Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction

Abstract

BackgroundThe quality and viability of mastectomy flaps remain a central challenge in reconstructive surgery, particularly for immediate breast reconstruction. Insufficient perfusion in tissue flaps is a leading cause of early complications following reconstructive procedures, and clinical judgment alone is not completely reliable for the assessment of flap viability. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis, thereby allowing for maneuvers to improve tissue flap viability.MethodsThis study evaluates the use of intraoperative laser angiography using the SPY System (LifeCell Corp., Branchburg, NJ) for the assessment of perfusion in mastectomy flaps for immediate breast reconstruction. The SPY System uses the contrast agent indocyanine green, which has an excellent safety profile and pharmacokinetics that allow for repeat evaluations during the same surgical procedure. In recent work, the SPY System has demonstrated high sensitivity and specificity for detection of tissues at risk for ischemia and necrosis during reconstructive surgery. Using a retrospective, chart-review design, the authors compared consecutive cases of immediate breast reconstruction using a prosthesis, before and after implementation of the SPY System.ResultsNinety-one subjects were included in the analysis: 52 prior to SPY (Pre-SPY) and 39 after implementation of SPY (Post-SPY). Baseline characteristics were similar between the groups. Both groups had high rates of comorbidities, chemotherapy, and radiation therapy. The rate of postoperative complications was two-fold higher in the Pre-SPY group compared to the Post-SPY group (36.5% vs. 17.9%); this difference was of borderline significance (P = 0.0631). However, mean number of repeat visits to the OR per patient was significantly higher in the Pre-SPY group (1.21 ± 1.47 vs. 0.41 ± 0.71; P = 0.0023). Of the seven patients with complications in the Post-SPY group, five were identified by SPY as having poor flap perfusion; none were identified by clinical judgment alone.ConclusionsThis study suggests that the SPY System can contribute to reduced ischemia-related complications in a population of women undergoing immediate breast reconstruction following mastectomy for breast cancer.

Systematic review of methodologies used to assess mastectomy flap viability

“…1). After detailed examination of 30 full‐text articles, 18 studies7 19, 20 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, including 2077 patients, were included in this review.…”

“…One was to compare rates of mastectomy necrosis and other complications, such as reoperation rates, and clinical outcomes between the techniques used ( Table 1). Seven case series7 28, 29, 30, 31, 32 34 and one cohort study33 used this approach. The alternative approach in seven prospective cohort studies19 20, 35, 36, 37, 38, 39 was to evaluate flap perfusion using the intraoperative modalities and to record the predicted areas of necrosis using photographic documentation or video recording.…”

“…Mastectomy flap necrosis rates were compared with clinical judgement in seven7 28, 29, 30, 31, 32, 33 studies using ICGA, one study using FA33 and one pilot study using ODIS34. Use of ICGA in 652 and FA in 34 breasts resulted in a decrease in mean mastectomy flap necrosis compared with clinical judgement in 1964 breasts (7·9 and 3 compared with 19·4 per cent) ( Table 3).…”

Available and emerging technologies for assessing intraoperative tissue perfusion during complex ventral hernia repair procedures

“…56,86,98,99 Both SPY ® and SPY Elite ® generate quantitative perfusion values based on fluorescence intensity detected in the tissue. [99][100][101] This system has been investigated for multiple intraoperative uses during breast reconstruction, including perfusion assessment of mastectomy skin flaps, Open Access Surgery 2014:7 submit your manuscript | www.dovepress.com Dovepress Dovepress 6 Ferzoco pedicle flaps, and free-tissue transfers, 56,98,99,[101][102][103] and in head and neck 104 and abdominal wall reconstruction surgeries. 100 The clinical utility of the SPY ® system in breast surgery has been described by Newman and Samson, 102 who reported that perfusion problems identified with SPY ® in four of eight patients undergoing free-flap breast reconstruction led to interventions that prevented flap necrosis in three patients.…”

Optimizing Safety, Predictability, and Aesthetics in Direct to Implant Immediate Breast Reconstruction

“…If the implant is accepted easily and without tension, a temporary suture is placed, and vascular skin flap perfusion is assessed with intravenous injection of indocyanine green fluorescence angiography using the SPY Elite protocol (Novadaq Technologies, Inc, Mississauga, ON), as previously reported by several authors. [27][28][29][30] If vascular perfusion is deemed adequate using accepted criteria, 28,29 the lateral pectoralis major muscle is reflected and a subpectoral cautery dissection performed with the inferior and inferomedial attachments of the pectoralis major (PM) to the ribs and sternum is released. It is critical to elevate the PM sufficiently in a cephalad direction to allow for adequate mobilization and proper redraping and insetting of the pectoralis/ADM composite with undue tension once constructed.…”