Summary
Background
Indocyanine green angiography (ICGA) reduces ischemic complications by assessing mastectomy
flap perfusion intraoperatively. However, outcomes of ICGA can be surgeon-dependent
due to its relative novelty. We aimed to determine whether patient outcomes improved
with the adoption of ICGA over time.
Methods
We conducted a single-institution retrospective study of mastectomy patients between
March 2012 (date of ICGA introduction) and October 2016. We included patients who
underwent immediate expander-based reconstruction with intraoperative ICGA, followed
by second-stage permanent implant placement. Patients were chronologically sorted
into 3 groups, of 45 patients each, based on the date of ICGA. Complications and reconstruction
wait times (time between initial expander placement and subsequent final reconstruction)
amongst the 3 groups were evaluated. Using the Cochran–Armitage test for trend, we
tested the change in median adjusted expander fill volumes (expander fill volume in
milliliter per gram of breast removed) over time.
Results
We identified 135 patients. Rates of ischemic complications significantly decreased
(Group 1, 36%; Group 2, 22%; Group 3, 11%; p = 0.03), despite significantly increasing median adjusted expander fill volumes (Group
1, 0.46 mL/g; Group 2, 0.63 mL/g; Group 3, 0.76 mL/g; p = 0.003) over time. The rates of unexpected returns to the operating room across
the 3 groups were not significantly different. The median reconstruction wait time
was significantly reduced in the later groups (Group 1, 146 days; Group 2, 122 days;
Group 3, 87 days; p = 0.01).
Conclusions
Outcomes for mastectomy with immediate expander-based reconstruction were found to
improve with increasing case volume after implementation of ICGA.
Keywords
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References
- SEER cancer statistics review, 1975–2014.National Cancer Institute, 2016 (2017)
Plastic Surgery Statistics Report, American Society of Plastic Surgeons https://d2wirczt3b6wjm.cloudfront.net/News/Statistics/2016/plastic-surgery-statistics-full-report-2016.pdf. Accessed June 22 2017.
- True incidence of all complications following immediate and delayed breast reconstruction.Plast Reconstr Surg. 2008; 122: 19-28https://doi.org/10.1097/PRS.0b013e3181774267
- Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study.Plast Reconstr Surg. 2002; 109: 2265-2274
- Management of massive mastectomy skin flap necrosis following autologous breast reconstruction.Ann Plast Surg. 2012; 69: 139-144https://doi.org/10.1097/SAP.0b013e3182250e23
- An investigation of the application of laser-assisted indocyanine green fluorescent dye angiography in pedicle transverse rectus abdominus myocutaneous breast reconstruction.Can J Plast Surg. 2011; 19: e1-e5
- Early experience with fluorescent angiography in free-tissue transfer reconstruction.Plast Reconstr Surg. 2009; 123: 1239-1244https://doi.org/10.1097/PRS.0b013e31819e67c1
- Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction.Plast Reconstr Surg. 2010; 125: 1065-1073https://doi.org/10.1097/PRS.0b013e3181d17f80
- How should quality-of-life data be incorporated into a cost analysis of breast reconstruction? A consideration of implant versus free TRAM flap procedures.Plast Reconstr Surg. 2008; 121: 1075-1082https://doi.org/10.1097/01.prs.0000304246.66477.cd
- Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis.Plast Reconstr Surg. 2004; 113: 1650-1661https://doi.org/10.1097/01.prs.0000117196.61020.fd
- Indocyanine-green fluorescence video angiography used clinically to evaluate tissue perfusion in microsurgery.J Trauma. 2004; 57: 1018-1024https://doi.org/10.1097/01.ta.0000123041.47008.70
- Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined.Plast Reconstr Surg. 2012; 129: 1043-1048https://doi.org/10.1097/PRS.0b013e31824a2b02
- Reliable assessment of skin flap viability using orthogonal polarization imaging.Plast Reconstr Surg. 2003; 112: 547-555https://doi.org/10.1097/01.prs.0000070968.42857.43
- Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green.Br J Plast Surg. 2002; 55: 635-644
- Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction.J Reconstr Microsurg. 2010; 26: 487-492https://doi.org/10.1055/s-0030-1261701
- The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction.J Reconstr Microsurg. 2009; 25: 21-26https://doi.org/10.1055/s-0028-1090617
