Advertisement

Patterns of ischaemia and reperfusion in nipple-sparing mastectomy reconstruction with indocyanine green angiography

Published:August 04, 2022DOI:https://doi.org/10.1016/j.bjps.2022.08.006

      Summary

      Background

      Intraoperative assessment of mastectomy flaps and nipple-areola complex (NAC) with indocyanine green angiography (ICGA) for decision-making in delayed breast reconstruction after nipple-sparing mastectomy (NSM) remains to be fully elucidated. We evaluated patterns of ischaemia and reperfusion in NSM with delayed breast reconstruction and their outcomes.

      Method

      Single-institution retrospective study of delayed implant-based breast reconstructions following NSM due to poor perfusion analysis on ICGA. Intraoperative ICGA perfusion values and fluorescence patterns during the delayed and subsequent reconstruction operations were analysed.

      Results

      Fifty-six (45 patients) delayed breast reconstructions following NSM were performed. The median time to reconstruction was seven days (range, 4–21 days). A total of 112 fluorescence images were reviewed. Four patterns of ischaemia were identified during initial mastectomy (Type I, diffuse ischaemia; Type II, geographic ischaemia; Type III, incisional ischaemia; Type IV, NAC only ischaemia). All, but 1 breast, had adequate reperfusion during delayed reconstruction. Obesity (BMI ≥ 30) was associated with Type I ischaemia (p < 0.001). Mean ICGA absolute and relative perfusion values during initial mastectomy were significantly lower than the perfusion values during delayed reconstruction (absolute value 6.7 versus 40.2 units, p < 0.001; relative value 10% versus 44%, p < 0.001, respectively). There were no cases of partial-thickness or full-thickness necrosis.

