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8 Use ofFluorescence Guidance inBreast Reconstruction
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4. Inject 0.2 ml of ICG intradermally into web spaces of the
distal hand (Fig.8.4).
5. Turn down the operating room lights and use the imaging
device to evaluate the lymphatic ow pattern.
6. Mark and select the linear ow pattern segment on the skin
with a skin marker.
7. Identify and mark “dark crossing areas” that may indicate
crossing veins which are possible LVA locations. Injection
0.3ml of lymphazurin blue into the dermis several centimeters distal to the incision site may assist with visualization of
the lymphatic channels.
8. Prepare and drape the extremity.
9. Under the microscope, make a supercial 1.5–2 cm transverse incision over the selected lymphatic vessel, which is
located in the supercial subcutaneous tissue.
10. Incise to the deep layer of the dermis using ne dissecting
instruments (Fig.8.5).
11. Once the lymphatic channel and adjacent venule have been
identied, anastomosis is carried out via a variety of techniques (Fig.8.6).
12. A new injection of lymphazurin blue or ICG lymphangiography can be used to conrm the patency of LVA.
Fig. 8.4 Injection of ICG dye into webspaces of the hand
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Fig. 8.5 Microsurgical instruments utilized for lymphaticovenous anastomosis
A. Turner et al.
Contraindications andAdverse Reactions
Indocyanine green can be used in adults and pediatric patients,
except for those less than 1month of age. Indocyanine green contains sodium iodide and is contraindicated in patients with iodine
hypersensitivity due to anaphylaxis or other allergic reactions that
may occur. There are very few reports of anaphylactic reaction to
ICG, with an incidence of 1in 40,000. In patients with renal failure or uremia and those on dialysis, ICG should be used with
caution due to reports of anaphylactoid reactions including dyspnea, palpitations, anxiety, nausea, edema, and hypotension. The
clear mechanism is unknown, but patients with anaphylactoid
reactions had higher eosinophil counts than those who did not.
ab
cd
8 Use ofFluorescence Guidance inBreast Reconstruction
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While not a contraindication to ICG use, the SPY Agent Green
contains iodine, and this could reduce the iodine binding capacity
of thyroid tissue for at least a week after administration. Therefore,
patients who are scheduled to undergo radioactive iodine uptake
studies should not do so for at least 1week following ICG administration. Finally, while there are no adverse events associated
251
Fig. 8.6 Lymphaticovenous anastomosis techniques. (a) Y-shaped LVA.
(b) Lambda-shaped LVA. (c) K-shaped LVA. (d) Pi-shaped LVA.
(e)X-shaped LVA
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A. Turner et al.
Fig. 8.6 (continued)
e
with pregnancy or breastfeeding, use of ICG in these patient populations should be used with caution. ICG is a US FDA category
C drug with animal studies showing an adverse effect on the fetus.
There are no well-controlled studies in humans nor is there con-
8 Use ofFluorescence Guidance inBreast Reconstruction
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trolled data in human pregnancy. The small studies published
have not reported major birth defects, miscarriage, or adverse
maternal or fetal outcomes. Additionally, there has been no report
of placental transfer of ICG or detectable levels of ICG in fetal
blood or umbilical vein blood after ICG administration in the
pregnant mother. There is currently no data on the presence of
ICG in human milk or the effects on milk production.
Adverse reactions can be mild, moderate, or severe. Mild reactions include ushing, syncope, weakness, headache, urticaria,
anxiety, vomiting, and diaphoresis. Moderate reactions include
edema, hypotension, erythema, wheezing, sinus tachycardia, palpitations, dyspnea, and confusion. Severe reactions include anaphylactic shock, anaphylactoid reactions, respiratory arrest,
cyanosis, cardiac arrest, laryngospasm, bronchospasm, and visual
impairment. There have been reports of anaphylaxis, urticaria,
and death with use of this product, and therefore, careful monitoring is important and cardiopulmonary resuscitation equipment
and personnel should always be available. Patients should be
warned of the risks and told to seek medical attention if they
develop signs of anaphylaxis such as difculty breathing, tongue
or throat swelling, hives, itching, ushed or pale skin, low blood
pressure, or a weak pulse or rapid pulse [21].
