Page 74 - Read Online

Black et al. Plast Aesthet Res 2023;10:31 https://dx.doi.org/10.20517/2347-9264.2023.04 Page 5 of 9

INTRAOPERATIVE STRATEGIES
Indocyanine green angiography
Though the incidence of skin flap necrosis is high, there are ways in which surgeons can both anticipate and
even mitigate the effects of necrosis intra-operatively. Fluorescent imaging can aid in assessing mastectomy
[30]
flap skin perfusion in real time, which can help predict the possible extent of skin necrosis . The intra-
operative use of fluorescence-guided imaging with indocyanine green (ICG) has been used in clinical
practice for over fifty years to assess vascular perfusion. Specialties such as ophthalmology and cardiology
have made ICG fluoroscopy a routine part of assessing pertinent vessels, such as retinal and coronary
[31]
arteries . ICG has multiple benefits in that it is nontoxic to the patient, remains contained within the
circulatory system, and is cost-effective .
[32]

For the past 15 years, ICG fluoroscopy has been implemented to help assess mastectomy flap perfusion
[33]
intra-operatively to predict skin flap viability . Fluoroscopy can be used during autologous reconstruction
to assess the patency of any free-flap microvascular anastomoses and subsequent flap perfusion, both
intraoperatively and postoperatively . It can also be particularly beneficial in pre-pectoral implant-based
[34]
reconstruction where preservation of mastectomy skin is of utmost importance due to the risk of device
extrusion.

One prospective study compared intraoperative skin perfusion using ICG-guided imaging to areas of the
breast affected by postoperative skin necrosis and found that breast skin with < 25% perfusion
intraoperatively was not viable 90% of the time, and areas with > 45% of perfusion on ICG imaging survived
98% of the time . Surgeons can use this intraoperative information to remove any potentially nonviable
[33]
skin at the time of mastectomy and to guide patient expectations postoperatively. Our imaging protocol
calls for an injection of 10 mg of reconstituted dye (or 4 mL of solution) followed by a 20 mL normal saline
flush. The imaging device of choice (e.g., Stryker Spy, Medtronic VisionSense) is brought onto the field and
run for at least 2 min to allow sufficient time for visualization of contrast media in the mastectomy flaps.
The false positive rate of ischemia is almost zero, but areas of delayed or poor perfusion on laser
angiography may still be clinically viable. With NSM, excising even a small amount of skin near the incision
may lead to nipple malposition and deformity. Therefore, it may be best to take a conservative approach if
the area to be excised may lead to deformity. This requires patient handholding and preoperative
counseling, as partial skin necrosis will take several weeks to mature and can appear alarming to the
uninitiated. In our practice, all patients with potentially compromised skin have a warming blanket and
nitroglycerin paste on the mastectomy flaps postoperatively, as discussed below.

Skin banking during autologous reconstruction
While fluorescent imaging using ICG may help predict the occurrence and extent of skin necrosis, skin
banking during autologous reconstruction helps address the loss of tissue due to necrosis. Skin loss can
significantly alter breast shape, nipple position, and overall breast symmetry . Although skin grafting may
[12]
mitigate these sequelae, it creates a color and texture mismatch to the bordering native breast skin and can
be costly. In cases of skin necrosis in implant-based reconstruction, converting to an autologous
reconstruction may be the sole option to address large areas of skin loss.

However, autologous reconstruction affords the surgeon the ability to bank donor skin in the event of skin
loss from necrosis or if further resection is needed due to positive margins at the NAC. The use of banked
skin to revise an autologous reconstruction has been demonstrated with abdominal flaps (TRAM, DIEP,
SEIA) and with transverse myocutaneous gracilis flaps [35,36] . A recent retrospective study from our institution
found that managing skin necrosis using banked skin was more cost-effective than using skin grafts with or