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BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery.METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement.RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments.CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy.Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator.The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another.The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

There are no guidelines on the safety of magnetic resonance imaging (MRI) in patients with breast tissue expanders with metallic/magnetic components. This narrative review was conducted to better understand what is currently known and to identify gaps in knowledge.A literature search was performed using PubMed and Embase and the following terms: "breast" AND ("imaging" OR "MRI" OR "resonance") AND "expander," with no date limitations. The authors identified 153 citations in PubMed and 154 citations in Embase.Nineteen publications were relevant for analysis: two retrospective studies, 10 case reports, six nonclinical studies, and one physician survey. All studies acknowledged the risks of using magnetic resonance imaging in patients with tissue expanders. Complications reported included breast/chest pain, discomfort, or burning sensation (46.2 percent); expander or infusion port displacement (38.5 percent); and magnetic resonance signal loss (23.1 percent). Increases in expander/tissue temperature and torque occurred with magnetic resonance imaging, causing pain or expander displacement. In some cases, no complications were reported. The retrospective studies and nonclinical analyses suggested that magnetic resonance imaging may not create serious problems if special precautions are taken. The case reports varied in their recommendations, with some recommending avoiding magnetic resonance imaging and others recommending exercising caution. The survey indicated that surgeons are uncertain about performing magnetic resonance imaging in patients with tissue expanders.The evidence on whether to perform magnetic resonance imaging in patients with tissue expanders with magnetic ports varies but underscores proceeding with caution. The risk-to-benefit profile for each patient must be weighed in each situation.