Fluorescent intraoperative tissue angiography during breast reduction: a single institution, single surgeon study evaluating decrease in complication rates with acquired proficiency

Introduction

Breast reduction mammaplasty remains one of the most common procedures performed by plastic surgeons (1). Therapeutic reduction mammaplasty of the female breast reduces constitutional symptoms related to breast hypertrophy such as neck and back pain, skin rashes and poor posture. As with all surgical procedures, knowledge of breast vascular anatomy is required to optimize postsurgical outcomes. At least 60% of the blood supply to the breast is known to arise from the superomedial perforators which come from the internal mammary artery (2). However, knowledge of vascular territories of the breast must be complemented with adequate perfusion within the respective territory.

Ensuring perfusion is critical for every reduction mammaplasty and there are multiple pedicle types that can be used to maximize both vascularity and sensation to the nipple while optimizing aesthetic outcomes (3). These pedicles can be superior, superomedial, inferior, central, medial, and lateral pedicles as well as vertical and horizontal bipedicles (4,5). There is also a multitude of skin excision patterns available for breast reduction surgery, which include: Wise (inverted T) pattern, vertical skin pattern, peri-areolar pattern, L-shaped pattern, and a short-scar peri-areolar incision with inferior pedicle reduction (6).

FITA may be particularly helpful in pedicle design of the reduced breast and in preservation of vascularity to optimize the aesthetic result. Rates of complications following breast reduction mammaplasty vary significantly from 4–63% (7). In a study by Palve et al. showed the overall rate of complications was 4.0% (8). Individual types of complication rates were postoperative hematoma (77.0%) tissue necrosis (13.0%) followed by deep infection (10.0%). More importantly, no total nipple-areola-complex loss was found.

Intraoperative assessment of tissue perfusion, during any surgery, has traditionally been based on the surgeon’s clinical judgement. The subjective assessment of skin color, blanching capillary refill time, and bleeding from the flap edges are routinely employed. However, with the addition of fluorescent angiography, the subjective assessment of soft tissue perfusion may be supported objectively as well. Indocyanine green (ICG), a precursor metabolite of fluorescein, has a short half-life (150 to 180 seconds); and consequently, ICG may be used multiple times during an operation (9). Accordingly, when used in breast reduction surgery, fluorescent intraoperative tissue angiography (FITA) has been shown to aid in intraoperative flap design and inset and to reduce postoperative tissue loss (6,10).

Using fluorescent imaging intraoperatively may help educate or train surgeons on pedicle development by identifying meaningful arterial perforators, which would lead to a greater FITA perfusion indicator. An objective analysis of perfusion to maintain the highest perfusion index possible may improve the clinical results and lead to higher patient satisfaction. The objective of our study was to evaluate clinical outcomes when compared to level of surgeon experience with FITA using ICG for superomedial-pedicle breast reduction (SBR). A sequential series of 50 patients underwent bilateral reduction mammaplasty using FITA, 25 in the first three years and 25 in the second three years. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2024-532/rc).

Methods

A retrospective cohort study of 100 breast reductions was completed on 50 female patients who presented with symptoms of bilateral mammary hypertrophy. The 50 patients who underwent bilateral breast reductions with a single surgeon (J.D.M.) at a single safety net hospital between April 2015 and September 2020 in Jacksonville, FL. Patients were included in the study if they underwent a bilateral breast reduction and the specialized infrared camera-computer system (SPY) (SPY Elite, Stryker, Kalamazoo, MI) data included perfusion indices in each relevant area of the breast. Patients were excluded from the study if they did not undergo a bilateral breast reduction or if the SPY data did not include perfusion indices. Patients with a documented history of iodinated contrast allergies prior to surgery were excluded from the study as well. The intraoperative perfusion assessment and postoperative clinical assessment were compared between the first three years (Group A) and the last three years (Group B) of surgeries.

Procedure

The University of Florida Institutional Review Board approval was obtained prior to study initiation (No. IRB201800521) and individual consent for this retrospective analysis was waived. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. All patients initially completed a clinical examination that included a history and physical examination. The same surgeon (J.D.M.) performed the breast reduction. All patients underwent operations using a superomedial pedicle Wise-pattern breast reduction. If the nipple-areolar complex (NAC) showed poor perfusion, then the pedicle or skin flaps would be revised, or the NAC would be grafted. We studied the SBR surgeries performed during the first three years and the last three years, respectively. Demographic variables included age, body mass index (BMI), SPY perfusion index, and resection weight. The outcome variables were postoperative complications (RTOR, decreased nipple sensation, skin or nipple loss). Assessment of nipple sensation was documented within 6 months post-operatively.

