Fat necrosis following microsurgical breast reconstruction is common and problematic for patients and surgeons alike. Indocyanine green angiography provides a means of evaluating flap perfusion at the time of surgery to inform judicious excision of hypoperfused tissue. The authors hypothesized that incorporation of protocolized indocyanine green–informed flap débridement at the time of surgery would decrease the incidence of fat necrosis.
A retrospective study of two cohorts was performed evaluating patients before and after implementation of protocolized indocyanine green–guided flap excision. Variables included demographics, procedural details, and complications. Multivariable analysis was used to determine significant differences between the cohorts and evaluate for meaningful changes in fat necrosis.
Eighty patients were included, accounting for 137 flaps. Flap type was the only significant difference between the two groups, with the indocyanine green group more likely to be deep inferior epigastric perforator flaps (43.1 percent versus 25.3 percent; p = 0.038). The overall postoperative incidence of fat necrosis was 14.6 percent (20 of 137 flaps). Comparing by cohort, the standard débridement group showed 18 of 79 flaps with fat necrosis (22.8 percent), whereas the indocyanine green–informed débridement group showed only two of 58 flaps with fat necrosis (3.4 percent; odds ratio, 0.11; 95 percent CI, 0.02 to 0.60; p = 0.011). There were no other significant differences in complication profile.
Intraoperative use of indocyanine green angiography was associated with significantly lower odds of fat necrosis. This technology may reduce additional revision operations and improve patient satisfaction. Additional studies are needed to determine whether this innovation is cost-effective and generalizable to the entire autologous breast reconstruction population.
CLINICAL QUESTION/LEVEL OF EVIDENCE: