The use of fluorescein dye as a predictor of mastectomy skin flap viability following autologous tissue reconstruction.

BACKGROUND: The skin sparing mastectomy continues to allow improvement in the esthetic outcome after immediate autologous breast reconstruction. However, native skin flap necrosis does occur and can significantly jeopardize the result. The purpose of this series was to evaluate objectively the utility of fluorescein dye as a tool to assist with evaluation of eventual flap viability or flap necrosis.
METHODS: Fifty consecutive periareolar mastectomy flaps were evaluated after autologous reconstruction. Patient demographics and risk factors were queried. The mastectomy skin flaps were evaluated clinically for viability and managed appropriately. Flap inset was performed. Intravenous fluorescein dye was then given, and areas of nonfluorescence were marked (size and location documented). Photodocumentation was performed intraoperatively and 1 week postoperatively. Areas of skin survival and skin necrosis were documented, and comparisons were made.
RESULTS: The type of reconstructions included TRAM flap (n = 31), and latissimus dorsi with expander (n = 19), with an average age of 50 years (range: 38-68 years). Patient demographics included previous radiation therapy (n = 5), smoking history (n = 14), hypertension (n = 13), and previous breast scars (n = 16). Skin fluorescence corresponded with flap survival (n = 48/50), giving a positive predictive value of 96%. Two flaps (1 patient) had some skin necrosis despite full fluorescence; however, she was eventually diagnosed with hepatitis C vasculitis. Of the 21 flaps with areas of nonfluorescence, skin necrosis was present in 5 of 21, a negative predictive value of 25%. The majority of areas of nonfluorescence were less than 4 cm2 and had full flap survival (n = 16/21). Two flaps with nonfluorescence of <4 cm2 and previous radiation therapy had skin necrosis. All flaps with areas >4 cm2 had skin necrosis, unless proximally located on the skin flaps.
CONCLUSIONS: Fluorescein dye is a sensitive test for determining native mastectomy skin flap viability after autologous reconstruction; however, viability is underpredicted. Location on the skin flaps, size of nonfluorescence, as well as history of radiation therapy should be taken into consideration. Areas of nonfluorescence <4 cm2 typically survive, except in the irradiated breast. Any area of nonfluorescence >4 cm2 typically does not survive, except when located more proximally on the flap.