Intraoperative Prediction of Mastectomy Skin Flap Necrosis using Standardized ICG Grading and Quantitative Perfusion...

Area of Science:

• Surgical Oncology
• Plastic Surgery
• Medical Imaging

Background:

• Mastectomy skin flap necrosis (MSFN) is a frequent complication following immediate breast reconstruction.
• Current indocyanine green (ICG) angiography lacks standardized interpretation, limiting its clinical utility for perfusion assessment.

Purpose of the Study:

• To evaluate a standardized qualitative grading system combined with quantitative perfusion (QP) mapping for intraoperative risk stratification of MSFN.
• To assess the predictive performance of this combined approach in patients undergoing immediate breast reconstruction.

Main Methods:

• A single-center cohort study involving 185 reconstructions (104 patients) undergoing skin- or nipple-sparing mastectomy with immediate reconstruction.
• Intraoperative ICG angiography with quantitative perfusion (QP) measurements and a five-point qualitative
• Yale Grade
• were utilized. Primary outcome was MSFN within 30 days.

Main Results:

• The MSFN rate was 24.3%. A stepwise decrease in MSFN incidence and severity was observed with improving Yale Grade (p < 0.001).
• Breasts with MSFN showed significantly lower QP across all quadrants (p ≤ 0.001). Average QP demonstrated high discrimination (AUC 0.792) with a threshold of 49.0.
• Perfusion metrics were independently predictive of MSFN on multivariable analysis, outperforming clinical variables.

Conclusions:

• A standardized ICG grading system (Yale Grade) coupled with QP mapping effectively predicts MSFN.
• Specific thresholds for average QP (≥ 49) and minimum QP (< 33.5), alongside Yale Grade ≤ 3, offer a practical framework for intraoperative decision-making and risk stratification.