Nipple sparing mastectomy and direct to implant breast reconstruction, validation of the safe procedure through the use of laser assisted indocyanine green fluorescent angiography

Role of Qualitative and Quantitative Indocyanine Green Angiography to Assess Mastectomy Skin Flaps Perfusion: A Prospective Monocentric Experience

INTRODUCTION

Mastectomy skin flap (MSF) necrosis remains a significant complication in breast reconstruction. This study aims to identify a correlation between the qualitative and quantitative analysis of the MSF perfusion grade and the skin necrosis rate 1 month after surgery using indocyanine green angiography (ICGA), focusing on lag time and perfusion metrics.

METHODS

Consecutive women scheduled for nipple/skin-sparing/skin-reducing mastectomy between May 2020 and October 2022 were prospectively enrolled. Patients were divided into Group 1 in the absence of superficial and full-thickness necrosis (SN; FTN) and Group 2 in the presence of both. Demographic data, lag time T1 (time between ICG injection and the initial perfusion of the least perfused MSF area), ICG-Q1, and ICG-Q% (absolute and relative perfusion values of the least vascularized area) were collected.

RESULTS

76 breasts were considered. FTN was reported in 8 breasts (10.5%) and SN in 4 (5.2%). The 2 groups statistically differ in T1 (Group2 > Group1), ICG-Q1, and ICG-Q% (Group1 > Group2) (P < 0.05). T1 longer than 170 seconds, body mass index, previous chemo/radiotherapy, arterial hypertension, breast weight, type of surgery, and ICG quantitative values can help in predicting MSF necrosis.

CONCLUSIONS

MSF qualitative and quantitative perfusion evaluation can be helpful to prevent MSF necrosis. However, it should be considered together with the patient's characteristics, the type of surgery, and T1. In this way, it is possible to predict the risk of MSF necrosis and plan the best reconstructive strategy.

Prospective Clinical Trial for Predicting Mastectomy Skin Flap Necrosis with Indocyanine Green Angiography in Implant-Based Prepectoral Breast Reconstruction

BACKGROUND

Indocyanine green angiography (ICG-A) is a useful tool for evaluating mastectomy skin flap (MSF) perfusion during breast reconstruction. However, a standardized protocol for interpreting and applying MSF perfusion after mastectomy has not been established yet. The purpose of this study is to establish criteria for assessing MSF perfusion in immediate implant-based prepectoral breast reconstruction while correlating ICG-A findings with postoperative outcomes METHODS: This prospective observational study was conducted at a single institution and involved patients with breast cancer who underwent mastectomy and immediate implant-based prepectoral breast reconstruction between August 2021 and August 2023. The terms "hypoperfused flap" and "hypoperfused area" were defined according to ICG-A perfusion. MSF exhibited < 30% perfusion, excluding the nipple and the corresponding region, respectively. Data on the hypoperfused flap, hypoperfused area, and MSF necrosis were collected.

RESULTS

Fifty-three breast cases were analyzed. Eight patients developed MSF necrosis (15.1%, 8/53). Of these, two patients underwent surgical debridement and revision within 3 months (3.8%, 2/53). There were nine cases of a hypoperfused flap, eight of which developed MSF necrosis. The hypoperfused flap was a significant predictor of the occurrence of MSF necrosis (p < 0.001). There was a tendency for increased full-thickness necrosis with a wider hypoperfused area.

CONCLUSIONS

The hypoperfused flap enabled the prediction of MSF necrosis with high sensitivity, specificity, positive predictive value, and negative predictive value. Considering the presumed correlation between the extent of the hypoperfused area and the need for revision surgery, caution should be exercised when making intraoperative decisions regarding the reconstruction method.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Diluted Indocyanine Green Angiography: A Novel Approach to Free Flap Perfusion Evaluation in Reconstructive Microsurgery

Background

Assessing perfusion in free flaps is crucial in clinical practice. Indocyanine green (ICG) angiography offers a more objective and reproducible method, utilizing near-infrared imaging to monitor flap vascularization. This study aims to evaluate the efficacy of diluted ICG as a tool for assessing free flap perfusion.