      Conclusions

      Delaying breast reconstruction for NSM with ischaemia predicted by ICGA may allow blood supply to the flap and NAC to improve, reducing the risk for necrosis. Distinct patterns of ischaemia and low perfusion values with ICGA may be used in the decision to delay reconstruction.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Karian L.S.
        • Therattil P.J.
        • Wey P.D.
        • Nini K.T.
        Delay techniques for nipple-sparing mastectomy: A systematic review.
        J Plast Reconstr Aesthet Surg. 2017; 70: 236-242
        • De La Cruz L.
        • Moody A.M.
        • Tappy E.E.
        • Blankenship S.A.
        • Hecht E.M.
        Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: A meta-analysis and systematic review.
        Ann Surg Oncol. 2015; 22: 3241-3249
        • Woerdeman L.A.E.
        • Hage J.J.
        • Smeulders M.J.C.
        • Rutgers E.J.T.
        • van der Horst C.M.A.M.
        Skin-sparing mastectomy and immediate breast reconstruction by use of implants: An assessment of risk factors for complications and cancer control in 120 patients.
        Plast Reconstr Surg. 2006; 118: 321-330
        • Kobraei E.M.
        • Nimtz J.
        • Wong L.
        • et al.
        Risk factors for adverse outcome following skin-sparing mastectomy and immediate prosthetic reconstruction.
        Plast Reconstr Surg. 2012; 129 (234e-41e)
        • Jeon F.H.K.
        • Varghese J.
        • Griffin M.
        • Butler P.E.
        • Ghosh D.
        • Mosahebi A.
        Systematic review of methodologies used to assess mastectomy flap viability.
        BJS Open. 2018; 2: 175-184
        • Robertson S.A.
        • Jeevaratnam J.A.
        • Agrawal A.
        • Cutress R.I.
        Mastectomy skin flap necrosis: challenges and solutions.
        Breast Cancer. 2017; 9: 141-152
        • Mastroianni M.
        • Lin A.M.
        • Smith B.L.
        • Austen Jr., W.G.
        • Colwell A.S
        Nipple loss following nipple-sparing mastectomy.
        Plast Reconstr Surg. 2016; 138: 24e-30e
        • Tondu T.
        • Hubens G.
        • Tjalma W.A.
        • et al.
        Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes.
        J Plast Reconstr Aesthet Surg. 2020; 73: 469-485
        • Singer R.
        • Lewis C.M.
        • Franklin J.D.
        • Lynch J.B.
        Fluorescein test for prediction of flap viability during breast reconstructions.
        Plast Reconstr Surg. 1978; 61: 371-375
        • Pruimboom T.
        • Schols R.M.
        • Van Kuijk S.M.
        • Van der Hulst R.R.
        • Qiu S.S.
        Indocyanine green angiography for preventing postoperative mastectomy skin flap necrosis in immediate breast reconstruction.
        Cochrane Database Syst Rev. 2020; 4CD013280
        • Reinhart M.B.
        • Huntington C.R.
        • Blair L.J.
        • Heniford B.T.
        • Augenstein V.A.
        Indocyanine green: historical context, current applications, and future considerations.
        Surg Innov. 2016; 23: 166-175
        • Phillips B.T.
        • Lanier S.T.
        • Conkling N.
        • et al.
        Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.
        Plast Reconstr Surg. 2012; 129 (778e-88e)
        • Koonce S.L.
        • Sarik J.R.
        • Forleiter C.M.
        • Newman M.I.
        A classification system and treatment algorithm for mastectomy flap ischemia in alloplastic breast reconstruction.
        J Plast Reconstr Aesthet Surg. 2020; 73: 1854-1861
        • Komorowska-Timek E.
        • Gurtner G.C.
        Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction.
        Plast Reconstr Surg. 2010; 125: 1065-1073
        • Alderman A.K.
        • Wilkins E.G.
        • Kim H.M.
        • Lowery J.C.
        Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study.
        Plast Re-Constr Surg. 2002; 109: 2265-2274
        • Ghali S.
        • Butler P.E.M.
        • Tepper O.M.
        • Gurtner G.C.
        Vascular delay revisited.
        Plast Reconstr Surg. 2007; 119: 1735-1744
        • Jensen J.A.
        • Lin J.H.
        • Kapoor N.
        • Giuliano A.E.
        Surgical delay of the nipple-areolar complex: a powerful technique to maximize nipple viability following nipple-sparing mastectomy.
        Ann Surg Oncol. 2012; 19: 3171-3176
        • Figueroa R.
        • Golse N.
        • Alvarez F.A.
        • et al.
        Indocyanine green fluorescence imaging to evaluate graft perfusion during liver transplantation.
        HPB: Off J Int Hepato Pancreato Biliary Assoc. 2019; 21: 387-392
        • Wapnir I.
        • Dua M.
        • Kieryn A.
        • et al.
        Intraoperative imaging of nipple perfusion patterns and ischemic complications in nipple-sparing mastectomies.
        Ann Surg Oncol. 2014; 21: 100-106
        • Robertson S.A.
        • Rusby J.E.
        • Cutress R.I.
        Determinants of optimal mastectomy skin flap thickness.
        Br J Surg. 2014; 101: 899-911
        • Spear S.L.
        • Shuck J.
        • Hannan L.
        • Albino F.
        • Patel K.M.
        Evaluating long-term outcomes following nipple-sparing mastectomy and reconstruction in the irradiated breast.
        Plast Reconstr Surg. 2014; 133 (605e-14e)
        • Colwell A.S.
        • Tessler O.
        • Lin A.M.
        • et al.
        Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends.
        Plast Reconstr Surg. 2014; 133: 496-506
        • Gould D.J.
        • Hunt K.K.
        • Liu J.
        • et al.
        Impact of surgical techniques, biomaterials, and patient variables on rate of nipple necrosis after nipple-sparing mastectomy.
        Plast Reconstr Surg. 2013; 132 (330e-8e)
        • Duggal C.S.
        • Grudziak J.
        • Metcalfe D.B.
        • Carlson G.W.
        • Losken A.
        The effects of breast size in unilateral postmastectomy breast reconstruction.
        Ann Plast Surg. 2013; 70: 506-512
        • Woerdeman L.A.
        • Hage J.J.
        • Hofland M.M.
        • Rutgers E.J.
        A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria.
        Plast Reconstr Surg. 2007; 119: 455-463
        • Phillips B.T.
        • Khan S.U
        Mastectomy Skin Flap Perfusion.
        Breast Reconstruction. 2016; : 1547-1557