Routine Laser-assisted Indocyanine Green Angiography in Immediate Breast Reconstruction: Is It Worth the Cost?

Clinical and Cost-Effectiveness of Intraoperative Flap Perfusion Assessment With Indocyanine Green Fluorescence Angiography in Breast and Head and Neck Reconstructions: A Systematic Review and Meta-Analysis

BACKGROUND

Indocyanine green fluorescence angiography (ICGFA) is gaining popularity for the assessment of reconstructive flap perfusion intraoperatively. This study analyses the literature with a focus on its clinical efficacy and cost-effectiveness across various plastic and reconstructive surgery procedures.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines on published studies in English comparing ICGFA with standard clinical assessment for flap perfusion. Meta-analysis concerned perfusion-related complications and cost data.

RESULTS

Twenty-five studies met the inclusion criteria, of which two were randomized controlled trials (RCTs) and four were prospective cohort studies. Twenty-one studies were AHRQ Standard 'Good'; however, the overall level of evidence remains low. ICGFA was predominantly performed in breast surgeries (n = 3310) and head and neck reconstruction (n = 701) albeit with inconsistency in protocols and predominantly subjective interpretations (only five studies utilized objective thresholds). In breast surgery, meta-analysis demonstrated significant reductions in mastectomy skin flap necrosis (odds ratio (OR) 0.58, p < 0.0001), fat necrosis (OR 0.31, p < 0.001), infection (OR 0.66, p = 0.02), and re-operation (OR 0.40, p < 0.0001), but no significant decrease in total or partial flap loss (OR 0.78, p = 0.57/OR 0.87, p = 0.56, respectively) or increase in dehiscence (OR 1.55, p = 0.11). In head and neck surgery, ICGFA significantly decreased total flap loss (OR 0.47, p = 0.04), although not partial flap loss (OR 0.37, p = 0.13) and reoperation (OR 0.92, p = 0.73). Lower limb (n = 104) and abdominal wall (n = 95) reconstructive surgeries were much less studied with no significant ICGFA impact. Seven studies reported cost savings with flap surgeries and breast reconstructions, although study heterogeneity precluded meta-analysis.

CONCLUSIONS

ICGFA appears to be a useful, cost-effective tool to identify otherwise unsuspected hypoperfusion in breast and head and neck reconstruction. There is a clear need for standardization, however, to avoid bias. Further RCTs are necessary to solidify these promising clinical findings.

Use of SPY angiography in tissue assessment for wound healing outcomes after breast reconstruction

OBJECTIVE

The objective of this study was to evaluate whether a systematic image assessment protocol using SPY Elite images (LifeCell Corp., US) of viable tissue at the periphery of the surgical field was associated with positive wound healing outcomes following mastectomy and breast reconstruction.

METHOD

Patients undergoing mastectomy and subsequent breast reconstruction surgery at a single tertiary medical centre were included. SPY images were prospectively analysed using a systematic image assessment protocol, and an absolute value of mean fluorescence was calculated by measuring peripheral, in-situ tissue from each image. Patient medical records were retrospectively reviewed for demographics, surgical characteristics and postoperative outcomes. These variables were statistically tested for associations with mean fluorescence.

RESULTS

A total of 63 patients were included in the final analysis. We found that objectively determined mean fluorescence values were not statistically significantly associated with postoperative complications.

CONCLUSION

In this study, objectively measured mean fluorescence values representing breast tissue remaining after dissection showed little utility in the assessment of postoperative wound healing outcomes as they did not identify patients who would later have complications of wound healing.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Using Laser-Assisted Indocyanine Green Angiography to Assess Nipple-Areolar Complex Survival During Reduction Mammoplasty

BACKGROUND

In reduction mammoplasty, preserving an appropriate skin flap is crucial to achieve a favorable postoperative appearance and prevent blood supply disorders in the nipple-areolar complex (NAC). Previous studies have indicated that a thinner or narrower flap is more favorable for breast shaping, but also increases the risk of blood supply disorders. Accessing the blood perfusion of the NAC and determining the critical threshold for NAC viability are essential aspects of reduction mammoplasty.

OBJECTIVES

The aim of this study was to utilize indocyanine green (ICG) angiography to assess NAC perfusion during reduction mammoplasty. It also sought to identify critical thresholds of various indicators affecting NAC survival and provide guidance for skin flap trimming.

METHODS

Thirty-eight patients who underwent reduction mammoplasty were included. Each patient received ICG angiography before and after skin flap trimming. Data on NAC perfusion, skin flap length, width, thickness, and other relevant indicators were collected.