- Improving the quality of coronary bypass surgery with intraoperative angiography: validation of a new technique.J Am Coll Cardiol. 2005; 46: 1521-1525https://doi.org/10.1016/j.jacc.2005.05.081
- A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts.J Thorac Cardiovasc Surg. 2006; 132: 585-594https://doi.org/10.1016/j.jtcvs.2005.09.061
- An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction.Aesthet Surg J. 2014; 34: 61-65https://doi.org/10.1177/1090820X13514995
- Tailoring through technology: a retrospective review of a single surgeon's experience with implant-based breast reconstruction before and after implementation of laser-assisted indocyanine green angiography.Breast J. 2016; 22: 274-281https://doi.org/10.1111/tbj.12576
- Postmastectomy reconstruction outcomes after intraoperative evaluation with indocyanine green angiography versus clinical assessment.Ann Surg Oncol. 2016; 23: 4080-4085https://doi.org/10.1245/s10434-016-5466-y
National Healthcare Safety Network, Centers for Disease Control and Prevention. Surgical Site Infection (SSI) Event National Healthcare Safety Network, Centers for Disease Control and Prevention. http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf Accessed March 8 2017.
- The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: a prospective trial.J Plast Reconstr Aesthet Surg. 2014; 67: 449-455https://doi.org/10.1016/j.bjps.2013.12.040
- Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction.Plast Reconstr Surg. 2014; 133: 448e-454ehttps://doi.org/10.1097/PRS.0000000000000025
- Indocyanine green angiography use in breast reconstruction: a national analysis of outcomes and cost in 110,320 patients.Plast Reconstr Surg. 2018; 141: 825-832
- Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction.Ann Surg Innov Res. 2013; 7: 9https://doi.org/10.1186/1750-1164-7-9
- The learning curve deskbook: a reference guide to theory, calculations, and applications.Quorum Books, New York1991
- The "learning curve" in the performance of laparoscopic cholecystectomy.Int Surg. 1993; 78: 1-3
- Laparoscopic cholecystectomy. The learning curve: report of 50 patients.Am Surg. 1991; 57 (discussion 545): 542-544
- The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club.Am J Surg. 1995; 170: 55-59
- What is the learning curve for laparoscopic colectomy?.Am Surg. 1995; 61: 681-685
- New surgical procedures: can our patients benefit while we learn?.Am J Obstet Gynecol. 1997; 176 (discussion 1298-1299): 1293-1298
Article info
Publication history
Published online: January 07, 2019
Accepted:
December 21,
2018
Received in revised form:
November 19,
2018
Received:
June 5,
2018
Footnotes
☆Part of this article has been presented as an oral presentation at the American College of Surgeons Clinical Congress 2017 in San Diego, CA.
Identification
Copyright
© 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Re: The use of indocyanine green angiography in postmastectomy reconstruction: Do outcomes improve over time?Journal of Plastic, Reconstructive & Aesthetic SurgeryVol. 72Issue 9
- PreviewWe read with interest the paper by Diep et al.1 The authors provide a retrospective review of Indocyanine green angiography (ICGA) use in two-stage implant-based immediate reconstruction comparing short-term complication rate in 135 patients over three different time points stratified into three equally sized groups. ICGA was used to determine areas of perfusion less than 20% to undergo debridement, prior to placement of the expander. The authors demonstrate a reduction in the incidence of mild skin flap necrosis and cellulitis over the study period.
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- Letter to the Editor: The use of indocyanine green angiography in postmastectomy reconstruction: Do outcomes improve over time?Journal of Plastic, Reconstructive & Aesthetic SurgeryVol. 72Issue 9
- PreviewWe read with interest the article by Diep and colleagues on the learning curve for the use of indocyanine green angiography (ICGA) in post mastectomy breast reconstruction to improve outcomes.1 This is an important finding on the surgeons’ experience required for effective use of the ICGA technique. As stated, clinical judgement remains the current standard at the time of tissue expander placement. However, it is a subjective assessment and varies between surgeons worldwide, partly due to differences in surgeons’ personal experience and surgical training.
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