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SPY Imaging Use in Post-mastectomy Breast Reconstruction Patients: Preventative or Overly Conservative?
Gennaya L. Mattison, BS1, Priya G. Lewis, BA1, Subhas C. Gupta, MD, CM, PhD, FACS, FRCSC2, Hahns Y. Kim, MD2.
1Loma Linda University School of Medicine, Loma Linda, CA, USA, 2Loma Linda University Medical Center, Loma Linda, CA, USA.
SPY imaging technology utilizes an injectable fluorescing agent to intra-operatively assess the perfusion and viability of tissue, including skin flaps during post-mastectomy reconstruction for breast cancer patients. This study sought to compare the surgeon’s assessment of flap viability with that of the SPY imaging perfusion, analyzing the clinical outcomes including necrosis and expander/implant viability post-operatively.
In this study, the intra-operative difference between the plastic surgeon’s assessment of skin viability and the SPY imaging assessment was analyzed by the skin flap area preserved in a total of sixteen breasts undergoing mastectomy. Following the mastectomy, the operating surgeon marked the area of the skin flap to excise then the SPY imaging was performed and photos and videos of the perfusion collected. The skin flap was resected prior to implant or tissue expander placement according to the plastic surgeon’s assessment. The patients were then routinely followed up in clinic post-operatively.
A total of sixteen breasts were analyzed and compared. During the study, there was one incidence of necrosis with a return to the OR for debridement along with tissue expander removal and replacement. In one of the sixteen cases, SPY imaging indicated a greater area of viability than the surgeon’s assessment. For the remaining fifteen breasts, however, resecting the area of diminished perfusion as indicated by the SPY imaging would have resulted in a statistically significant increased area of resection (t=0.038). In addition, three of the fifteen cases were nipple-sparing mastectomies; none of the nipples were well-perfused by SPY imaging, but no post-operative necrosis occurred.
SPY imaging has a great deal of potential for use in reconstructive procedures. In this study, it was found to be conservative in its estimation of viability and, if followed, would result in a more aggressive resection than the area deemed viable by the human eye (Figure 1). It is possible that the case of necrosis with a return to the operating room for a tissue expander removal and replacement might have been prevented following the SPY imaging guidance for the tissue viability (Figure 2). Overall, SPY imaging is a valuable tool to assist in the evaluation of skin flap viability following a mastectomy. If some future returns to the operating room can be prevented by following the conservative estimation by SPY imaging and filling the tissue expander more slowly, that is clearly the most appropriate course to pursue. Though it should not be used as the only determining factor of viability, SPY imaging has a great deal of potential as a complementary tool to be integrated with the experienced surgeon’s analysis during post-mastectomy breast reconstruction.
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