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In immediate breast reconstruction with direct-to-implant reconstruction, implants may be placed in the prepectoral plane or in the submuscular plane with total coverage or partial coverage by the pectoralis major muscle, the serratus muscle, or an acellu­lar dermal matrix. While submuscular placement has historically been the predominant location of implants, prepectoral placement has increased in popularity as patients experience less postopera­tive pain and have lower rates of animation distortion seen in sub­muscular placement. The use of SPY angiography allows patients to undergo DTI reconstruction in the prepectoral plane with lower rates of postoperative complications [6]. Using this tool permits surgeons to assess the vascular integrity of mastectomy skin aps, thereby guiding intraoperative decision-making. When mastec­tomy skin aps display an adequate percentage of skin perfusion, surgeons may move forward with prepectoral implant placement. However, when mastectomy skin aps display a lack of vascular integrity proven by SPY uorescent imaging, prepectoral placement is no longer the best option and necessitates conversion to submuscular implant or expander. Following movement of the implant, a repeated vascular assessment according to the SPY ELITE or SPY Portable Handheld Imager protocol can then be used to conrm the absence of implant-induced vascular compro­mise. In both planes of implant placement, the use of acellular dermal matrix is important. Its use in the prepectoral plane pro­vides superior pole fullness and provides adequate coverage that is comparable to the pectoralis major muscle coverage. In the sub­muscular plane, the acellular dermal matrix provides lower pole coverage, often needed during the tissue expansion process which muscular coverage is inadequate [6].

There are special considerations that the plastic surgeon should address when following this decision-making algorithm. They are based on the angiography assessment as well as patient factors. Cutoffs for skin perfusion values that necessitate conversion to sub­muscular range from 25% to 45% relative perfusion. Skin with 25% or less relative tissue perfusion is nonviable in most patients, and skin with 45% relative tissue perfusion will survive in most patients. Therefore, a gray area exists between these values. Moyer etal. studied this “gray area” and found that the use of a 33% cutoff is associated with a positive predictive value of removing nonviable skin of 88% with a negative predictive value of removing healthy skin of 16% [8]. These values, however, should be determined on an individual basis after evaluating the patient’s risk factors for increased mastectomy skin ap necrosis. The main risk factors that affect skin ap necrosis and therefore contribute to angiography success in predicting skin ap necrosis are smoking status, BMI, and mastectomy weight [9]. In patients who are smokers, have a BMI greater than 30, and have a mastectomy weight greater than 800g, rates of mastectomy skin ap necrosis are higher compared to nonsmokers, patients with a BMI less than 30, or patients with lower mastectomy weights [9]. After accounting for values of tissue perfusion and patient risk factors, the plastic surgeon can then determine an adequate amount of tissue that can be excised without compromising the skin envelope. SPY angiography provides both qualitative and quantitative assessments that allow plastic surgeons to make informed decisions regarding patient eligibility for DTI reconstruction. In doing so, it guides excision of poorly perfused areas and determination of the best plane of implant placement. When factoring in patient factors, these two surgical decisions lead to reduced rates of mastectomy skin ap necrosis and reduce the need for subsequent surgical revision.