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Conclusion
Since the introduction of indocyanine green (ICG) angiography to
medical use in the mid-1950s, it has become a reliable and popular method to assess tissue perfusion. However, it was not until
1999 that it was used in plastic surgery as a tool to assess ap
perfusion in burn reconstruction. Since then, it has had multiple
applications throughout plastic surgery, including the management of diabetic ulcers, assessment of ap perfusion, lymph ow
reconstruction, and breast reconstruction, with experimental use
in face transplant preoperative planning. This chapter serves an
overview of ICG in breast reconstruction encompassing mastectomy ap perfusion, free ap viability, and breast cancerassociated lymphedema.
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A. Turner et al.
ICG angiography provides surgeons with objective visual evidence of poor perfusion that may not manifest clinically until several days postoperatively. Therefore, the use of ICG has been
found to reduce rates of mastectomy skin necrosis, partial ap
loss, and fat necrosis by guiding intraoperative decision-making,
reducing patient costs associated with complications management, and improving patient satisfaction. Its short half-life enables
repeated examinations via multiple injections without reaching
toxic levels, vital to plastic surgery applications.
ICG lymphangiography is a noninvasive test that allows precise, real-time evaluation of supercial lymphatic drainage without utilizing radioactive particles. ICG lymphography permits a
qualitative assessment of the lymphatic circulation, facilitates its
staging, and guides the intraoperative restoration of the lymph
ow. Moreover, there is evidence that ICG lymphangiography is
more accurate at detecting early upper extremity lymphedema
when compared to lymphoscintigraphy and before measurable
volume changes on clinical exams.
Overall, applications of ICG in plastic surgery have expanded
over the past two decades with a focus on angiography and lymphangiography. In this chapter, we have focused on its use in breast
reconstruction, which has shown to be expansive. ICG enables intraoperative tissue assessment via direct visualization that improves
decision-making with the goal of improving overall patient satisfaction and outcomes. While it is a relatively new technology in the
eld of plastic surgery, it has shown potential for improving the
overall operative experience and associated outcomes.
References
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MR.The role of intraoperative perfusion assessment: what is the current
state and how can i use it in my practice? Plast Reconstr Surg.
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2. Phillips BT, Lanier ST, Conkling N, Wang ED, Dagum AB, Ganz JC,
etal. Intraoperative perfusion techniques can accurately predict mastectomy skin ap necrosis in breast reconstruction: results of a prospective
trial. Plast Reconstr Surg. 2012;129(5):778e–88e.
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3. Rinker B.A comparison of methods to assess mastectomy ap viability
in skin-sparing mastectomy and immediate reconstruction: a prospective
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et al. Early detection of lymphatic disorder and treatment for lymphedema following breast cancer. Plast Reconstr Surg.
2016;138(2):192e–202e.
5. Momeni A, Sheckter C.Intraoperative laser-assisted indocyanine green
imaging can reduce the rate of fat necrosis in microsurgical breast reconstruction. Plast Reconstr Surg. 2020;145(3):507E–13E.
6. Bilezikian JA, Tenzel PL, Bebb GG, Kays CR.The broad application of
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T, etal. Indocyanine green–enhanced lymphography for upper extremity
lymphedema: a novel severity staging system using dermal backow patterns. Plast Reconstr Surg [Internet]. 2011;128(4):941–7. Available from:
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Indocyanine_Green_Enhanced_Lymphography_for_Upper.26.aspx.
8. Moyer HR, Losken A.Predicting mastectomy skin ap necrosis with
Indocyanine green angiography: the gray area dened. Plast Reconstr
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9. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of
laser-assisted indocyanine green angiography in prevention of mastectomy skin ap necrosis during prosthesis-based breast reconstruction.
Plast Reconstr Surg. 2014;133(4):448e–54e.
10. Varela R, Casado-Sanchez C, Zarbakhsh S, Diez J, Hernandez-Godoy J,
Landin L.Outcomes of DIEP ap and uorescent angiography: a randomized controlled clinical trial. Plast Reconstr Surg. 2020;145(1):1–10.
11. Chattha A, Bucknor A, Chen AD, Lee BT, Lin SJ. Indocyanine green
angiography use in breast reconstruction: a national analysis of outcomes
and cost in 110,320 patients. Plast Reconstr Surg. 2018;141(4):825–32.
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AA.Indocyanine green laser angiography improves deep inferior epigastric perforator ap outcomes following abdominal suction lipectomy.
