A. M. Botty Van Den Bruele1, M. Crandall1, D. Chesire1, J. Murray1 1University of Florida- Jacksonville,Department Of Surgery,Jacksonville, FL, USA
Introduction: Insufficient perfusion in breast skin is a leading cause of early complications following mastectomy reconstructive procedures. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis. Image guided mastectomy with indocyanine green (ICG) fluorescent angiography has emerged as form of intraoperative imaging that helps provide assessment of tissue perfusion. Perfusion indices have been developed for ICG imaging to indicate when the operative surgeon should remove ischemic tissue. Less than 20% perfusion has been shown to correlate with necrosis. While tumescent priming of the breast with lidocaine-epinephrine solution facilitates dissection and decreases blood loss, associated dermal vasoconstriction may affect ICG perfusion indices. Our goal was to study the effect of pre-mastectomy breast lidocaine priming on intraoperative perfusion indices and aesthetic outcomes.
Methods: We performed a retrospective review of perfusion indices and aesthetic outcomes for 49 mastectomies performed on 31 consecutive patients (some unilateral vs bilateral). Patient data recorded included age, race, BMI, smoking status, HTN, DM, and history of radiation therapy. All mastectomies were performed with lidocaine-epinephrine tumescence and received paravertebral block; ICG measurements <20% and mastectomy weight were recorded. Outcomes of interest were dermal necrosis/epidermolysis and hematoma or seroma formation.
Results: Of the 49 mastectomies performed, 44 were reviewed and included in our analysis due to incomplete data in 5 of the mastectomies. Thirty-four breasts exhibited areas of <20% perfusion by ICG fluorescent analysis. Of these, only 5 demonstrated minor necrosis in postoperative follow-up, none of which warranted operative intervention. Multivariate analysis was performed and independent t-test employed. Increased BMI was noted to be a risk factor for minor necrosis, although not statistically significant (p=0.051). Only smoking history was noted to have a positive correlation with minor necrosis (p£ 0.001), whereas ICG perfusion was not significantly associated with necrosis in our sample (p=0.146).
Conclusion: Several previous studies have found ICG angiography to be highly accurate at predicting mastectomy skin flap viability after breast reconstruction. Therefore, the 34 patients who were noted to have decreased perfusion with ICG imaging in our study should have gone on to have extensive necrosis. Fortunately, however, all of those breasts went on to uneventful healing without additional intervention. Given our results, future research should focus on whether it is a difference in demographic factors or operative technique that may explain the discordance.