.Because of its reliable intravascular pattern and its ability to be used multiple times in a single operation, indocyanine green with near-infrared fluorescence has gained increased utility in plastic surgery. Many large-volume clinical studies have supported its use in breast surgery, ranging from breast reduction, to mastectomy flap assessment, to breast reconstruction.1–5 In addition, although plastic surgery will likely remain largely objective in technique and outcome, objective determination of meaningful tissue ischemia may help decrease reoperation rates and ultimately improve surgical outcomes and patient safety. In our study, we determined that a relative fluorescence level of 18 percent or less predicted partial- or full-thickness mastectomy flap necrosis. We also found that comorbid medical conditions, such as exposure to radiation and smoking, positively correlated to necrosis depth. 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. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article.

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