Multivariable analysis for flap-related complications in autologous breast reconstruction and economic analysis of intraoperative indocyanine green angiography_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Zeyang ,  LI Zan , PENG Xiaowei , ZHOU Bo , TANG Yuanyuan , WU Peng , SONG Dajiang , LÜ Chunliu , PENG Wen , LI Hui , OU Yan , XU Anji

Department of Oncology Plastic Surgery/Head & Neck Surgery, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha Hunan, 410013, P.R.China;

Corresponding author：

LI Zan, Email: zzanli@163.com

Keywords：

Breast reconstruction; flap-related complication; indocyanine green; neoadjuvant chemotherapy; economic analysis

DOI：

10.7507/1002-1892.201906023

Video：

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Objective To investigate the influencing factors of flap-related complications and the economic benefits of intraoperative indocyanine green (ICG) angiography in the patients undergoing autologous breast reconstruction.Methods Between July 2013 and June 2018, the clinical data of 150 patients (152 breasts) who met the selection criteria after autologous breast reconstruction were analyzed retrospectively. Ten factors including age, body mass index, preoperative neoadjuvant chemotherapy (NC), chest radiation history, diabetes, abdominal operation history, chest wall reconstruction, reconstruction timing, flap type, intraoperative ICG angiography were analyzed by univariate analysis. Significant variables found in univariate analysis were used to perform backward multivariate logistic regression of flap related complications and local necrosis. According to the above multi factor analysis results, the patients were divided into 4 groups: ICG+NC group (group A), ICG+non-NC group (group B), non-ICG+NC group (group C), non-ICG+non-NC group (group D). The average extra costs of surgical treatment (including ICG imaging cost+cost of handling flap related complications) of each group was calculated.Results All the 152 flaps survived. There were 33 flap-related complications, including 22 regional necrosis, 9 regional infection, 5 hematoma, 5 simple fat liquefaction, and 2 anasto-motic thrombosis. Univariate analysis showed that preoperative NC, flap type, and intraoperative ICG angiography had significant influence on the incidence of flap-related complications (P<0.05). Multivariate analysis showed that preoperative NC and non-ICG angiography were the risk factors of flap-related complications (P<0.05), and also the risk factors of regional flap necrosis (P<0.05). For patients who had NC, intraoperative ICG angiography could greatly save the average extra costs. The average extra costs in group A was 1 378 yuan less than that in group C. For the patients without NC, intraoperative ICG angiography would increase the average extra costs, which was 747 yuan in group B more than that in group D.Conclusion In autologous breast reconstruction, ICG angiography can reduce the incidence of flap-related complications, especially the incidence of regional flap necrosis, while NC is the opposite. For patients without NC, ICG angiography is not cost-effective but still can be used if conditions permit. However, for those with NC, ICG angiography is cost-effective and recommended.

Citation： LIU Zeyang, LI Zan, PENG Xiaowei, ZHOU Bo, TANG Yuanyuan, WU Peng, SONG Dajiang, LÜ Chunliu, PENG Wen, LI Hui, OU Yan, XU Anji. Multivariable analysis for flap-related complications in autologous breast reconstruction and economic analysis of intraoperative indocyanine green angiography. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(1): 92-97. doi: 10.7507/1002-1892.201906023 Copy

1.	Kamali P, Paul MA, Ibrahim AMS, et al. National and regional differences in 32,248 postmastectomy autologous breast reconstruction using the updated national inpatient survey. Ann Plast Surg, 2017, 78(6): 717-722.
2.	Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J, 2014, 34(1): 61-65.
3.	Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg, 2010, 125(5): 1335-1341.
4.	Moon KC, Baek SO, Yoon ES, et al. Predictors affecting complications and aesthetic outcomes in autologous breast reconstruction with free muscle-sparing transverse rectus abdominis myocutaneous flaps. Microsurgery, 2019. [Epub ahead of print].
5.	Hembd A, Teotia SS, Zhu H, et al. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg, 2018, 142(3): 583-592.
6.	Malagón-López P, Vilà J, Carrasco-López C, et al. Intraoperative indocyanine green angiography for fat necrosis reduction in the deep inferior epigastric perforator (DIEP) flap. Aesthet Surg J, 2019, 39(4): N45-N54.
7.	Li L, Chen Y, Chen J, et al. Adjuvant chemotherapy increases the prevalence of fat necrosis in immediate free abdominal flap breast reconstruction. J Plast Reconstr Aesthet Surg, 2014, 67(4): 461-467.
8.	Diep GK, Hui JY, Marmor S, et al. Postmastectomy reconstruction outcomes after intraoperative evaluation with indocyanine green angiography versus clinical assessment. Ann Surg Oncol, 2016, 23(12): 4080-4085.
9.	Reinhart MB, Huntington CR, Blair LJ, et al. Indocyanine green: historical context, current applications, and future considerations. Surg Innov, 2016, 23(2): 166-175.
10.	Desai ND, Miwa S, Kodama D, et al. A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts. J Thorac Cardiovasc Surg, 2006, 132(3): 585-594.
11.	Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg, 2014, 133(4): 448e-454e.
12.	Chattha A, Bucknor A, Chen AD, et al. Indocyanine green angiography use in breast reconstruction: a national analysis of outcomes and cost in 110,320 patients. Plast Reconstr Surg, 2018, 141(4): 825-832.
13.	柳泽洋, 宋达疆, 李赞, 等. 吲哚菁绿造影在乳房重建中的应用进展. 中国修复重建外科杂志, 2018, 32(11): 1463-1468.
14.	周波, 周晓, 李赞, 等. 吲哚菁绿血管造影在自体组织乳房重建中的应用. 中国修复重建外科杂志, 2018, 32(4): 491-494.
15.	Oh E, Chim H, Soltanian HT. The effects of neoadjuvant and adjuvant chemotherapy on the surgical outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg, 2012, 65(10): e267-e280.
16.	Beugels J, Meijvogel JLW, Tuinder SMH, et al. The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat, 2019, 176(2): 367-375.
17.	van der Vorst JR, Schaafsma BE, Verbeek FP, et al. Randomized comparison of near-infrared fluorescence imaging using indocyanine green and 99(m) technetium with or without patent blue for the sentinel lymph node procedure in breast cancer patients. Ann Surg Oncol, 2012, 19(13): 4104-4111.
18.	Yuan L, Qi X, Zhang Y, et al. Comparison of sentinel lymph node detection performances using blue dye in conjunction with indocyanine green or radioisotope in breast cancer patients: a prospective single-center randomized study. Cancer Biol Med, 2018, 15(4): 452-460.

