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The Clinical Efficacy And Financial Impact Of Laser-assisted Indocyanine Green Angiography On Implant-based Breast Reconstruction At A Large Academic Medical Center
Christin A. Harless, MD, Sue Visscher, PhD, Steven R. Jacobson, MD.
Mayo Clinic, Rochester, Rochester, MN, USA.
The clinical efficacy and financial impact of laser-assisted indocyanine green angiography on implant-based breast reconstruction at a large academic medical center
Mastectomy flap necrosis continues to be a significant source of morbidity in patients undergoing implant-based breast reconstruction. Laser-assisted indocyanine green angiography (LA-ICGA) technology provides surgeons with an objective, real-time assessment of skin perfusion in the operating room, allowing for maximal preservation of the mastectomy skin flap while avoiding skin necrosis. The purpose of this study is to evaluate the clinical efficacy and financial impact of LA-ICGA use at a large academic medical center.
A retrospective comparative analysis was performed on consecutive patients undergoing implant-based reconstruction from 2010 to 2013. Patients were divided into two group based on the use of LA-ICGA. The primary complication analyzed was mastectomy flap skin necrosis requiring operative intervention. Secondary outcomes included: flap salvage, extrusion, bleeding, infection, explantation, and implant deflation. Mastectomy flap skin necrosis, implant extrusion, infection, bleeding, and deflation were noted if they required operative intervention. Those experiencing skin necrosis were further analyzed to identify additional hospital costs incurred due to the skin necrosis.
A total of 942 breasts were reconstructed between 2010 and 2013; 590 without the use of LA-ICGA and 352 with LA-ICGA. In both groups, the majority of mastectomies performed were skin sparing. However, with the use of LA-ICGA there was a trend towards more nipple sparing mastectomies; without LA-ICGA 28% were nipple sparing compared to 32% with LA-ICGA (p=0.21). Additionally, there was a significant increase in single-stage, direct-to-implant reconstructions with the use of LA-ICGA; without LA-ICGA only 7% of reconstructions were direct-to-implant compared to 23% with the use of LA-ICGA (p<0.001). Overall, there were fewer complications with the use of LA-ICGA; 17% of reconstructions experienced at least one complication without LA-ICGA compared to only 6% with LA-ICGA (p<0.001). Specifically, there was a significant decrease in patients experiencing skin necrosis (6% (n=32) without the use of LA-ICGA compared to 1% (n=2) with LA-ICGA, p<0.001). The average additional costs incurred secondary to skin necrosis was \,441 per patient. Over a 5 year period, the use of LA-ICGA would potentially avoid 59 episodes of skin necrosis for a total cost savings of \,019.
Implementation of LA-ICGA provided the surgeon with an objective assessment of mastectomy flap perfusion resulting in a trend towards overall reduction in complications as well as an 83% decrease in the rate of skin necrosis. Furthermore, modelled over a 5 year period, the technology potentially prevents 59 patients from experiencing the devastating effects of skin necrosis and saves the institution \,019. The objective assessment of mastectomy flap perfusion allows the plastic surgeon to tailor breast reconstruction intraoperatively, in real-time, accommodating for the individual patient’s mastectomy flap perfusion not only preventing patients from experiencing the devastating sequela of skin necrosis but also having a positive financial impact on breast reconstruction.
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