All eight patients underwent NSM. One patient was identified as having severely compromised flaps prior to reconstruction; consequently, immediate reconstruction was deferred in this patient. The remaining seven patients received immediate breast reconstruction using tissue expanders or implants. Tissue expanders were not inflated with saline until after the completion of HBO2 therapy. Breast closure was performed without tension. 

Intraoperative skin flap viability was evaluated by a single reconstructive surgeon using ICGA immediately following mastectomy and reconstruction. For the ICGA procedure, a 5cc bolus of indocyanine green dye was administered through a peripheral intravenous line followed by a 10cc saline flush. A SPY camera (Novadaq Technologies, Inc., Toronto, Canada) was positioned appropriately over the breast so as to include the xiphoid process, and a 120-second video of the infusion was obtained. Still, images were captured at approximately 100 seconds. Perfusion was assessed by comparing the fluorescence of the darkest area of interest to the fluorescence at a control area located over the xiphoid process. The decision to treat the patient with HBO2 was made at the end of each surgery based on the post-closure ICGA fluorescence. In line with the standard of care at our institution, ICGA fluorescence values of ≤20% of the control area indicate tissue at risk for postoperative ischemia (Figure 1a) and prompt a referral for HBO2 treatment. ICGA images were assessed retrospectively using the SPY-Q Analysis Toolkit (Novadaq Technologies, Inc., Toronto) to determine relative perfusion (a percentage of fluorescence compared with the control area) of the at-risk region for pre and post-HBO2 images. ImageJ software (NIH, Bethesda, Maryland) was used to calculate the area (in cm2 ) of the image with <20% relative fluorescence intensity for each breast, also known as the “contour” (Figure 1b) [22].

HBO2 was performed using a monoplane hyperbaric chamber (Perry Baromedical Corp., Riviera Beach, Florida, U.S.) pressurized to a depth of either 2.0 or 2.5 atmospheres absolute (ATA). The treatment depth for each patient was determined by a hyperbaric medicine physician according to the patient’s underlying medical comorbidities. Treatments were administered twice daily on weekdays, and once daily on weekends, for a minimum of 10 treatments per patient. Flap perfusion was assessed using ICGA immediately following the final hyperbaric treatment. 

SAS 9.4 statistical software (SAS Institute, Cary, North Carolina, U.S. ) was used for all statistical analysis.

RESULTS

Demographics and comorbidities of the eight patients included in this study are listed in Table 1. Seven patients received immediate breast reconstruction with tissue expanders or implants prior to referral for HBO2. Breast reconstruction was delayed in one patient due to extensive intraoperative ischemia with resultant necrosis and infection. Seven patients were referred for HBO2 and began treatment within 24 hours of mastectomy. HBO2 was administered at a depth of 2.5 ATA in seven patients, and at 2.0 ATA in one patient due to a history of seizures. There were no adverse events related to HBO2 reported in this patient population.

One patient failed to improve despite starting hyperbaric treatment within 24 hours. Her pre-HBO2 perfusion percentage was 11.7% and increased to 17.1% after completing 17 HBO2 treatments. This patient failed to improve adequately and was returned to the operating room for debridement of the nipple-areola complex. All other patients manifested successful healing of their mastectomy skin flaps with acceptable cosmesis after 10 HBO2 treatments.

Two patients did not complete the post-treatment ICGA and were excluded from the ICGA analysis. However, after completing HBO2 treatment these patients’ breast flaps recovered without requiring additional intervention. The remaining patients mean relative values of perfusion pre- and post-HBO2 are illustrated in Table 2.

DISCUSSION

Early initiation of HBO2 following mastectomy has been shown to improve breast flap survival, thereby reducing the risk of infection, esthetic deformity, and implant extrusion [23-25]. The results of this case series demonstrated a greater than sixfold increase in relative perfusion values between pre-and post-HBO2, indicating the potential of HBO2 to improve flap viability and avoid skin necrosis. 

Although HBO2 is a recognized treatment for compromised skin grafts and flaps, the available evidence for HBO2 therapy to treat mastectomy flap hypoperfusion is limited. Our results suggest that flap salvage can be accomplished with a limited number of HBO2 treatments, especially when patients are referred for HBO2 within 24 hours of mastectomy and reconstruction.

This case series demonstrates that ICGA represents a valuable adjunct for monitoring response in patients receiving HBO2 therapy. Limitations of this case series include a small sample size and the retrospective nature of the study. In this study, patients were referred for HBO2 within 24 hours of mastectomy; as the referral patterns for HBO2 are variable, the results of this study may not be generalizable to all institutions. In addition, ICGA poses additional limitations, as the timing of injection and image capture are operator-dependent. Future studies should explore the utility of ICGA for monitoring the response of HBO2 therapy over the course of the treatment, as this may help identify the point of maximal effect during the HBO2 treatment course.

CONCLUSIONS

In this series of patients with intraoperative identification of mastectomy flap compromise, tissue expander and implant reconstructions were successfully salvaged with a short course of HBO2. ICGA obtained in six patients demonstrated a greater than sixfold increase in relative perfusion values between pre-and post-HBO2, indicating the remarkable capacity of HBO2 therapy to improve flap survival and prevent progression to necrosis. In patients with compromised skin flaps after mastectomy, ICGA can be used to guide and monitor a patient’s response to HBO2 therapy.

Acknowledgments

Novadaq Technologies, Inc., provided the SPY camera and ICGA dye kits used in this study.

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