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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.

Breast reconstruction has become an important consideration for women after mastectomy. Over the past decade, there have been a variety of technological advancements that have facilitated the ability to deliver reproducible and predictable outcomes with autologous breast reconstruction. This article chronicles many of the technological advancements and reviews the current toolbox that surgeons now have at their disposal when performing autologous reconstruction. It focuses on preoperative, intraoperative, and postoperative tools that have enabled the achievement of more reliable and predictable outcomes, especially in the setting of microvascular breast reconstruction.

Creation of the nipple-areolar complex is the final and important component of the breast reconstruction process. Various techniques using a variety of local flaps are available. This article covers the pre- and postoperative care of the woman having nipple reconstruction, reviews the author's preferred techniques, discusses the use of supplemental materials for nipple augmentation, and comments on the common complications.

The surgical management of melanoma continues to evolve. A large body of information serves as a foundation for the oncologic principles, surgical excisions, and reconstructive methodologies that are currently in use. This article serves as a guide for the physician considering surgical management of the melanoma patient.

Pregnancy following abdominal flap-based breast reconstruction may cause stress to the abdominal wall. These changes may result in weakness and hernia or bulge. We present two patients who previously underwent unilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction and became pregnant twice. Both patients maintained abdominal contour without bulges or hernias. Subjectively, patients reported minor changes to abdominal strength. Therefore, these two patients had minimal abdominal morbidity following pregnancy after unilateral DIEP flap reconstruction.

We report on four patients with partial and full thickness burns following autogenous tissue breast reconstruction. Three burns were confined to the flap and one burn involved the flap and rim of adjacent skin. Heat sources included a heating pad (n = 3) and sunlight through a bathing suit (n = 1). The injuries occurred from 6 days to 4 years following the reconstruction. The burns were the result of impaired thermoregulatory capacity of transplanted tissue. All wounds healed with local wound care or debridement and skin grafting.