The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial

Munabi, Naikhoba C.O.; Olorunnipa, Olushola; Goltsman, David; Rohde, Christine; Ascherman, Jeffrey A.

doi:10.1016/j.bjps.2013.12.040

Cited by 167 publications

(153 citation statements)

References 18 publications

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“…The sensitivity and specificity were the highest for ICGA in five studies19 20, 35 37, 38, ranging from 38 to 100 per cent and 68 to 91 per cent respectively. Two studies37 39 using FA reported a sensitivity of 75–90 per cent and specificity of 30–71 per cent.…”

Section: Resultsmentioning

confidence: 93%

“…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.…”

Section: Resultsmentioning

confidence: 99%

“…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. Tissue resection, however, was done according to the surgeon's clinical judgement.…”

Section: Resultsmentioning

confidence: 99%

“…Five studies19 20, 37 38, 40 used SPY‐Q™ software to determine perfusion values to guide resection. There were divided opinions on whether absolute or relative perfusion units were more reliable.…”

Section: Resultsmentioning

confidence: 99%

“…Over‐resection of potentially unviable tissue may be the safest option, but this may limit reconstructive options and compromise aesthetic outcomes12. Rates of necrosis reported using this approach are approximately 10–15 per cent19, with a specificity of 10–30 per cent20.…”

Section: Introductionmentioning

confidence: 99%

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Systematic review of methodologies used to assess mastectomy flap viability

et al. 2018

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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.

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Section: Resultsmentioning

confidence: 93%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Systematic review of methodologies used to assess mastectomy flap viability

et al. 2018

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Utility of Indocyanine Green Angiography to Identify Clinical Factors Associated With Perfusion of Paramedian Forehead Flaps During Nasal Reconstruction Surgery

Abdelwahab

Kandathil

Most

et al. 2019

JAMA Facial Plast Surg

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Identifying factors affecting forehead flap neovascularization during nasal reconstruction surgical procedures using quantitative dynamics of fluorescence from indocyanine green angiography may be associated with reduced vascular complications.OBJECTIVES To identify quantifiable forehead flap perfusion measures using indocyanine green angiography during nasal reconstruction procedures and to evaluate clinical factors associated with neovascularization. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 71 patients at a tertiary referral center of Stanford University, Stanford, California, between January 1, 2010, and March 31, 2018, undergoing forehead flap nasal reconstruction surgery with flap perfusion assessed by indocyanine green angiography.EXPOSURES Indocyanine green angiography was performed intraoperatively to record forehead flap neovascularization during the second stage of nasal reconstruction surgery after temporary clamping of the pedicle. MAIN OUTCOMES AND MEASURESWith use of quantifiable data of fluorescence dynamics, flap perfusion in association with a reference point in the cheek after pedicle clamping was assessed by 2 methods: (1) ingress (arterial inflow) and egress (venous outflow) flap-to-cheek ratio and (2) flap-to-cheek perfusion (fluorescence) ratio at 3 time points (midpoint of indocyanine green flap inflow, maximum fluorescence [peak], and midpoint of indocyanine green flap outflow) and their calculated mean. Association of the perfusion measures with patient and procedural factors was performed using linear regression models. RESULTSOf the 71 patients included in the study, 43 (61%) were men; the mean (SD) age was 71.1 (11.0) years. The mean (SD) flap-to-cheek inflow ratio was 0.48 (0.40), peak fluorescence ratio was 0.59 (0.34), and outflow ratio was 0.88 (0.42). The calculated mean (SD) flap-to-cheek perfusion ratio of these measures was 0.65 (0.35). The mean (SD) flap-to-cheek ingress ratio was 0.54 (0.36) and egress ratio was 0.65 (0.98). With use of a multivariable regression model, the time between stages was positively associated with flap-to-cheek ingress ratio (β, 0.015; 95% CI, 0.001 to 0.030), and cartilage grafting was negatively associated with flap-to-cheek outflow ratio (β, -0.240; 95% CI, -0.472 to -0.008). CONCLUSIONS AND RELEVANCEThe findings suggest that indocyanine green angiography is an effective method to quantify relative neovascularization perfusion of forehead flaps. Future applications may include the use of this technology to aid in early flap division and ensure adequate perfusion among high-risk patients.LEVEL OF EVIDENCE NA.

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