SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis.

BACKGROUND: Previously, we and other investigators have reported the benefits of using SPY Intraoperative Perfusion Assessment System to assist in the prediction of mastectomy flap necrosis. To date, analysis of the SPY images has been subjective. However, the new SPY-Q postprocessing software allows for objective quantification of SPY images through the application of absolute and relative values of fluorescence intensity. This study seeks to determine the use of these objective, numerical data and their role in potentially predicting mastectomy flap necrosis. METHODS: In a retrospective fashion, 20 SPY images from immediate breast reconstructions were randomly selected from a database of more than 100 images: 10 from breasts that developed flap necrosis and 10 from breasts that demonstrated adequate healing. Groups were matched for age, body mass index, and comorbidities. The points of necrosis and points of adequate healing were evaluated using the postprocessing software, and the groups were compared. RESULTS: The mean "relative" fluorescence of the necrosis and the adequate healing groups was 25.2% and 43.3%, respectively (P < 0.001). The mean absolute fluorescence of the 2 groups was 18.5 and 25.0, respectively (P = 0.07). CONCLUSIONS: These findings suggest that quantitative "relative" perfusion values as generated by the postprocessing software may augment clinical judgment of flap viability in an objective and reproducible fashion.

An investigation of the application of laser-assisted indocyanine green fluorescent dye angiography in pedicle transverse rectus abdominus myocutaneous breast reconstruction.

BACKGROUND: Pedicle transverse rectus abdominus myocutaneous (pTRAM) flaps remain the most common method of autologous tissue breast reconstruction. Using pTRAM flaps, complications often arise postoperatively, secondary to inadequate circulation. Tissues from distant angiosomes are associated with poorer perfusion, but this differs among patients. Many modalities have been used to reduce the risk of complications, but none have achieved widespread application. The authors believe that laser-assisted indocyanine green fluorescent dye angiography (LA-ICGA) can potentially reduce the risk of complications. METHODS: In two routine, single-pedicle, ipsilateral pTRAM flaps, LA-ICGA imaging was performed following the division of the distal rectus muscle and deep inferior epigastric pedicle. The resulting images were used to guide design of the flap and debridement. RESULTS: In case 1, good perfusion was observed in zone 1 and part of zone 2. In case 2, good perfusion was observed in zone 1 and 50% of zone 3, with little perfusion in zone 2. In both cases, tissues with poor perfusion were debrided before transfer and inset. In both patients, there were no issues with wound healing, tissue necrosis or fat necrosis. CONCLUSIONS: The variability of perfusion of the pTRAM flap among individuals is well appreciated. LA-ICGA helped to determine the limits of good perfusion and, therefore, the limits of tissue to be preserved for transfer and inset. This helped to avoid harvesting poorly perfused tissue that would have almost certainly experienced necrosis and, ultimately, would have reduced the risk of postoperative complications.

The true incidence of near-term postoperative complications in prosthetic breast reconstruction utilizing human acellular dermal matrices: a meta-analysis.

BACKGROUND: The use of human acellular dermal matrix (HADM) materials in prosthetic-based breast reconstruction has gained popularity in recent years. Questions remain, however, regarding the nature and incidence of postoperative complications associated with this technique. The results reported in the available literature vary widely. This meta-analysis examines this question further with a broad review of the available literature in an effort to better define the true nature and incidence of near-term complications associated with the use of HADM in prosthetic-based breast reconstruction. It does not aim to compare this method of reconstruction to others. METHODS: A review of the available literature was performed in July 2009. The goal was to identify all previous works describing the placement of HADM at prosthetic-based breast reconstruction. Included were studies that documented the use of HADM for coverage of tissue expanders or permanent implants following therapeutic or prophylactic mastectomy. Excluded were studies that reported on the use of HADM in cosmetic breast surgery or studies that included the use of xenografts. Data collected included demographics as well as the nature and incidence of complications, with separate categories assigned for seroma, infection, flap necrosis, and "other." Data were analyzed using Comprehensive Meta-Analysis(®) software (Biostat, Englewood, NJ). Raw proportions, fixed-effect models, and random-effect models were used to assess the complication rates across studies. RESULTS: Eleven published articles and one abstract that was later published as an article were identified. Within these 12 studies, a total of 789 breasts were identified that had undergone reconstruction with HADM. The mean follow-up was 13.7 months. Under the random-effects model, the total complication rate was 12.0%. The most common complications were flap necrosis (3.3%), seroma (3.3%), and infection (5.6%). All complications not included in these categories were set apart in a separate category, "Other," and totaled 3.0% CONCLUSION: The true incidence of postoperative complications in the near term utilizing HADM in prosthetic-based breast reconstruction appears to be approximately 12%. The incidence of long-term complications such as capsular contracture remains unknown. However, as surgical experience with HADM grows, operative techniques designed at reducing risks will mature, strategies for managing complications will advance, and more advanced products designed to reduce the incidence of complications are likely to become available.

Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction.

Skin-sparing mastectomy has been associated with flap ischemia and necrosis. Current clinical methods for assessment of flap viability following mastectomy are largely subjective and lack objective data to guide intraoperative decisions. Intraoperative laser-assisted indocyanine green angiography (LA-ICGA) was performed on 20 skin sparing mastectomy flaps. LA-ICGA data were retrospectively compared with clinical outcome. Preoperative, intraoperative, and postoperative digital photographs along with clinical course were evaluated in an effort to identify potential complications. LA-ICGA was performed on 20 breasts in 12 patients. Eleven breasts (55%) demonstrated no wound-healing issues. Nine breasts (45%) experienced wound-healing issues, which were stratified as follows: 1 (5%) mild, 1 (5%) moderate, and 7 (35%) severe. Of these seven severe wound-healing issues, 5 (25%) required debridement and 2 (10%) required complete removal of the prosthetic device. Retrospective analysis demonstrated a 95% correlation between intraoperative imaging and clinical course with 100% sensitivity and 91% specificity. There was a false-positive rate of 9%. This series suggests LA-ICGA is a useful adjunct to determine mastectomy flap viability. Further quantitative advances in this technology may provide objective numerical thresholds to guide intraoperative mastectomy flap debridement when indicated.

The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction.

The benefits of laser-assisted indocyanine green fluorescence angiography have previously been demonstrated in cardiac surgery. The purpose of this study was to determine the value of this technology in microsurgical breast reconstruction. Intraoperative laser-assisted indocyanine green fluorescence angiography was performed on all microsurgical breast reconstruction cases (deep inferior epigastric perforator flap or free transverse rectus abdominus muscle flap) during the study period. Ten consecutive free tissue transfer autologous breast reconstructions were performed on 8 women. In four cases, imaging demonstrated flow or perfusion deemed "marginal" or "poor" by the operating surgeons. In three of these cases, one involving poor arterial inflow, one of poor venous outflow, and one of poor perfusion of a mastectomy flap, the intraoperative plan was adjusted accordingly and follow-up imaging demonstrated improvement. In the fourth case, no adjustment was made at operation. However this patient required a return to the operating room for venous congestion of the flap, which was corrected without sequela. Overall flap survival was 100%. We concluded that laser-assisted indocyanine green fluorescence angiography appears to provide important information that has helped guide intraoperative decision making in our series.

Epidermal inclusion cyst of the umbilicus following abdominoplasty.

The incidence of retained epidermal inclusion cyst at the site of the umbilicus following abdominoplasty has yet to be well documented. Compliant patients who are seen in scheduled follow-up, and who display signs of infection or wound issues at the site of the umbilicus, usually have these factors addressed before inclusion cysts manifest. Here, however, we present a patient who underwent abdominoplasty, lost her surgeon because of geographic relocation, presented to our office 1 year following surgery with a large retained umbilical epidermal inclusion cyst. This case gave us a unique opportunity to observe a well-developed retained umbilical epidermal inclusion cyst. Her evaluation and management are reviewed in an effort to familiarize the practicing plastic surgeon with a rare, but significant potential complication of abdominoplasty.