Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

Abstract

Background: This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Methods: A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure. Results: Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits. Conclusion: Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours

“…There were no clinical signs of fat necrosis in this series. All flaps were evaluated with indocyanine green 15 at time of inset. Intraoperative details and postoperative course is shown in Tables 2 and 3 .…”

Assessment of deep inferior epigastric perforator flap perfusion with near-infrared fluorescence: A pilot study and description of a standardized working protocol

“…A similar reduction in FN (from 71% to 0%) was described by Casey et al (2015) 19 , and in a randomized controlled trial by Varela et al ( 2020) 18 (from 59% to 8.3%). Hembd et al (2020) 22 recently demonstrated that use of NIRF was associated with a decrease in the odds of developing FN (OR, 0.38; p=0.004). Taken together, reported incidence of FN in the above mentioned studies was variable (0%-71%).…”

Abdominal subcutaneous fat thickness as a substitute for BMI in predicting complications in abdominally‐based autologous breast reconstruction

“…While patients with a thicker abdominal fat pad may be at increased risk for flap fat necrosis, intraoperative precautions may improve outcomes. Among these are increasing the number of perforators the flap is based on as well as using intraoperative tools such as indocyanine green angiography to assess flap perfusion, which have previously been shown to reduce fat necrosis occurrence rates (Hembd et al, 2020; Malagón‐López et al, 2019; Momeni & Sheckter, 2020).…”