Implication of indocyanine green angiography for chest wall perforator flap reconstruction in breast-conserving surgery.

Abstract

Background: Volume replacement after breast-conserving surgery (BCS) can help achieve a good cosmetic outcome, especially in patients with small breast size, where volume displacement is limited. Latissimus dorsi myocutaneous flaps, which are widely used, require a longer hospital stay and have a risk of donor site morbidity. Chest wall perforator flap (CWPF) could be used as an alternative option. Although this has the advantage of a shorter hospital stay and muscle preservation, the dissection of perforator vessels is required. Using indocyanine green (ICG) intraoperatively can help the surgeon to visualize the perforators and assess the flap perfusion. Our study aimed to examine the roles of these techniques for CWPF reconstruction in BCS.

Methods: We retrospectively reviewed 22 patients who underwent CWPF reconstruction at the Queen Sirikit Centre for Breast Cancer, King Chulalongkorn Memorial Hospital from January 2023 to October 2024. Patients' baseline characteristics, types of CWPF, number of perforators identified by ICG and by direct visualization, complications, and perfusion time of ICG were reviewed.

Results: Eight patients had anterior intercostal artery perforator (AICAP) flap reconstruction. Thirteen patients had lateral intercostal arterial perforator (LICAP) flap reconstruction with or without lateral thoracic arterial perforator (LTAP) flap reconstruction. One patient had thoracodorsal arterial perforator (TDAP) reconstruction. The ICG was used in 21 flaps. ICG perfusion was completed within 2 minutes (range, 20-110 seconds). Most of the patients had two perforators identified by ICG. In 88% of cases, ICG perfusion of the perforator flap and adjacent normal tissue was visualized simultaneously. There was a difference in ICG perfusion onset time between flaps with one versus multiple perforators.

Conclusions: ICG angiography can be used intraoperatively for flap assessment with helpful information. A perfusion time of less than 2 minutes was correlated with a good clinical outcome. Intraoperative ICG angiography can guide surgeons in evaluating flap perfusion, which can help address both immediate and long-term morbidity concerns.