Abstract
Sir: Laser-assisted indocyanine green fluorescence angiography is a promising technique that is widely used and studied in plastic and reconstructive surgery. We read with great interest the article recently published in Plastic and Reconstructive Surgery entitled “Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance,” in which the authors concluded that the use of indocyanine green angiography intraoperatively can effectively reduce the fat necrosis rate and save tissue volume of DIEP flaps through a well-designed retrospective clinical trial.1 In this communication, we raise a few questions concerning the trial, hoping to benefit further studies. On the one hand, we realized that in the indocyanine green angiography cohort, the operators recognized the hypoperfusion area through subjective assessment after 1 to 2 minutes dwelling time for the arterial phase and 15 to 20 minutes for the venous phase. However, we think it is necessary to set a fluorescence intensity criterion for deciding which part is to be excised. We believe that a detailed, standard protocol can not only make the experimental results more reliable but also facilitate the promotion of this technology. On the other hand, the authors mentioned using indocyanine green angiography to ensure adequate perfusion in 62 percent of the 200 DIEP flaps, without elaborating on the excision criteria for these flaps. If these samples were not excised for achieving good perfusion, we are confused why they were included in the statistical analysis of the average weight of the resected portion. From our perspective, there exists a better outcome measurement to illustrate the effectiveness of indocyanine green angiography for avoiding overresection; that is, to compare the ratio of flaps that need to be excised between the two cohorts. If the percentage of the indocyanine green angiography cohort is lower than that of the non–indocyanine green angiography cohort, it reveals the overresection phenomenon without the assistance of indocyanine green. A further comparison of the average resected weight ratio between the excised flaps in the two groups may be more convincing for explaining the difference in the amount of tissue removed in between. Overall, we appreciate the authors’ contributions in promoting indocyanine green fluorescence angiography. In addition, we strongly agree with the authors’ opinion that fat necrosis and other complications caused by breast reconstruction operations will bring huge and painful costs to the patients; thus, we seek better ways to improve our own technique in addition to assistive methods to benefit our patients. DISCLOSURE The authors have no financial interest to declare in relation to the content of this study. No funding was received for this communication. Ziying Zhang, M.D.Chenglong Wang, M.D.Zixuan Zhang, M.D.Minqiang Xin, M.D.Department of Aesthetic and Reconstructive Breast SurgeryPlastic Surgery HospitalChinese Academy of Medical SciencesPeking Union Medical CollegeBeijing, People’s Republic of China
Published Version
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