The role of intraoperative and early postoperative assessment of skin flap perfusion in skin-sparing/subcutaneous mastectomies

The surgical stage is the main one in the complex and combined treatment of patients with breast cancer. After performing skin-sparing and subcutaneous mastectomies, there is a risk of postoperative complications in the form of skin flap necrosis associated with its insufficient perfusion. In order to reduce the incidence of postoperative complications, it is necessary to improve the quality of intraoperative assessment of skin flap perfusion after reconstructive plastic surgery on the mammary gland. This article reviews the literature on current issues of assessing the efficacy and safety of this technique. Indocyanine green angiography has been proposed to assess skin flap perfusion. 
The method involves intraoperative injection of dye followed by illumination of the skin flap to assess perfusion and remove non-viable tissue.

1. Malignant neoplasms in Russia in 2022 (morbidity and mortality). Ed. by A.D. Kaprin, V.V. Starinskiy, A.O. Shakhzadova. Moscow, 2023. P. 18. (In Russ.).

2. Zikiryakhodzhaev A.D., Rasskazova E.A., Tukmakov A.Yu., Shirokikh I.M. Recurrences after radical subcutaneous/skin-sparing mastectomies with simultaneous reconstruction for breast cancer. Issledovanie i praktika v meditsine = Research and Practice in Medicine 2019;(6):33–40. (In Russ.).

3. McCartan D., Sacchini V.S. Skin-Sparing Mastectomy. In: Oncoplastic and Reconstructive Breast Surgery. Springer, 2019. DOI: 10.1007/978-3-319-62927-8_20

4. Indocyanine green solution. National Cancer Institute. Available at: https://www.cancer.gov/publications/dictionaries/cancer-drug/def/indocyanine-green-solution.

5. Wipper S. Validation of fluorescent angiography for intraoperative monitoring and quantitative assessment of myocardial perfusion. Munich, 2006. Pp. 18–23.

6. Augustin A.J., Krieglstein G.K. Augenheilkunde. Springer-Verlag, 2001.

7. Alander J.T., Kaartinen I., Laakso A. et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging 2012:2012:940585. DOI: 10.1155/2012/940585

8. Harless C.A., Jacobson S.R. Tailoring through technology: A retrospective review of a single surgeon’s experience with implant-based breast reconstruction before and after implementation of laser-assisted indocyanine green angiography. Breast J 2016;22(3):274–81. DOI: 10.1111/tbj.12576

9. Zeyang L., Dajiang S., Zan L. et al. Application progress of indocyanine green angiography in breast reconstruction. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2018;32(11):1463–8. DOI: 10.7507/1002-1892.201803040

10. Dua M., Bertoni D.M., Nguyen D. et al. Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomy. Gland Surg 2015;4(6):497–505. DOI: 10.3978/j.issn.2227-684X.2015.04.15

11. Mirhaidari S.J., Beddell G.M., Orlando M.V. et al. A prospective study of immediate breast reconstruction with laser-assisted indocyanine green angiography. Plast Reconstr Surg Glob Open 2018;6:e1774. DOI: 10.1097/GOX.0000000000001774

12. Venturi M.L., Mesbahi A.N., Copeland-Halperin L.R. et al. SPY elite’s ability to predict nipple necrosis in nipple-sparing mastectomy and immediate tissue expander reconstruction. Plast Reconstr Surg Glob Open 2017;5:e1334. DOI: 10.1097/GOX.0000000000001334

13. Momeni A., Sheckter C. Intraoperative laser-assisted indocyanine green imaging can reduce the rate of fat necrosis in microsurgical breast reconstruction. Plast Reconstr Surg 2020;145(3):507e–13e. DOI: 10.1097/PRS.0000000000006547

14. Mastronardi M., Fracon S., Scomersi S. et al. Role of qualitative and quantitative indocyanine green angiography to assess mastectomy skin flaps perfusion in nipple/skin-sparing and skin-reducing mastectomies with implant-based breast reconstruction. Breast J 2022:2022:5142100. Available at: https://onlinelibrary.wiley.com/doi/10.1155/2022/5142100.

15. Malagón-López P., Vilà J., Carrasco-López C. et al. Intraoperative indocyanine green angiography for fat necrosis reduction in the deep inferior epigastric perforator (DIEP) flap. Aesthet Surg J 2019;39:NP45–54. 16. Varela R., Casado-Sanchez C., Zarbakhsh S. et al. Outcomes of DIEP flap and fluorescent angiography: a randomized controlled clinical trial. Plast Reconstr Surg 2020;145:1–10. DOI: 10.1097/PRS.0000000000006393