Indocyanine Green Angiography in Breast Reconstruction: Utility, Limitations, and Search for Standardization

Abstract

During reconstructive breast surgery, intraoperative assessment of tissue perfusion has been solely based on subjective clinical judgment. However, in the last decade, intraoperative indocyanine green angiography (ICGA) has become an influential tool to visualize blood flow to the tissue of interest. This angiography technique produces real-time blood flow information to provide an objective assessment of tissue perfusion.

Methods: A comprehensive literature search of articles pertaining to ICGA in breast reconstruction surgery was performed. The overall findings of the articles are outlined here by surgical procedure: skin-sparing and nipple-sparing mastectomy, implant-based reconstruction, and autologous reconstruction.

Results: Overall, there were 133 articles reviewed, describing the use of ICGA in breast reconstruction surgery. We found that ICGA can provide valuable information that aids in flap design, anastomotic success, and perfusion assessment. We also included example photographs and videos of ICGA use at our institution.

Conclusions: ICGA can reduce postoperative tissue loss and aid in intraoperative flap design and inset. Despite the benefits of ICGA, its technical use and interpretation have yet to be standardized, limiting its widespread acceptance.

Fig. 1.

Preferred Reporting Items for Systemic Reviews and Meta-analysis Statement flow diagram depicting the flow of information through the different phases of this systematic review.

Fig. 2.

Skin-sparing mastectomy flap assessment intraoperatively. After placement of deflated tissue expander in the subpectoral pocket, the mastectomy skin flap was stapled, and ICGA was used to visualize perfusion. ICG images demonstrated hypoperfusion at the very superior portion of the lateral incision (A), which was marked (B) and excised. The patient had no postoperative complications.

Fig. 3.

A, Assessment of nipple perfusion after NSM. A prepectoral tissue expander was placed with acellular dermal matrix sling. B, Clinical pictures correlating to intraoperative ICG images. Area of concern was treated conservatively with no need for intervention.

Fig. 4.

Prepectoral implant breast reconstruction after skin-sparing mastectomy. Assessment of perfusion of the mastectomy skin after tissue expander placement under acellular dermal matrix pocket. Image shows good perfusion of the mastectomy skin.

Fig. 5.

Assessment of unilateral DIEP flap perfusion in situ. During dissection of flap, a large perforator in the midflap was noted, and a superior perforator that appeared in-line with the larger one noted on preoperative CTA. The remaining perforators were clamped with atraumatic clamps. The SPY imaging device was brought into the field and the patient received ICG as per manufacturers’ guidelines: (A) right side of flap, (B) left side of flap. Zone 4 did not perfuse as well, and it was marked for removal as was the small tip of the right flap, as it perfused more slowly than the rest of the flap.

Fig. 6.

Assessment of perfusion after flap inset in DIEP procedure. A, Intraoperative ICGA imaging of DIEP flap at time of inset. B, Postoperative day 8 clinical image of reconstructed breast. The patient suffered no clinical complications.