Methods

This pilot randomized clinical trial compares the fluorescence concentrations of ICG at 3 different dilutions: 5 mg/mL (standard concentration), 2.5 mg/mL (half the standard concentration), and 0.5 mg/mL (one-tenth of the standard concentration). Inclusion criteria required participants to have serum albumin levels above 3 g/dL, hemoglobin levels over 10 g/dL, and no comorbidities. Participants were randomized into 3 groups based on ICG concentration. Fluorescence analysis was performed using ImageJ software to determine mean gray values. Both surgeons and data analysts were blinded to the ICG concentrations administered, ensuring unbiased evaluation.

Results

Forty-five patients undergoing free flap surgery, predominantly male (60%) with a mean age of 37.76 ± 19.79 years and a mean body mass index of 21.23 ± 4.49 kg/m², primarily received osteoseptocutaneous fibular free flaps (46.67%), with an average skin flap area of 66.07 ± 46.94 cm². The primary etiology was underlying tumors (84.4%), with the head and neck as the most common reconstruction site (82.2%). The superior thyroid artery was the most frequently used recipient vessel (37.78%). Analysis revealed mean gray values of 64.10 ± 8.27 (5 mg/mL), 79.03 ± 2.7 (2.5 mg/mL), and 33.56 ± 3.47 (0.5 mg/mL), with 2.5 mg/mL yielding the highest value (P < 0.001).

Conclusions

Findings suggest using 2.5 mg/mL concentration enhances fluorescence emission, offering a dosage alternative in clinical practice.

Postmastectomy dual-plane submuscular-subcutaneous implant-based reconstruction: a series of 100 consecutive patients

BACKGROUND

Advances in cancer knowledge and surgical techniques over the last decades have enabled plastic surgeons to use muscle-sparing procedures and more conservative approaches for implant-based reconstructions. In this paper, the authors describe an innovative subpectoral/subcutaneous implant pocket that represents an evolution of the classical submuscular technique and they report on the first consecutive hundred patients undergoing this procedure.

METHODS

Between April 2019 and May 2022, 100 consecutive patients underwent immediate postmastectomy implant-based reconstruction using the subpectoral/subcutaneous space, for a total of 122 procedures. Medical records were retrospectively reviewed and patients were prospectively followed. During plastic consultations, medical photographs were taken and aesthetic outcomes were scored with patients.

RESULTS

Mean follow-up was 18 months (range 6-46). Implant loss was observed in two patients (2%). Early minor complications were registered in 19 patients. A total of 80 out of 100 patients completed satisfaction survey assessing their postoperative outcomes. Results were considered satisfactory or very satisfactory by the surgeons and patients in more than 90% of cases.

CONCLUSION

The submuscular/subcutaneous pocket can be considered a new tool in the armamentarium of reconstructive procedures, in between submuscular/subfascial procedures and prepectoral ones. It is a one-stage procedure, its a simple and short time surgery, reproducible, its very well accepted by patients. It has specific indications, advantages, and drawbacks, a careful indication and an accurate surgical technique are mandatory to achieve good results.

The value of radiomics model based on ultrasound image features in the differentiation between minimal breast cancer and small benign breast masses

BACKGROUND

Female breast cancer has surpassed lung cancer as the most common cancer, and is also the main cause of cancer death for women worldwide. Breast cancer <1 cm showed excellent survival rate. However, the diagnosis of minimal breast cancer (MBC) is challenging.

OBJECTIVE

The purpose of our research is to develop and validate an radiomics model based on ultrasound images for early recognition of MBC.

METHODS

302 breast masses with a diameter of <10 mm were retrospectively studied, including 159 benign and 143 malignant breast masses. The radiomics features were extracted from the gray-scale ultrasound image of the largest face of each breast mass. The maximum relevance minimum reduncancy and recursive feature elimination methods were used to screen. Finally, 10 features with the most discriminating value were selected for modeling. The random forest was used to establish the prediction model, and the rad-score of each mass was calculated. In order to evaluate the effectiveness of the model, we calculated and compared the area under the curve (AUC) value, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the model and three groups with different experience in predicting small breast masses, and drew calibration curves and decision curves to test the stability and consistency of the model.

RESULTS

When we selected 10 radiomics features to calculate the rad-score, the prediction efficiency was the best, the AUC values for the training set and testing set were 0.840 and 0.793, which was significantly better than the insufficient experience group (AUC = 0.673), slightly better than the moderate experience group (AUC = 0.768), and was inferior to the experienced group (AUC = 0.877). The calibration curve and decision curve also showed that the radiomics model had satisfied stability and clinical application value.

CONCLUSION

The radiomics model based on ultrasound image features has a satisfied predictive ability for small breast masses, and is expected to become a potential tool for the diagnosis of MBC, and it is a zero cost (in terms of patient participation and imaging time).

Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.

Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques

Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons' clinical experience. Even though numerous studies have already addressed the patients' risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.

Is Using Closed Incision Negative Pressure Therapy in Reconstructive and Oncoplastic Breast Surgery Helpful in Reducing Skin Necrosis?

Introduction Skin necrosis is a major concern of morbidity in patients undergoing reconstructive and oncoplastic breast surgery (ROBS) as it may lead to a poor aesthetic outcome, necessitate further surgery, and delay adjuvant chemotherapy and radiotherapy if required postoperatively. Some studies have reported that closed incision negative pressure therapy (ciNPT) immediately after surgery can reduce the incidence of wound complications. Our study aimed to investigate the effect of ciNPT on skin necrosis rate after ROBS. Methods Our study included 82 patients in a single center who underwent 121 ROBS procedures. We used conventional dressing in 42 patients (62 procedures, group A), while we used ciNPT in 40 patients (59 procedures, group B). When ciNPT dressing was introduced in our breast unit, 40 patients with 59 ROBS procedures who had ciNPT dressing were studied prospectively. The risk factors recorded were age, body mass index (BMI), history of previous radiotherapy, history of smoking, type of incision, type of operation, breast tissue specimen weight, use of neoadjuvant chemotherapy, and implant size. Skin necrosis was classified as "minor" if it was managed conservatively with regular dressings and "major" if surgical debridement in theater and/or exchange or implant removal was necessary. Results The incidence of overall skin necrosis in the conventional dressing group was 17.7% (11/62), while in the ciNPT group, it was higher at 25.4% (15/59), although this was not statistically significant (p = 0.51). ciNPT also did not show a statistically significant difference from the conventional dressing in the rate of minor necrosis (18.6% versus 11.2%, respectively; p = 0.44) and major necrosis (6.7% versus 6.4%, respectively; p = 1.00) Conclusion Our data has shown no superiority of ciNPT in reducing skin necrosis rate in a patient undergoing reconstructive and oncoplastic breast surgery, contrary to many other published reports. However, it may have reduced rates of other wound complications such as wound dehiscence, wound infection, and hypertrophic scar formation, which were not studied in our cohort. Further studies are needed to confirm its benefits, especially in high-risk patients.

Should Acellular Dermal Matrices Be Used for Implant-based Breast Reconstruction after Mastectomy? Clinical Recommendation Based on the GRADE Approach

Acellular dermal matrices (ADMs) entered the market in the early 2000s and their use has increased thereafter. Several retrospective cohort studies and single surgeon series reported benefits with the use of ADMs. However, robust evidence supporting these advantages is lacking. There is the need to define the role for ADMs in implant-based breast reconstruction (IBBR) after mastectomy.

Methods

A panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints, and establish recommendation for the use of ADMs for subpectoral one-/two-stage IBBR (compared with no ADM use) for adult women undergoing mastectomy for breast cancer treatment or risk reduction using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

Results

Based on the voting outcome, the following recommendation emerged as a consensus statement: the panel members suggest subpectoral one- or two-stage IBBR either with ADMs or without ADMs for adult women undergoing mastectomy for breast cancer treatment or risk reduction (with very low certainty of evidence).

Conclusions

The systematic review has revealed a very low certainty of evidence for most of the important outcomes in ADM-assisted IBBR and the absence of standard tools for evaluating clinical outcomes. Forty-five percent of panel members expressed a conditional recommendation either in favor of or against the use of ADMs in subpectoral one- or two-stages IBBR for adult women undergoing mastectomy for breast cancer treatment or risk reduction. Future subgroup analyses could help identify relevant clinical and pathological factors to select patients for whom one technique could be preferable to another.

Role of Qualitative and Quantitative Indocyanine Green Angiography to Assess Mastectomy Skin Flaps Perfusion in Nipple/Skin-Sparing and Skin-Reducing Mastectomies with Implant-Based Breast Reconstruction

Methods

Consecutive women scheduled for nipple/skin-sparing/skin-reducing mastectomy between May 2020 and April 2021 were prospectively enrolled. Patients were divided into Group 1 in the absence of superficial and full-thickness necrosis (SN; FTN) and Group 2 in the presence of both. T1 (time between ICG injection and the initial perfusion of the least perfused MSF area), ICG-Q1, and ICG-Q% (absolute and relative perfusion values of the least vascularized area) were collected.

Results

38 breasts were considered. FTN was reported in 4 breasts (10.5%) and SN in 3 (7.9%). The two groups statistically differ in T1 (Group2 > Group1) and ICG-Q% (Group1 > Group2) (p < 0.05). T1 could statistically predict ICG-Q1 and ICG-Q%. Both quantitative values have a sensitivity of 57% and a NPV of 89%; ICG-Q% shows higher specificity (81% vs 77%) and PPV (40% vs 36%).

Conclusions

Quantitative ICG angiography may additionally reduce MSF necrosis. Moreover, longer T1 may indicate possible postoperative necrosis. Considering these factors, intraoperative changes of reconstructive strategy could be adopted to reduce reconstructive failure.

Direct-to-implant breast reconstruction following nipple-sparing mastectomy: predictive factors of adverse surgical outcomes in Asian patients

BACKGROUND

Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes.

METHODS

Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed.

RESULTS

There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025).

CONCLUSIONS

Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

Implant-based immediate reconstruction in prophylactic mastectomy: is the caudal dermis flap a reliable alternative to synthetic mesh or acellular dermal matrix?

Introduction

The demand for prophylactic mastectomy has increased significantly over the last 10 years. This can be explained by a substantial gain of knowledge about the clinical risk and outcome of patients with high risk mutations such as BRCA1 and 2, the improved diagnostic possibilities for detecting the genetic predisposition for the development of breast cancer and the awareness for those mutations by health care professionals as well as patients. In addition to expander-to-implant reconstruction and microsurgical flap surgery, definitive immediate reconstruction with subpectoral insertion of breast implants is often preferred. The prosthesis is covered at its inferior pole by a synthetic mesh or acellular dermal matrix. In these cases, in addition to the silicone prosthesis, a further foreign body must be implanted. This can be exposed in the event of wound healing disorder or necrosis of the usually thin soft tissue covering after subcutaneous mastectomy, thus calling into question the reconstructive result. In this study, the coverage of the lower pole by a caudal deepithelialized dermis flap, which allows the implant to be completely covered with well vascularized tissue, is compared to coverage by a synthetic mesh or acellular dermal matrix.

Patients and methods

From January 2014 to June 2020, 74 patients (106 breasts) underwent breast reconstruction following uni or bilateral prophylactic mastectomy. Reconstruction was performed with autologous tissue (15 breasts), with tissue expander or implant without implant support (15 breasts), with implant and use of an acellular dermal matrix or synthetic mesh (39 breasts) and with implant and caudal dermis flap (37 breasts).

In this study, we compared the patients with implant and dermal matrix/mesh to the group reconstructed with implant and dermal flap.

Results

In the group with the caudal dermis flap, 4 patients developed skin necrosis, which all healed conservatively due to the sufficient blood supply through the dermis flap. In the group with the use of a synthetic mesh or acellular dermal matrix, skin necrosis was found in three cases. In one of these patients the implant was exposed and had to be removed.

Discussion

For patients with excess skin or macromastia, the caudal dermis flap is a reliable and less expensive option for complete coverage of an implant after prophylactic mastectomy. In particular, the vascularized dermis flap can protect the implant from the consequences of skin necrosis after prophylactic mastectomy.

