Indocyanine green angiography for autologous breast reconstruction: a prospective observational study

Background: Indocyanine green angiography (ICG-A) is a valuable tool in assessment of intraoperative tissue perfusion in autologous breast reconstruction (ABR). This study evaluated the effectiveness of ICG-A in guiding surgical decision-making and its correlation with postoperative complications. Methods: A prospective observational study was conducted including 36 patients undergoing immediate or delayed ABR using pedicled latissimus dorsi (pLD) or deep inferior epigastric perforator (DIEP) flaps. ICG-A assessed intraoperative tissue perfusion which was compared to clinical assessments. Patients were followed for 1 year. Postoperative complications evaluated by the Clavien-Dindo (CD) classification, patient-reported outcomes (BREAST-Q), scar assessments [Patient and Observer Scar Assessment Score (POSAS)], incidence of lymphedema and administration of adjuvant therapy were evaluated. Results: In pLD-flap reconstructions, 52.6% of flaps demonstrated insufficient perfusion on ICG-A, leading to intraoperative modifications in 90%. The overall CD >3 complication rate was 15.8%. Among the flaps with insufficient perfusion, 70% experienced postoperative complications, with 28.6% classified as CD >3 complications. In DIEP-flap reconstructions, 68% showed insufficient perfusion on ICG-A, resulting in intraoperative adjustments in 48%. The overall CD >3 complication rate was 24%. Among the flaps with insufficient perfusion, 64.7% experienced postoperative complications, with 63.6% classified as CD >3 complications. There were no significant associations between ICG-A results and overall postoperative complications, changes in surgical decision-making resulting from insufficient ICG-A, or complications at the recipient site for both pLD-and DIEP-flaps. The discrepancy between preoperative computed tomography angiography (CTA) and peroperative ICG-A was 36%, resulted alteration in the selection of perforators in a 20% and the inclusion of an additional perforator in 16%. Patient satisfaction improved significantly during follow-up. Patient-reported scar assessments were consistently worse than observer assessments. The incidence of postoperative lymphedema remained unchanged, with no new cases developing after surgery. No patients experienced delay in adjuvant treatment due to surgical complications. Conclusions: ICG-A is valuable for assessment of tissue perfusion and guiding surgical decision-making in ABRs. However, while the results of ICG-A did not show a significant correlation with postoperative complications, an inadequate intraoperative ICG-A may indicate compromised tissue perfusion prompting immediate intraoperative intervention. Future research including larger-scale studies are needed to obtain higher-quality data and more definitive conclusions.