Does indocyanine green imaging perfusion scoring reduce mastectomy flap necrosis in immediate autologous breast reconstruction? A single-centre cohort study.

[BACKGROUND] Mastectomy skin flap necrosis (MFN) occurs in 7-40% of patients undergoing immediate breast reconstruction, leading to significant morbidity, delayed healing and potential delays in adjuvant treatment. Indocyanine green (ICG) imaging assesses tissue perfusion intraoperatively, but an optimal perfusion threshold for resection remains debated. We evaluated the impact of the introduction of ICG fluorescence imaging (SPY-PHI Stryker Endoscopy) combined with a perfusion score on MFN rates in immediate deep inferior epigastric perforator (DIEP) breast reconstruction and identified a safe perfusion threshold. Secondary outcome measures were based on national Getting It Right First Time (GIRFT) benchmarks.

[METHODS] A total of 74 patients (87 breasts) who underwent immediate DIEP breast reconstruction from January 2022 to December 2024 were analysed, with 37 flaps in the control group and 50 flaps in the intervention group.

[RESULTS] The MFN rate decreased from 24.3% to 4.0% with ICG (p=0.0048), alongside reduced readmission (27.3% to 4.9%, p=0.0071) and wound complications (39.4% to 9.8%, p=0.0026).

[CONCLUSION] Introducing ICG significantly improved MFN rates and service performance against the national GIRFT benchmarks. Following a brief learning curve and strict adherence to a 40% perfusion score, we eliminated mastectomy flap necrosis. Additional benefits include improved assessment of contralateral symmetry, DIEP flap viability and post-anastomotic patency.