Use of Indocyanine Green Angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: A systematic review and meta-analysis

INTRODUCTION

Indocyanine Green Angiography (ICG-A) is an imaging technique used to visualize tissue perfusion in real time. The aim of this systematic review and meta-analysis is to evaluate all published papers on breast reconstruction using ICG-A, which provides information on complication rates and to investigate whether the use of this peroperative method decreases the risk of complications.

MATERIALS AND METHODS

MEDLINE/PubMed, EMBASE, Cochrane, and UpToDate were searched using relevant terms. The literature was assessed using the PRISMA guidelines. Inclusion criteria were: original articles written in English assessing ICG-angiography in breast reconstruction. The individual studies were evaluated according to Cochrane guidelines.

RESULTS

The search yielded 243 papers on ICG-A and breast reconstruction. Twenty-six of these were included for analysis. The risk of overall major complications ([OR] = 0.53, 95% confidence interval (CI) = 0.43-0.66, p = 0.00001) and overall loss of reconstruction ([OR] = 0.58, 95% CI = 0.37-0.92, and p = 0.020) was significantly lower when peroperative ICG-A was used. When using ICG-A to evaluate mastectomy flaps, a statistically lower risk of major complications ([OR] = 0.56 and p = 0.0001) and the loss of reconstruction was found ([OR] = 0.46, p = 0.006). ICG-A used in autologous breast reconstruction significantly reduced the risk of minor ([OR] = 0.62 and p = 0.001) and major complications ([OR] = 0.53 and p = 0.0028).

CONCLUSIONS

This is the first systematic review to analyze the use of ICG-A on both mastectomy flaps and autologous reconstruction. The results obtained in the current study indicate that the use of ICG-A in breast reconstructive procedures reduces the complications as well as the loss of reconstruction.

Value of contrast-enhanced ultrasound area ratio in identifying benign and malignant small breast masses

Background

Tumor size affects clinical staging and is closely related to prognosis. Therefore, early diagnosis of breast cancer is one of the most important methods to reduce mortality and improve prognosis. However, minimal breast cancer is difficult to differentiate from small benign breast masses due to insufficient typical malignant signs. The significantly increased range of enhancement can be an important indication for the prediction of malignancy; however, quantitative studies on the extent of enhancement are rarely reported. The purpose of this study was to investigate the value of contrast-enhanced ultrasound (CEUS) area ratio in finding benign and malignant small breast masses.

Methods

A retrospective analysis was conducted on 88 patients with breast masses confirmed by surgery or needle biopsy (the maximal diameter not over 1 cm). 88 breast masses were divided into the younger age group (not over 40 years old) and older age group (over 40 years old) according to the patient's age. The receiver operating characteristic (ROC) curve was used to determine the cutoff values of CEUS area ratio in diagnosing benign or malignant small breast masses in each group. The efficiency of different cutoff values in finding benign and malignant small breast masses of the distinct groups was analyzed.

Results

The CEUS area ratio of malignant mass was larger than benign masses (P<0.05). The CEUS area ratio of malignant masses in the younger age group was larger than that in the older age group (P<0.05). The results of the ROC curve analysis showed that the area under the curve (AUC) and the cutoff values of the entire group, the younger age group, and the older age group were 0.887, 1.65; 0.909, 1.95; and 0.908, 1.22, respectively. When the cutoff value of the older age group was reduced from 1.65 to 1.22, its diagnostic sensitivity was improved significantly (P<0.05).

Conclusions

CEUS area ratio has specific application value in finding benign and malignant small breast masses. Proper reduction of the cutoff value of elderly patients can further improve its diagnostic sensitivity without significantly reducing the specificity.

Indocyanine Green Angiography in Breast Reconstruction: Utility, Limitations, and Search for Standardization

Supplemental Digital Content is available in the text.

During reconstructive breast surgery, intraoperative assessment of tissue perfusion has been solely based on subjective clinical judgment. However, in the last decade, intraoperative indocyanine green angiography (ICGA) has become an influential tool to visualize blood flow to the tissue of interest. This angiography technique produces real-time blood flow information to provide an objective assessment of tissue perfusion.