Statistical analysis

Descriptive summaries in the form of frequencies and percentages were quantified for categorical variables, while means ± standard deviations (SDs) were reported for numeric variables. Differences in medians of categorical and non-normally distributed variables were assessed with the Wilcoxon Rank Sum test. Differences in means of continuous variables found to be normally distributed were assessed with the independent samples t-test. We used the Wilcoxon signed rank test to detect a difference in surgeon experience with patient outcomes. Clinical postoperative complications were statistically analyzed by the Chi-squared test. The level of significance was set at 0.05. All analyses were conducted using R statistical software version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria) (11).

Results

Fifty patients were included in the final analysis of the study, with 25 patients in each group. The mean age in Group A was 37.9±10.8 years, while the mean age in Group B was 36.0±11.5 years. The mean BMI in Group A was 37.1±6.2 years, while the mean BMI in Group B was 34.6±4.7 years. The two groups did not show significant differences in either age or BMI (P=0.56 and P=0.12), respectively.

Statistically significant differences were found for left and right medial perfusion indices as well as left and right resection weights. Left medial perfusion index mean values were higher in Group B than in Group A (P=0.02). Similarly, Group B had higher right medial mean values than Group A (P<0.001). Left resection weight median values were lower in Group B than those in Group A (P=0.007). Right resection weight median values were also lower in Group B than those in Group A (P=0.044). All other surgical site locations did not show statistically significant differences. Table 1 shows patient factors, perfusion indices, and breast resection weights for both groups.

Two patients required a free nipple graft in the second series of reduction mammaplasty, one right free nipple graft and one bilateral graft. Among Group A patients, 28% experienced decreased nipple sensation (6 with bilateral decreased sensation and 1 with decreased sensation of the right NAC). For Group B patients, 20% experienced decreased nipple sensation (1 with bilateral decreased sensation, 3 with decreased sensation on the left, and 1 with decreased sensation on the right). For the Wilcoxon signed rank test, the probability of between 0 and 9 postoperative normal nipple sensitivity reported was less than the significance level (P=0.044). Post-operative nipple sensation changed significantly more than expected.

Seven Group A patients (28%) reported minor skin loss (4 with bilateral skin loss, 2 with skin loss on the left breast, and 1 with skin loss on the right breast). There were 3 Group B patients (12%) who experienced minor skin loss [1 with bilateral skin loss of both breasts, 1 with skin loss of bilateral inframammary folds (IMF), and 1 with skin loss of the right IMF]. For Group A patients, 20% required RTOR for reoperation (2 had left-sided hematomas, 1 with a right-sided hematoma, and 2 with left-sided seromas). Also, 20% of Group B patients required RTOR (3 with right-sided hematomas, 1 with a left-sided hematoma, and 1 patient who required excision and closure of wounds). Table 2 shows the set of postoperative complications for both groups. The postoperative complications chi-square test was not statistically significant (P=0.62).

Discussion

Intraoperative ICG angiography has proven to be beneficial when assessing tissue perfusion to decrease rates of necrosis in a variety of surgical fields (12,13). The purpose of our study was to evaluate clinical outcomes compared to level of surgeon experience with FITA for single-surgeon SBR. FITA provides real-time perfusion analysis which objectively predicts which tissues will progress to postoperative ischemic necrosis, thus guiding the surgeon to resect the respective tissues preemptively. Our findings revealed that left and right medial perfusion indices and left and right resection weights were significantly different.

As noted in this study, consistent use of intraoperative ICG angiography has shown an improvement in the average perfusion index of the entire breast of each reduction mammaplasty. The reason for this improvement is possibly due to the use of perfusion analysis as a tool to learn how to optimize the surgical procedure through preservation of perforator arteries. Better identification of these arteries leads to enhanced NAC and skin perfusion, pedicle position, and reliability of intact NAC sensation.

The decrease in resection weights between the two studied groups was relative to the surgeon becoming more conservative with pedicle excision, rather than simply smaller breasts undergoing reduction in the second group. The surgeon found that beveling the inferomedial aspect of the superomedial pedicle inferiorly preserved more meaningful pectoralis perforators. Providing more robust perfusion improved perfusion to the inferomedial skin flap and decreased minor skin loss respectively. As a collateral benefit, by beveling the inferior aspect of the pedicle inferiorly to preserve perforators the shape of the resultant breast and consequently the inferomedial convexity of the breast improved.

