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Breast skin flap ischemia and necrosis is a serious consequence of breast reconstruction with reported incidence of 10% to 15%. Current clinical method of assessing breast skin flap perfusion includes combination of skin color, temperature, dermal edge bleeding, and capillary refill. Given the high incidence of ischemia and the presence of certain cohort of patient with greater risk, there is a need for an objective method of assessing the skin flap perfusion. Near infrared fluorescence imaging using indocyanine green is a new technique of assessing skin flap perfusion. We present a first reported case where breast skin flap ischemia was objectively identified intraoperatively by NIRF imaging, and this ischemia was reversed through active intra- and postoperative measures, which was objectively again identified by NIRF imaging. Case presentation: A 36-year-old female patient underwent bilateral nipple sparing mastectomies with immediate reconstruction using tissue expanders. Clinical assessment of the breast skin flap was equivocal. NIRF imaging using SPY imaging system (Novadaq Technologies Inc, Toronto, ON, Canada) showed poor perfusion in the periareolar region. As a result, it was decided to completely deflate the expander, actively warm the skin flap and encourage cutaneous perfusion through use of topical glycerin trinitrate patch. A repeat NIRF imaging 48 hours showed 10-fold increase in perfusion in the skin flap. Conclusion: NIRF imaging is a useful tool in assessing breast skin perfusion and to predict potential ischemia, which can aid in surgeon's management of patient.

Near Infrared Fluorescence Imaging to Assess Breast Flap Perfusion and Prevention of Ischemia: Case Report