Breast cancer prevention in high-risk women

Women at high risk of developing breast cancer are a heterogeneous group of women including those with and without high-risk germline mutation/s. Prevention in these women requires a personalised and multidisciplinary approach. Preventive therapy with selective oestrogen receptor modulators (SERMs) like tamoxifen and aromatase inhibitors (AIs) substantially reduces breast cancer risk well beyond the active treatment period. The importance of benign breast disease as a marker of increased breast cancer risk remains underappreciated, and although the benefit of preventive therapy may be greater in such women, preventive therapy remains underutilised in these and other high-risk women. Bilateral Risk-Reducing Mastectomy (BRRM) reduces the risk of developing breast cancer by 90% in high-risk women such as carriers of BRCA mutations. It also improves breast cancer-specific survival in BRCA1 carriers. Bilateral risk-reducing salpingo-oophorectomy may also reduce risk in premenopausal BRCA2 carriers. Further research to improve risk models, to identify surrogate biomarkers of preventive therapy benefit and to develop newer preventive agents is needed.

Optimizing Indocyanine Green Fluorescence Angiography in Reconstructive Flap Surgery: A Systematic Review and Ex Vivo Experiments

Background. Indocyanine green angiography (ICGA) offers the potential to provide objective data for evaluating tissue perfusion of flaps and reduce the incidence of postoperative necrosis. Consensus on ICGA protocols and information on factors that have an influence on fluorescence intensity is lacking. The aim of this article is to provide a comprehensive insight of in vivo and ex vivo evaluation of factors influencing the fluorescence intensity when using ICGA during reconstructive flap surgery. Methods. A systematic literature search was conducted to provide a comprehensive overview of currently used ICGA protocols in reconstructive flap surgery. Additionally, ex vivo experiments were performed to further investigate the practical influence of potentially relevant factors. Results. Factors that are considered important in ICGA protocols, as well as factors that might influence fluorescence intensity are scarcely reported. The ex vivo experiments demonstrated that fluorescence intensity was significantly related to dose, working distance, angle, penetration depth, and ambient light. Conclusions. This study identified factors that significantly influence the fluorescence intensity of ICGA. Applying a weight-adjusted ICG dose seems preferable over a fixed dose, recommended working distances are advocated, and the imaging head during ICGA should be positioned in an angle of 60° to 90° without significantly influencing the fluorescence intensity. All of these factors should be considered and reported when using ICGA for tissue perfusion assessment during reconstructive flap surgery.

Indocyanine Green (ICG) in Urologic Surgery

Indocyanine green (ICG) is a dye used for fluorescent-guided surgery. This review article addresses the recent surge in reported uses of ICG in various surgical fields and provides a comprehensive and up to date review of the uses of ICG in urologic surgery.

Breast Reconstruction Actualized in Nipple-sparing Mastectomy and Direct-to-implant, Prepectoral Polyurethane Positioning: Early Experience and Preliminary Results

BACKGROUND

Implant-based breast reconstruction after nipple-sparing mastectomy has been the most common breast reconstruction procedure performed, for both breast cancer treatment and prophylactically. Subpectoral implant placement with partial detachment of the pectoralis major muscle has been the procedure of choice for staged reconstruction and direct-to-implantation. Prepectoral implant placement has recently increased in popularity among plastic surgeons owing to the high rates of animation deformity, loss of muscle function, and chronic pain observed with submuscular implant placement. Acellular dermal matrices or synthetic meshes have been used for implant coverage and support to avoid capsular contracture and implant visibility. In the present study, we have introduced breast reconstruction actualized in nipple-sparing mastectomy and direct-to-implant with prepectoral polyurethane positioning (BRAND4P).

PATIENTS AND METHODS

A total of 34 nipple-sparing mastectomies and immediate direct-to-implant breast reconstructions with prepectoral polyurethane-coated implant placement were performed in 21 patients (13 bilateral and 8 unilateral). The implant was placed subcutaneously in the exact place of the excised breast parenchyma with no further coverage.

RESULTS

After a mean follow-up of 4 months, no major complications had been observed. No patient presented with animation deformity or grade III-IV capsular contracture. Patient satisfaction, assessed using the BREAST-Q, was excellent.

CONCLUSIONS

The BRAND4P method represents a novel prepectoral approach and a feasible alternative to subpectoral implant placement among the available implant-based breast reconstruction techniques.