Systematic review of methodologies used to assess mastectomy flap viability

Abstract

BackgroundAccurate prediction of mastectomy skin flap viability is vital as necrosis causes significant morbidity, potentially compromising results and delaying oncological management. Traditionally assessed by clinical judgement, a more objective evaluation can be provided using intraoperative imaging modalities. This systematic review aimed to compare all intraoperative techniques for assessment of mastectomy flap viability.MethodsA systematic literature review was performed using MEDLINE and Embase databases. Primary outcomes reported included specificity, sensitivity and predictive values of each test, and mean rates of mastectomy flap necrosis and reoperation. Secondary outcomes included cost analysis.ResultsSome 18 studies were included. Designs were prospective cohort study (8), retrospective case series (4), prospective case series (3), retrospective case–control study (1), prospective pilot trial (1) and cost analysis study (1). The studies compared indocyanine green angiography (ICGA) (16 studies) and fluorescein dye angiography (FA) (3 studies) with clinical judgement. Sensitivity and specificity were highest for ICGA (5 studies) ranging from 38 to 100 and 68 to 91 per cent respectively. Both methods overpredicted necrosis. Mean rates of flap necrosis and reoperation decreased with ICGA (7·9 and 5·5 per cent respectively) and FA (3 and 0 per cent) compared with clinical judgement (19·4 and 12·9 per cent). Two studies were designed to define numerical parameters corresponding to perfusion using intraoperative techniques. Two studies performed a cost analysis for ICGA; one claimed a cost benefit and the other advocated its use in high‐risk patients only.ConclusionICGA and FA are potentially useful tools for mastectomy flap assessment. However, the predictive accuracy is subject to the specific settings and model of equipment used. Current recommendations support their use in high‐risk patients.

The Bell Pattern: A Novel Breast Incision Approach to Skin-Reducing Mastectomies

“…ICGLA was used in all cases and has been shown to decrease mastectomy flap necrosis and reoperation rates, 7 and likely contributes to our low complication rates. We recognize criticism regarding additional cost to every surgery, and some authors recommend limiting ICG use to high-risk patients.…”

“…The costs are real: In 2014, the estimated institutional cost alone of a failed IBBR in the United States was $32,500. 5 The risks are well founded, as surgeons report difficulty managing the redundant mastectomy skin with less reliable blood supply 6 , 7 as seen with current skin-reducing mastectomy (SRM) techniques.…”

An animal experiment study on the application of indocyanine green angiography in the harvest of multi-angiosome perforator flap

“…The absolute value reflects the true fluorescence intensity in the study area, but is susceptible to temperature, ICG concentration, individual patient condition, etc. (31). Due to the strong subjectivity of the reference area selection, there are great variations between different types of flaps and individuals, and there is no uniform standard for the obtained relative indicators in different individuals.…”

Implant-based Prepectoral Breast Reconstruction: The Importance of Oncoplastic Plane, its Blood Supply and Assessment Methods

“…Intraoperative flap assessment 13,14 is done by visual inspection and palpation of the mastectomy flap thickness, non-exposure of the dermis during dissection, good capillary refill and bleeding skin edges all of which indicate adequate flap vascularity. Role of intraoperative blood/ tissue pH assessment for flaps has been studied with variable outcomes [15][16][17] .…”