Evaluation of Intraoperative Anastomotic Patency with Angiography in Microsurgical Breast Reconstruction

Background: Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction. Methods: Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success. Results: Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps. Conclusions: The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.