Indocyanine green fluorescence angiography algorithm for determining additional anastomosis in deep inferior epigastric perforator flap for breast reconstruction.

Abstract

Background: Intraoperative indocyanine green (ICG) fluorescence angiography (ICG-FA) is commonly used to detect areas with poor perfusion. Fat necrosis caused by poor perfusion is often associated with the use of deep inferior epigastric perforator (DIEP) flaps. We report the development of an effective ICG-FA algorithm to prevent the occurrence of fat necrosis in the use of DIEP flaps.

Methods: Fifty patients who underwent unilateral breast reconstruction using a DIEP flap and intraoperative ICG-FA were included. ICG-FA was performed after free-flap elevation to determine the extent of blood flow in the main perforating branch and the need for additional anastomosis (AA). Data on the presence of AA, vessels used, flap utilization rate, and postoperative course were collected and investigated.

Results: AA was performed in 24 of the 50 patients (48%). The average flap utilization rates were 78.4% and 53.5% (p < 0.001) in the AA and non-AA groups, respectively. The probability of AA increased significantly when the flap utilization rate was > 70%. Seven types of AA were identified. The most common vessels used for AA were the contralateral deep inferior epigastric artery and vein. Postoperatively, localized fat necrosis was observed in only one case (2%) in the AA group.

Conclusion: Our ICG-FA algorithm was useful for minimizing the occurrence of fat necrosis and aiding the use of extensive DIEP flaps without complications, leading to better functional results for patients.