Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques

• Published in: Clinical breast cancer 2023-04, Vol.23 (3), p.249-254
• Main Authors: Pagliara, Domenico, Schiavone, Laurenza, Garganese, Giorgia, Bove, Sonia, Montella, Rino Aldo, Costantini, Melania, Rinaldi, Pierluigi Maria, Bottosso, Stefano, Grieco, Federica, Rubino, Corrado, Salgarello, Marzia, Ribuffo, Diego
• Format: Article
• Language: English
• Subjects: Breast - surgery; Breast envolope evaluation; Breast Implants - adverse effects; Breast Neoplasms - complications; Female; Humans; Implant-based reconstruction; Mammaplasty - adverse effects; Mammaplasty - methods; Mastectomy - adverse effects; Mastectomy - methods; Necrosis - complications; Necrosis - surgery; Post-operative complications; Postoperative Complications - etiology; Prepectoral breast reconstruction; Retrospective Studies; Skin Diseases; Subpectoral breast reconstruciton
• ISSN: 1526-8209; 1938-0666
• DOI: 10.1016/j.clbc.2022.12.021

•Mastectomy skin-flap necrosis (MSFN) after immediate implant-based breast reconstruction represents a dreaded complication, with a reported incidence up to 41%.•Preoperative techniques such as mammography, ultrasound, and MRI can provide useful information especially when combined together and compared with intraoperative findings.•Indocyanine angiography showed better prediction of MSFN than other intraoperative mastectomy flap assessment, however both thermal imaging and spectroscopy demonstrated novel and promising results. Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons’ clinical experience. Even though numerous studies have already addressed the patients’ risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.