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Health technology assessment of using icg versus other tracers such as tc-99 and blue for sentinel lymph node detection rates
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Background
Conserving mastectomy techniques, such as nipple-sparing and skin-sparing mastectomy, enable immediate breast reconstruction, improving aesthetic outcomes but increasing the risk of postoperative complications, particularly ischemic events related to mastectomy skin flap perfusion. Intraoperative assessment with indocyanine green angiography has emerged as a tool to evaluate vascularization in real time.
Patients and Methods
A single-center retrospective study was conducted on patients undergoing conserving mastectomy with immediate prosthetic reconstruction from 2023 to 2026. Intraoperative flap perfusion was graded using indocyanine green (ICG) angiography. Clinical variables, surgical characteristics, postoperative complications, and time-to-adjuvant therapy were analyzed. Univariate and multivariate analyses were performed to identify predictors of complications.
Results
Forty-eight conserving mastectomies were included. Nine patients (18.7%) showed intraoperative hypoperfusion (score < 2). Complication rates were significantly higher in the hypoperfused group (P = .001). Mastectomy flap thickness was lower in hypoperfused flaps (mean difference ≈2 mm; P = .031). Low perfusion was also associated with delayed initiation of adjuvant therapy (36.8 vs. 13.7 days; P = .051). In multivariate analysis, hypoperfusion remained the strongest predictor of complications and longer interval to adjuvant treatment (P = .030 and P < .001).
Conclusion
ICG angiography documented mastectomy skin flap hypoperfusion is strongly associated with ischemic complications and delayed access to adjuvant treatments. Intraoperative perfusion assessment may guide surgical decision-making and support preventive strategies. Prospective studies are warranted to validate objective perfusion scoring models.
Introduction: Implant-based breast reconstruction is associated with an increased risk of ischemic complications, which may result in implant loss, suboptimal aesthetic outcomes, and delays in adjuvant oncological treatment. Additionally, axillary surgery carries a risk of upper-limb lymphedema. Indocyanine green (ICG) angiography enables more accurate real-time assessment of tissue perfusion than clinical evaluation alone, while axillary reverse mapping (ARM) facilitates the preservation of upper-limb lymphatics. The integration of these techniques reduces complications and improves both functional and aesthetic outcomes. Materials and methods: A total of 208 breast cancer patients who underwent mastectomy followed by immediate implant-based breast reconstruction were enrolled in this case–control study. The prospective intervention group received intraoperative ICG angiography at three time points and underwent ARM with ICG. Conventional surgical techniques were applied in the retrospective control group. Results: ICG angiography showed excellent diagnostic accuracy for predicting postoperative ischemic complications (AUC = 0.93, 95% CI 0.82–0.99, p < 0.001). Compared with the control group, patients in the ICG group had significantly lower rates of mastectomy skin flap necrosis (11.5% vs. 30.8%, p = 0.001), seroma (4.8% vs. 14.4%, p = 0.032), hematoma (1.9% vs. 9.6%, p = 0.033), and lymphedema (2.9% vs. 17.3%, p < 0.001). They also experienced shorter hospitalization (6.2 ± 1.9 vs. 8.0 ± 2.8 days, p < 0.001), fewer delays in adjuvant treatment initiation (16.3% vs. 32.7%, p = 0.010), and higher aesthetic satisfaction scores (81.41 ± 10.12 vs. 76.03 ± 9.74, p <0.001). Conclusions: Intraoperative indocyanine green angiography is a valuable tool for predicting ischemic complications in alloplastic breast reconstruction and is associated with reduced morbidity, fewer delays in adjuvant treatment, and improved aesthetic outcomes. Preliminary evidence suggests that axillary reverse mapping is associated with lower rates of upper-limb lymphedema.
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