The benefits of laser-assisted indocyanine green fluorescence angiography have previously been demonstrated in cardiac surgery. The purpose of this study was to determine the value of this technology in microsurgical breast reconstruction. Intraoperative laser-assisted indocyanine green fluorescence angiography was performed on all microsurgical breast reconstruction cases (deep inferior epigastric perforator flap or free transverse rectus abdominus muscle flap) during the study period. Ten consecutive free tissue transfer autologous breast reconstructions were performed on 8 women. In four cases, imaging demonstrated flow or perfusion deemed ''marginal'' or ''poor'' by the operating surgeons. In three of these cases, one involving poor arterial inflow, one of poor venous outflow, and one of poor perfusion of a mastectomy flap, the intraoperative plan was adjusted accordingly and follow-up imaging demonstrated improvement. In the fourth case, no adjustment was made at operation. However this patient required a return to the operating room for venous congestion of the flap, which was corrected without sequela. Overall flap survival was 100%. We concluded that laser-assisted indocyanine green fluorescence angiography appears to provide important information that has helped guide intraoperative decision making in our series.
Skin-sparing mastectomy has been associated with flap ischemia and necrosis. Current clinical methods for assessment of flap viability following mastectomy are largely subjective and lack objective data to guide intraoperative decisions. Intraoperative laser-assisted indocyanine green angiography (LA-ICGA) was performed on 20 skin sparing mastectomy flaps. LA-ICGA data were retrospectively compared with clinical outcome. Preoperative, intraoperative, and postoperative digital photographs along with clinical course were evaluated in an effort to identify potential complications. LA-ICGA was performed on 20 breasts in 12 patients. Eleven breasts (55%) demonstrated no wound-healing issues. Nine breasts (45%) experienced wound-healing issues, which were stratified as follows: 1 (5%) mild, 1 (5%) moderate, and 7 (35%) severe. Of these seven severe wound-healing issues, 5 (25%) required debridement and 2 (10%) required complete removal of the prosthetic device. Retrospective analysis demonstrated a 95% correlation between intraoperative imaging and clinical course with 100% sensitivity and 91% specificity. There was a false-positive rate of 9%. This series suggests LA-ICGA is a useful adjunct to determine mastectomy flap viability. Further quantitative advances in this technology may provide objective numerical thresholds to guide intraoperative mastectomy flap debridement when indicated.
These findings suggest that quantitative "relative" perfusion values as generated by the postprocessing software may augment clinical judgment of flap viability in an objective and reproducible fashion.
The dorsalis pedis flap has been used successfully for 20 years, both as a pedicled transfer for local foot reconstruction and as a free microvascular transfer. Proponents cite the reliable vascularity, versatility, ease of harvest, and thinness. Although significant donor-site morbidity has been recognized previously, published reports have inadequately documented the long-term effects of dorsalis pedis flap harvest. The purpose of the present study was to obtain long-term follow-up data regarding the donor site on a total of 10 male patients who underwent dorsalis pedis flap harvest during the period from 1982 to 1984. Standardized questionnaires and chart reviews were completed, and physical examinations and photographs of each patient were carried out when possible. Eight patients were reviewed, and seven of them were examined and photographed (mean follow-up 13 years). All patients had initially experienced delayed donor-site healing (mean 18 months; range 3 to 36 months). In addition, soft-tissue infections (five of eight cases), osteomyelitis (one of eight cases), wound breakdown (seven of eight cases), scarring and contracture (four of seven cases), pain or other uncomfortable sensations in the foot (six of seven cases), and requirement for reoperation (three of eight cases) were significant complications of the procedure. Most patients were able to attain their preoperative level of physical activity (five of eight cases). Although generally favorable reconstructive results were obtained in this series, the long-term follow-up of donor-site healing indicates that this flap should be used with caution. In particular, delayed donor-site healing, need for wound revision, and long-term and possibly permanent donor-site symptoms are common.
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