RESULTS

Among the patients, 5 experienced NAC blood supply disorders. Multiple linear regression analysis demonstrated that the NAC blood supply had a significant correlation with the tissue thickness at the pedicle base (P < .001) and with the length-to-width ratio across the nipple (P < .05). To optimize NAC survival and achieve favorable breast shaping, cutoff points for the thickness at the pedicle base and the length-to-width ratio across the nipple of 1.15 cm and 1.71, respectively, were established.

CONCLUSIONS

ICG angiography provides an effective means to assess NAC blood supply and postoperative survival. The cutoff points established in this study help to predict the survival of the NAC and guide flap trimming.

LEVEL OF EVIDENCE: 3

Cost-effectiveness of indocyanine green angiography in postmastectomy breast reconstruction

BACKGROUND

Mastectomy skin flap necrosis is a major complication of skin- or nipple-sparing mastectomy. Indocyanine green angiography (ICGA) is a novel technology that can identify flaps at risk of necrosis, but there is paucity of cost-effectiveness data particularly in the Australian context. We evaluated its cost-effectiveness in breast reconstruction surgery.

METHODS

Single-institution retrospective study of 295 implant-based breast reconstructions using ICGA compared with 228 reconstructions without ICGA from 2015 to 2020. Costs were calculated using Medicare item numbers and micro-costing analysis. Break-even point analysis determined the number needed to break-even. Cost-utility analysis compared probabilities of ischaemic complications and utility estimates derived from surveys of surgeons to fit into a decision model.

RESULTS

There were 295 breast reconstructions using ICGA with a total cost of AU$164,657. The average cost of treating an ischaemic complication was AU$21,375. Use of ICGA reduced the ischaemic complication rate from 14.9% to 8.8%. Ischaemic complications were prevented in 18 breasts resulting in gross cost savings of AU$384,745 and net savings of AU$220,088. Three hundred eighteen cases using ICGA are needed to break-even. The decision model demonstrated a baseline cost difference of AU$1,179, a quality-adjusted life-years (QALY) difference of 1.77, and an incremental cost-utility ratio (ICUR) of AU$656 per QALY favouring ICGA.

CONCLUSIONS

Routine use of ICGA during implant-based breast reconstruction is a cost-effective intervention for the reduction of ischaemic complications in the Australian setting. ICGA use was associated with a gain of 1.77 additional years of perfect health at a cost of AU$656 more per year.

Use of Indocyanine Green Angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: A systematic review and meta-analysis

INTRODUCTION

Indocyanine Green Angiography (ICG-A) is an imaging technique used to visualize tissue perfusion in real time. The aim of this systematic review and meta-analysis is to evaluate all published papers on breast reconstruction using ICG-A, which provides information on complication rates and to investigate whether the use of this peroperative method decreases the risk of complications.

MATERIALS AND METHODS

MEDLINE/PubMed, EMBASE, Cochrane, and UpToDate were searched using relevant terms. The literature was assessed using the PRISMA guidelines. Inclusion criteria were: original articles written in English assessing ICG-angiography in breast reconstruction. The individual studies were evaluated according to Cochrane guidelines.

RESULTS

The search yielded 243 papers on ICG-A and breast reconstruction. Twenty-six of these were included for analysis. The risk of overall major complications ([OR] = 0.53, 95% confidence interval (CI) = 0.43-0.66, p = 0.00001) and overall loss of reconstruction ([OR] = 0.58, 95% CI = 0.37-0.92, and p = 0.020) was significantly lower when peroperative ICG-A was used. When using ICG-A to evaluate mastectomy flaps, a statistically lower risk of major complications ([OR] = 0.56 and p = 0.0001) and the loss of reconstruction was found ([OR] = 0.46, p = 0.006). ICG-A used in autologous breast reconstruction significantly reduced the risk of minor ([OR] = 0.62 and p = 0.001) and major complications ([OR] = 0.53 and p = 0.0028).

CONCLUSIONS

This is the first systematic review to analyze the use of ICG-A on both mastectomy flaps and autologous reconstruction. The results obtained in the current study indicate that the use of ICG-A in breast reconstructive procedures reduces the complications as well as the loss of reconstruction.

What Is in a Number? Evaluating a Risk Assessment Tool in Immediate Breast Reconstruction

Supplemental Digital Content is available in the text.

Ischemic complications after immediate breast reconstruction have devastating consequences; however, individual risk assessment remains challenging. We seek to develop an intraoperative assessment tool to assist in estimating risk of ischemic complications in immediate breast reconstruction.