Improved pedicle position optimizes the central pole shape leading to a better aesthetic value. Patient reported outcomes in gigantomastia (mass of resection 1,000 to 2,000 g) have proven favorable if the pedicle is adequately developed and remains well vascularized (14,15). Accordingly, perfusion analysis may prove helpful in identifying largely consistent anatomical vascular perfusion zones to enhance the quality of outcomes, especially when surgeon-appreciated perfusion is compromised (16-21). ICG FITA rapidly and reliably assesses perfusion of the NAC and its short half-life means it can be used multiple times within the same operation.

The outcome of reduction mammaplasty seems to be affected by several variables. Surgical indications for breast reduction and patient selection issues have been debated, including evaluation of various predisposing factors (e.g., age, obesity, comorbidities). For instance, the preoperative degree of a patient’s total body fat and consequently the amount of breast tissue resection in proportion to the patient’s body weight may be significant factor (22). Smoking status was another risk factor found to increase complications following reduction mammoplasty (23). In other words, variables which may play a role in perfusion may not be directly associated with the physical characteristics of the patient nor physical performance of the surgeon.

Palve et al. found the most common postoperative complication after reduction mammoplasty was delayed wound healing (8). In our study, the postoperative complications were not significantly different based on surgeon experience with FITA. While studies of preoperative perfusion were not performed, the reason for the significant increases in perfusion indices of the medial portion of the breast across the series is conceivably due to the use of a superomedial flap that was used in every patient. Beveling the inferomedial border of the superomedial pedicle likely captured more internal mammary perforators. Thus, more experience at identifying these with ICG angiography likely provided better overall perfusion to the breast.

With regard to the post-operative complications reported, the post-operative data in both series of surgeries found the greatest improvement appeared to be in minor skin/nipple loss. Patients’ “minor skin loss”, as reflected in the results, was seen only in the breast skin itself, at the inferior aspect of the inverted-T closure. We did not observe any partial or full nipple areolar necrosis. Similarly, we did not find the observation of fat necrosis to be qualitatively prevalent, and certainly not to a degree to warrant quantitative measurement.

Observation of the postoperative nipple sensation was traditionally a byproduct of the preservation of nipple perfusion. Nipple sensitivity was correlated with BMI and may change with aging in some patients, especially with hormonal changes. Regardless, patient satisfaction has remained largely dependent upon the subjective experience of patients (24). While the improvement of perfusion did not significantly lower the incidents of decreased sensation of the NAC or returns to operating room, the number of incidents of nipple or skin loss was reduced by over half (28% to 12% in Groups A & B, respectively).

Effectively learning and then mastering therapeutic bilateral reduction mammaplasty relies on several patient and surgeon variables (25-30). A variable may only be controllable if it is first recognized, such as preservation of adequate large vessel perfusion. However, as with any perfused tissue, the surgeon’s appreciation of perfusion may also be confounded by a myriad of factors, such as appreciated capillary flow in very light or dark-skinned patients or inherent small vessel disease. As such, fluorophore-based intraoperative perfusion analysis can be particularly useful to learn, refine, and then improve one’s surgical technique, especially in larger reductions.

Strengths and limitations

Our study was performed by a single, experienced surgeon that reduced information bias. This eliminated the confounding factors of training, experience, technique, and expertise differences among providers. However, there were several limitations in the present study. The first limitation was the retrospective nature of the study design, which predisposed the study to biases inherent of retrospective cohort studies such as recall bias. For example, we did not have available the pre-operative measures of perfusion or nipple sensitivity to compare with post-operative change. Therefore, caution must be taken when drawing conclusions.

The second limitation was the sample size of 50 patients (25 patients at the beginning of the study period and 25 patients at the end of the study period) was determined by convenience and not by statistical power. The relative smaller sample of patients included decreased our statistical power and may have contributed to the non-statistical differences in the complications and the increased probability of a type II error. The third was the limited dataset that was collected at a single urban center, a safety net hospital. Thus, the ability to extrapolate the findings sufficiently supported by the data beyond that was limited. Finally, the generalizability of the results is likely restricted to similar patients.

Conclusions

Our research suggests that increased experience with intraoperative ICG angiography improved the average perfusion index, most significantly of the medial breast during breast reduction surgery. When viewed as a learning tool, perfusion analysis can aid to optimize shape while decreasing complications. However, follow-up studies will be needed to evaluate more long-term benefits as these conclusions are tentative. Indices such as ICU availability and personnel staffing ratios are also potentially valuable factors to establish benchmarks for optimum patient safety and as means of assessing surgeon performance. Future research with the addition of a control group will be imperative to fully understand the benefits and potential risks associated with breast reduction surgery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2024-532/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2024-532/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2024-532/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2024-532/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of the University of Florida (No. IRB201800521) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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