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

Marlies Michi,Pieter S Verduijn,Leonard U.M Corion,Alexander L Vahrmeijer,Babs G Sibinga Mulder

doi:10.1016/j.bjps.2021.11.043

Abstract

Fat necrosis (FN) is a common complication after autologous breast reconstruction (ABR) using a free flap, which can influence reconstruction outcome and patient satisfaction. Intraoperative near-infrared fluorescence imaging using indocyanine green (ICG) permits the visualization of flap perfusion. The aim of this study was to assess the effect of near-infrared fluorescence on FN incidence in patients undergoing an ABR with a deep inferior epigastric perforator flap (DIEP) and to propose a standard working protocol for this technique. In this prospective study, patients undergoing one-sided ABR with a DIEP were included. The standard DIEP procedure was complemented with near-infrared fluorescence imaging using the fluorescent tracer ICG to evaluate flap perfusion. This cohort was compared to a retrospective cohort of DIEP procedures without near-infrared fluorescence imaging. Patients and surgery characteristics, as well as postoperative complications, were registered and compared. In both cohorts, 24 patients were included. No significant differences were present between patients and surgery characteristics, including no difference in duration of surgery. In the prospective and retrospective group, the incidence of FN was 4.2% and 33%, respectively (p-value=0.023). Moreover, microsurgeons were positive about using near-infrared fluorescence as it either provided additional information about perfusion or confirmed the clinical assessment. Our pilot study showed a significant decrease of FN in patients undergoing an ABR with a DIEP when near-infrared fluorescence imaging was used to assess flap perfusion. This study provides a standardized working protocol for near-infrared fluorescence imaging. In the future, large multicenter studies should focus on the quantification of near-infrared fluorescence imaging.

Highlights

Ethical statementPatients eligible for autologous breast reconstruction (ABR) after mastectomy aim for a lifelong naturally feeling breast.[1]
Our pilot study showed a significant decrease of fat necrosis (FN) in patients undergoing an ABR with a deep inferior epigastric perforator flap (DIEP)
A prospective, single-center study was designed to evaluate the use of Near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) in ABR with a DIEP flap

Summary

Introduction

Patients eligible for autologous breast reconstruction (ABR) after mastectomy aim for a lifelong naturally feeling breast.[1] During the past thirty years, there has been an increase in the use of the deep inferior epigastric perforator flap (DIEP) for this purpose.[2,3,4] Among the most common complications of ABR is fat necrosis (FN), due to inadequate perfusion of the transplanted fat.[5] FN can have a great impact on reconstruction outcome and patient satisfaction. The severity of necrosis, infection, or pain may delay further oncologic treatment and might result in reinterventions.[6,7] FN can result in (1) poor aesthetic outcomes, (2) cause fear and anxiety by mimicking breast cancer, and (3) might lead to additional invasive diagnostics. Intraoperative flap design is based on clinical assessment of adequate perfusion, the incidence of FN is still high, ranging from 10 to 60%.5,8–10

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