Mastectomy skin flap (MSF) necrosis remains a significant complication in breast reconstruction. This study aims to identify a correlation between the qualitative and quantitative analysis of the MSF perfusion grade and the skin necrosis rate 1 month after surgery using indocyanine green angiography (ICGA), focusing on lag time and perfusion metrics.
Methods
Consecutive women scheduled for nipple/skin-sparing/skin-reducing mastectomy between May 2020 and October 2022 were prospectively enrolled. Patients were divided into Group 1 in the absence of superficial and full-thickness necrosis (SN; FTN) and Group 2 in the presence of both. Demographic data, lag time T1 (time between ICG injection and the initial perfusion of the least perfused MSF area), ICG-Q1, and ICG-Q% (absolute and relative perfusion values of the least vascularized area) were collected.
Results
76 breasts were considered. FTN was reported in 8 breasts (10.5%) and SN in 4 (5.2%). The 2 groups statistically differ in T1 (Group2 > Group1), ICG-Q1, and ICG-Q% (Group1 > Group2) (P < 0.05). T1 longer than 170 seconds, body mass index, previous chemo/radiotherapy, arterial hypertension, breast weight, type of surgery, and ICG quantitative values can help in predicting MSF necrosis.
Conclusions
MSF qualitative and quantitative perfusion evaluation can be helpful to prevent MSF necrosis. However, it should be considered together with the patient’s characteristics, the type of surgery, and T1. In this way, it is possible to predict the risk of MSF necrosis and plan the best reconstructive strategy.
PeledAWWangFFosterRD, et al.Expanding the indications for total skin-sparing mastectomy: is it safe for patients with locally advanced disease?Ann Surg Oncol. 2016;23(1):87-91. doi:10.1245/s10434-015-4734-6
2.
GerberBKrauseAReimerT, et al.Skin-sparing mastectomy with conservation of the nipple–areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg. 2003;238(1):120-127. doi:10.1097/01.SLA.0000077922.38307.cd
3.
MatsenCBNeumayerLA. Breast cancer: a review for the general surgeon. JAMA Surg. 2013;148(10):971-979. doi:10.1001/jamasurg.2013.3393
4.
GriffithsMChaeMPRozenWM. Indocyanine green-based fluorescent angiography in breast reconstruction. Gland Surg. 2016;5(2):133-149. doi:10.3978/j.issn.2227-684X.2016.02.01
5.
LucasDJSabinoJShriverCDPawlikTMSinghDPVertreesAE. Doing more: trends in breast cancer surgery, 2005 to 2011. Am Surg. 2015;81(1):74-80.
6.
TohUTakenakaMIwakumaNAkagiY. Clinical outcomes of patients after nipple-sparing mastectomy and reconstruction based on the expander/implant technique. Surg Today. 2021;51(6):862-871. doi:10.1007/s00595-020-02175-4
7.
MirhaidariSJBeddellGMOrlandoMVParkerMGPedersenJCWagnerDS. A prospective study of immediate breast reconstruction with laser-assisted indocyanine green angiography. Plast Reconstr Surg Glob Open. 2018;6(9):e1774. doi:10.1097/GOX.0000000000001774
8.
PruimboomTScholsRMVan KuijkSMVan der HulstRRQiuSS. Indocyanine green angiography for preventing postoperative mastectomy skin flap necrosis in immediate breast reconstruction. Cochrane Database Syst Rev. 2020;4(4):CD013280. doi:10.1002/14651858.CD013280.pub2
9.
PagliaraDSchiavoneLGarganeseG, et al.Predicting mastectomy skin flap necrosis: a systematic review of preoperative and intraoperative assessment techniques. Clin Breast Cancer. 2023;23(3):249-254. doi:10.1016/j.clbc.2022.12.021
10.
ZennMR. Evaluation of skin viability in nipple sparing mastectomy (NSM). Gland Surg. 2018;7(3):301-307. doi:10.21037/gs.2018.04.04
11.
de VitaRBuccheriEM. Nipple sparing mastectomy and direct to implant breast reconstruction, validation of the safe procedure through the use of laser assisted indocyanine green fluorescent angiography. Gland Surg. 2018;7(3):258-266. doi:10.21037/gs.2018.04.03
12.
