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Intraoperative Perfusion Techniques Can Accurately Predict Mastectomy Skin Flap Necrosis in Breast Reconstruction: Results of a Prospective Trial

Phillips, Brett T. M.D., M.B.A.; Lanier, Steven T. B.A., B.S.; Conkling, Nicole B.A., B.S.; Wang, Eric D. B.S.; Dagum, Alexander B. M.D.; Ganz, Jason C. M.D.; Khan, Sami U. M.D.; Bui, Duc T. M.D.

Plastic and Reconstructive Surgery: May 2012 - Volume 129 - Issue 5 - p 778e–788e
doi: 10.1097/PRS.0b013e31824a2ae8
Breast: Original Articles

Background: Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment.

Methods: The authors conducted a prospective clinical trial of tissue expander–implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis.

Results: Fifty-one tissue expander–implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity.

Conclusions: Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis.


Stony Brook, N.Y.

From the Division of Plastic and Reconstructive Surgery, Stony Brook University Medical Center, and the Stony Brook University School of Medicine.

Received for publication September 24, 2011; accepted October 31, 2011.

Abstract presented in its entirety at the 27th Annual Meeting of the Northeastern Society of Plastic Surgeons, in Washington, D.C., October 28 through 31, 2010; the 67th Annual Meeting of the American Society for Reconstructive Microsurgery, in Cancun, Mexico, January 15 through 18, 2011, where it received the award for Best Clinical Translational Paper; the 56th Annual Meeting of the Plastic Surgery Research Council, in Louisville, Kentucky, April 27 through 30, 2011; and the 16th Congress of the International Confederation for Plastic, Reconstructive and Aesthetic Surgery, in Vancouver, British Columbia, Canada, May 22 through 27, 2011.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Brett T. Phillips, M.D., M.B.A.; Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19, Room 020, Stony Brook, N.Y. 11794-8191,

©2012American Society of Plastic Surgeons