Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability. Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed. In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors. This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.

Soft-tissue and bony reconstruction with free-tissue transfer is one of the most versatile tools available to the reconstructive surgeon. Determination of flap perfusion and early detection of vascular compromise with prompt correction remain critical in free-tissue transfer success. The aim of this report is to describe the utility of laser-assisted indocyanine green fluorescent dye angiography in free-tissue transfer reconstruction. From October of 2007 to March of 2008, 27 nonrandomized, nonconsecutive patients underwent surgical free flaps in conjunction with intraoperative Novadaq SPY fluorescent angiography. Twenty-seven patients underwent 29 free-tissue transfers. There was one partial flap loss in this group requiring operative revision. No complications attributable to indocyanine green fluorescent dye administration were noted. Imaging procedures (including dye administration) added minimal additional time to the operative time and anesthesia, and assisted in intraoperative decision-making. Novadaq's SPY fluorescent angiography system provides simple and efficient intraoperative real-time surface angiographic imaging. This technology places control of vascular anastomosis evaluation and flap perfusion in the hands of the surgeon intraoperatively in a visual manner that is easy to use and is helpful in surgical decision-making.

Intraoperative angiography is a useful tool for predicting both tissue perfusion during postmastectomy breast reconstruction and mastectomy flap and free flap survival.