PhillipsBTLanierSTConklingN, et al.Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial. Plast Reconstr Surg. 2012;129(5):778e-788e. doi:10.1097/PRS.0b013e31824a2ae8
MastronardiMFraconSScomersiSFezziMBortulM. Role of qualitative and quantitative indocyanine green angiography to assess mastectomy skin flaps perfusion in nipple/skin-sparing and skin-reducing mastectomies with implant-based breast reconstruction. Breast J. 2022;2022:5142100. doi:10.1155/2022/5142100
15.
von ElmEAltmanDGEggerM, et al.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-349. doi:10.1016/j.jclinepi.2007.11.008
16.
SardanelliFBoetesCBorischB, et al.Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group. Eur J Cancer. 2010;46(8):1296-1316. doi:10.1016/j.ejca.2010.02.015
17.
RubioITMarottiLBiganzoliL, et al.EUSOMA quality indicators for non-metastatic breast cancer: an update. Eur J Cancer. 2024;198:113500. doi:10.1016/j.ejca.2023.113500
18.
NavaMBCortinovisUOttolenghiJ, et al.Skin-reducing mastectomy. Plast Reconstr Surg. 2006;118(3):603-613. doi:10.1097/01.prs.0000233024.08392.14
19.
SogaNInokoAFurusawaJOguraY. Evaluation to differentiate between tumor lesions and the parenchyma in partial nephrectomies for renal tumors based on quantitative fluorescence imaging using indocyanine green dye. Curr Urol. 2019;13(2):74-81. doi:10.1159/000499289
20.
GolemiISalazar AdumJPTafurACapriniJ. Venous thromboembolism prophylaxis using the Caprini score. Dis Mon. 2019;65(8):249-298. doi:10.1016/j.disamonth.2018.12.005
21.
OleckNCGuCPyferBJPhillipsBT. Defining mastectomy skin flap necrosis: a systematic review of the literature and a call for standardization. Plast Reconstr Surg. 2022;149(5):858e-866e. doi:10.1097/PRS.0000000000008983
22.
SueGRLongCLeeGK. Management of mastectomy skin necrosis in implant based breast reconstruction. Ann Plast Surg. 2017;78(5 Suppl 4):S208-S211. doi:10.1097/SAP.0000000000001045
23.
ElderEEBrandbergYBjörklundT, et al.Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast Edinb Scotl. 2005;14(3):201-208. doi:10.1016/j.breast.2004.10.008
24.
Hammer-HansenNJuhlAADamsgaardTE. Laser-assisted indocyanine green angiography in implant-based immediate breast reconstruction: a retrospective study. J Plast Surg Hand Surg. 2018;52(3):158-162. doi:10.1080/2000656X.2017.1372289
25.
LauritzenEDamsgaardTE. Use of Indocyanine Green Angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2021;74(8):1703-1717. doi:10.1016/j.bjps.2021.03.034
Van Den HovenPVerduijnPSVan CapelleL, et al.Quantification of near-infrared fluorescence imaging with indocyanine green in free flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2022;75(6):1820-1825. doi:10.1016/j.bjps.2021.12.004
28.
NguyenCLTamSKMEaswaralingamN, et al.Patterns of ischaemia and reperfusion in nipple-sparing mastectomy reconstruction with indocyanine green angiography. J Plast Reconstr Aesthet Surg. 2022;75(11):4144-4151. doi:10.1016/j.bjps.2022.08.006
29.
NguyenCLDayaratnaNGrahamS, et al.Evolution of indocyanine green fluorescence in breast and axilla surgery: an australasian experience. Life. 2024;14(1):135. doi:10.3390/life14010135
30.
NguyenCLComerfordAPDayaratnaN, et al.Trends in outcomes with adoption of indocyanine green angiography in postmastectomy reconstruction. ANZ J Surg. 2023;93(1-2):270-275. doi:10.1111/ans.18241
31.
SigaloveSMaxwellGPSigaloveNM, et al.Prepectoral implant-based breast reconstruction and postmastectomy radiotherapy: short-term outcomes. Plast Reconstr Surg Glob Open. 2017;5(12):e1631. doi:10.1097/GOX.0000000000001631
32.
MattisonGLLewisPGGuptaSCKimHY. SPY imaging use in postmastectomy breast reconstruction patients: preventative or overly conservative?Plast Reconstr Surg. 2016;138(1):15e-21e. doi:10.1097/PRS.0000000000002266