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13. Hembd AS, Yan J, Zhu H, Haddock NT, Teotia SS.Intraoperative assessment of DIEP ap breast reconstruction using indocyanine green angiography: reduction of fat necrosis, resection volumes, and postoperative
surveillance. Plast Reconstr Surg. 2020;146(1):1e–10e.
14. Chatterjee A, Krishnan NM, Van Vliet MM, Powell SG, Rosen JM,
Ridgway EB.A comparison of free autologous breast reconstruction with
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15. Yamamoto T, Iida T, Yoshimatsu H, Fuse Y, Hayashi A, Yamamoto
N.Lymph ow restoration after tissue replantation and transfer: importance of lymph axiality and possibility of lymph ow reconstruction
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16. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm
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18. Patel KM, Lin C-Y, Cheng M-H.A prospective evaluation of lymphedemaspecic quality-of-life outcomes following vascularized lymph node
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Use ofFluorescence
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Guidance inPlastic
andReconstructive Surgery:
Skin andMuscle Flaps
ZacharyA.Koenig, CristianeM.Ueno,
JackJ.Gelman, andKerriWoodberry
Introduction
Fluorescence angiography using indocyanine green is a valuable
tool to assess ap viability, both for skin aps and muscle aps.
Image-guided surgery is a technique that uses optical imaging to
assess tissues during reconstructive surgery in plastic surgery.
Examples of these technologies include indocyanine green (ICG)
angiography, dynamic infrared thermography (DIRT), and photospectrometry. One of the most common methods involves the use
of near-infrared (NIR) uorescence imaging that requires an
injection of a uorescent dye that can be captured using NIR cameras. ICG is the most used dye, and it has multiple indications
including utilization to identify tissue perfusion, vessels, nerves,
and lymphatic drainage.
9
Z. A. Koenig · J. J. Gelman · K. Woodberry
Department of Surgery, Division of Plastic and Reconstructive Surgery,
West Virginia University School of Medicine, Morgantown, WV, USA
C. M. Ueno (*)
Department of Plastic and Reconstructive Surgery, Ohio State University
College of Medicine, Columbus, OH, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
N. Szoka et al. (eds.), The SAGES Manual of Fluorescence-Guided
Surgery, https://doi.org/10.1007/978-3-031-40685-0_9
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Z. A. Koenig et al.
The use of image-guided technologies such as ICG angiography allows detection of areas of poor or no blood perfusion that is
often not clearly visible to the human eye. Its applications have
been described in evaluation of orthopedic, trauma, military, and
vascular injuries as well as plastic surgery reconstructions.
Traditionally, clinical judgment has been one of the most acceptable parameters to determine tissue viability. Other methods of
assessment include subjective assessment of skin or tissue color,
capillary rell, ap temperature, tissue bleeding, prick tests,
Doppler ultrasound, and use of tactile sensation. The use of ICG
angiography allows an objective measure of perfusion and tissue
viability.
Images provided by NIR cameras can provide real-time information in the operating room which is an advantage for surgical
planning. For example, uorescence angiography can be used for
identication of lymphatic vessels in lymphatic anastomosis,
identication of lymph nodes during lymph node dissection, evaluation of patency of a vessel anastomosis, or evaluation of tissue
perfusion.
According to Burns etal. (level of evidence 3), the use of
NIR technologies intraoperatively has the potential to provide
data that can improve intraoperative decisions about flap
design with subsequent better outcomes [1]. In another study
group (level of evidence 3), authors compared three technologies and their capability to “predict” tissue perfusion. Their
findings showed that the intraoperative sensitivity for ICG
angiography was 90.9% (95% CI: 77.5–100) with an accuracy
of 98.6% (95% CI: 97.6–99.7), sensitivity for DIRT was 33%
(95% CI: 11.3–64.6) with specificity of 100% (95% CI 84.9–
100) and accuracy of 80% (95% CI: 71.2–89.7), and sensitivity for photo-spectrometry was 92% (95% CI: 72.4–98.6) with
specificity of 100% (95% CI: 98.8–100) and accuracy of
100% (95% CI: 98.7–100) [2].
The advantages of ICG are its short half-life (3–4 min in
healthy adults) which allows multiple runs in one single surgery
without exceeding the maximum dosage, its efcacy in predicting
clinical outcomes for partial or total tissue necrosis, and its evaluation of maximal size of a ap with delineation between the zones
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