1. Kamali P, Paul MA, Ibrahim AMS, et al. National and regional differences in 32,248 postmastectomy autologous breast reconstruction using the updated national inpatient survey. Ann Plast Surg, 2017, 78(6): 717-722.
2. Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J, 2014, 34(1): 61-65.
3. Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg, 2010, 125(5): 1335-1341.
4. Moon KC, Baek SO, Yoon ES, et al. Predictors affecting complications and aesthetic outcomes in autologous breast reconstruction with free muscle-sparing transverse rectus abdominis myocutaneous flaps. Microsurgery, 2019. [Epub ahead of print].
5. Hembd A, Teotia SS, Zhu H, et al. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg, 2018, 142(3): 583-592.
6. Malagón-López P, Vilà J, Carrasco-López C, et al. Intraoperative indocyanine green angiography for fat necrosis reduction in the deep inferior epigastric perforator (DIEP) flap. Aesthet Surg J, 2019, 39(4): N45-N54.
7. Li L, Chen Y, Chen J, et al. Adjuvant chemotherapy increases the prevalence of fat necrosis in immediate free abdominal flap breast reconstruction. J Plast Reconstr Aesthet Surg, 2014, 67(4): 461-467.
8. Diep GK, Hui JY, Marmor S, et al. Postmastectomy reconstruction outcomes after intraoperative evaluation with indocyanine green angiography versus clinical assessment. Ann Surg Oncol, 2016, 23(12): 4080-4085.
9. Reinhart MB, Huntington CR, Blair LJ, et al. Indocyanine green: historical context, current applications, and future considerations. Surg Innov, 2016, 23(2): 166-175.
10. Desai ND, Miwa S, Kodama D, et al. A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts. J Thorac Cardiovasc Surg, 2006, 132(3): 585-594.
11. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg, 2014, 133(4): 448e-454e.
12. Chattha A, Bucknor A, Chen AD, et al. Indocyanine green angiography use in breast reconstruction: a national analysis of outcomes and cost in 110,320 patients. Plast Reconstr Surg, 2018, 141(4): 825-832.
13. 柳泽洋, 宋达疆, 李赞, 等. 吲哚菁绿造影在乳房重建中的应用进展. 中国修复重建外科杂志, 2018, 32(11): 1463-1468.
14. 周波, 周晓, 李赞, 等. 吲哚菁绿血管造影在自体组织乳房重建中的应用. 中国修复重建外科杂志, 2018, 32(4): 491-494.
15. Oh E, Chim H, Soltanian HT. The effects of neoadjuvant and adjuvant chemotherapy on the surgical outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg, 2012, 65(10): e267-e280.
16. Beugels J, Meijvogel JLW, Tuinder SMH, et al. The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat, 2019, 176(2): 367-375.
17. van der Vorst JR, Schaafsma BE, Verbeek FP, et al. Randomized comparison of near-infrared fluorescence imaging using indocyanine green and 99(m) technetium with or without patent blue for the sentinel lymph node procedure in breast cancer patients. Ann Surg Oncol, 2012, 19(13): 4104-4111.
18. Yuan L, Qi X, Zhang Y, et al. Comparison of sentinel lymph node detection performances using blue dye in conjunction with indocyanine green or radioisotope in breast cancer patients: a prospective single-center randomized study. Cancer Biol Med, 2018, 15(4): 452-460.

Chinese Journal of Reparative and Reconstructive Surgery

Multivariable analysis for flap-related complications in autologous breast reconstruction and economic analysis of intraoperative indocyanine green angiography

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