Study of the Protocol Used to Evaluate Skin-Flap Perfusion in Mastectomy Based on the Characteristics of Indocyanine Green

Abstract BACKGROUND Vascularized intranasal flaps are the primary reconstructive option for endoscopic skull base defects. Flap vascularity may be compromised by injury to the pedicle or prior endonasal surgery. There is currently no validated technique for intraoperative evaluation of intranasal flap viability. OBJECTIVE To evaluate the efficacy of indocyanine green (ICG) near-infrared angiography in predicting the viability of pedicled intranasal flaps during endoscopic skull base surgery through a pilot study. METHODS ICG near-infrared fluorescence endoscopy was performed during endoscopic endonasal surgery for skull base tumors. Intraoperative and postoperative data were collected regarding enhancement of the flap body and pedicle. Fluorescence was rated qualitatively. Postoperatively, flap perfusion was evaluated via MRI-contrast enhancement in addition to clinical outcomes (cerebrospinal fluid leak and endoscopic flap appearance). RESULTS Thirty-eight patients underwent ICG fluorescence angiography. Both the body and pedicle enhanced in 20 patients (53%), while the pedicle only enhanced for 12 patients (32%), the body only for 3 (8%), and neither for 3 (8%). When both the pedicle and body enhanced with ICG, the rate of postoperative MRI contrast enhancement was 100% and the rate of flap necrosis was 0%. The sensitivity and specificity of flap pedicle ICG enhancement for predicting postoperative flap MRI enhancement were 97% and 67%, respectively. Two of 3 patients without enhancement developed flap necrosis. CONCLUSION ICG fluorescence angiography of intraoperative flap perfusion is feasible and correlates well with outcomes of postoperative MRI flap enhancement and flap necrosis. Additional study is needed to further refine the imaging technique and optimally characterize the clinical utility.

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Near Infrared Fluorescence Imaging to Assess Breast Flap Perfusion and Prevention of Ischemia: Case Report

International Surgery ◽

10.9738/intsurg-d-16-00230.1 ◽

2019 ◽

Vol 103 (9-10) ◽

pp. 473-476

Author(s):

Ju Yong Cheong ◽

David Goltsman ◽

Sanjay Warrier

Keyword(s):

Fluorescence Imaging ◽

Near Infrared ◽

Imaging System ◽

Skin Flap ◽

Color Temperature ◽

Near Infrared Fluorescence ◽

Clinical Method ◽

Nirf Imaging ◽

Near Infrared Fluorescence Imaging ◽

Flap Perfusion

Introduction: Breast skin flap ischemia and necrosis is a serious consequence of breast reconstruction with reported incidence of 10% to 15%. Current clinical method of assessing breast skin flap perfusion includes combination of skin color, temperature, dermal edge bleeding, and capillary refill. Given the high incidence of ischemia and the presence of certain cohort of patient with greater risk, there is a need for an objective method of assessing the skin flap perfusion. Near infrared fluorescence imaging using indocyanine green is a new technique of assessing skin flap perfusion. We present a first reported case where breast skin flap ischemia was objectively identified intraoperatively by NIRF imaging, and this ischemia was reversed through active intra- and postoperative measures, which was objectively again identified by NIRF imaging. Case presentation: A 36-year-old female patient underwent bilateral nipple sparing mastectomies with immediate reconstruction using tissue expanders. Clinical assessment of the breast skin flap was equivocal. NIRF imaging using SPY imaging system (Novadaq Technologies Inc, Toronto, ON, Canada) showed poor perfusion in the periareolar region. As a result, it was decided to completely deflate the expander, actively warm the skin flap and encourage cutaneous perfusion through use of topical glycerin trinitrate patch. A repeat NIRF imaging 48 hours showed 10-fold increase in perfusion in the skin flap. Conclusion: NIRF imaging is a useful tool in assessing breast skin perfusion and to predict potential ischemia, which can aid in surgeon's management of patient.

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