Photodiagnosis and Photodynamic Therapy 35 (2021) 102401

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Photodiagnosis and Photodynamic Therapy

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Study of the protocol used to evaluate skin-flap perfusion in mastectomy

based on the characteristics of indocyanine green
Ayumi Ogawa a, Tsuyoshi Nakagawa a, *, Goshi Oda a, Tokuko Hosoya a, Kumiko Hayashi a,
Maho Yoshino a, Hiroki Mori b, Noriko Uemura b, Tomoyuki Fujioka c, Mio Mori c,
Iichiroh Onishi d, Kimihiro Igari e, Hiroyuki Uetake e
a
Department of Breast Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
b
Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
c
Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
d
Department of Pathology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
e
Department of Specialized Surgeries, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo,
Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Indocyanine green angiography enables real-time visualization of blood vessels at depths of up to
Mastectomy 10 mm beneath the body surface, thereby aiding the evaluation of the viability of skin flaps and predicting
Skin-flap necrosis in surgical fields requiring good tissue perfusion. Although skin-flap necrosis also occurs in mastectomy
Perfusion
without reconstruction, most studies have focused on reconstructive plastic surgery. Several patients undergoing
Indocyanine green
mastectomy are eligible for postoperative adjuvant therapy, but complications can lead to delays in treatment
Breast
Reconstruction and thus require prevention. However, a lack of a standard protocol for evaluating skin-flap perfusion using
indocyanine green necessitates the study of its characteristics to facilitate comparison of the perfusion rate
among individuals.
Methods: This retrospective study focused on the characteristics of indocyanine green and established a
protocol for indocyanine green angiography using laser-assisted imaging (SPY system) to predict postoperative
skin-flap necrosis from intraoperative images of 30 patients who underwent mastectomy without reconstruction.
Results: Our protocol predicted postoperative skin-flap necrosis as follows. First, the intravenous dose and
concentration were set at 2.5 mg/mL and 0.05 mg/kg, respectively. Second, the timing of measurement was set
to 100 s after the entry of indocyanine green into the skin (plateau phase); the analysis pattern was set to single
frame. Third, comparisons among individuals were made using relative values.
Conclusions: We analyzed the area of postoperative flap necrosis using this protocol. We found that the
intraoperative images showed decreased perfusion in that area, which was useful in predicting skin-flap necrosis,
as reported by previous breast reconstruction studies.

1. Introduction
Mastectomy is considered a safe surgical procedure with relatively
few fatal complications; this is because the surgical field is close to the
body surface. The level of surgical invasion is low, and the patient can be
discharged soon after surgery [1]. In 2004, Yamauchi et al. reported
complications in 2023 mastectomies: postoperative bleeding in 44 cases
(2%), seroma in 196 cases (10%), and skin-flap necrosis in 24 cases (1%)
[2]. Several studies have reported on the prevention of seroma to date
[3]. On the other hand, most previous studies on skin-flap necrosis in
breast surgery have been from plastic surgeons [4-15].
No study has focused on preventing skin-flap necrosis, including
wound necrosis, after mastectomy without reconstruction. Moreover,
the thin-layer skin flaps that prioritize oncological safety have the po­
tential to cause necrosis, thereby resulting in the need to prevent skin-
flap necrosis at the time of mastectomy [16]. Several patients who
require mastectomy have large tumors that often require adjuvant
therapy after surgery [17]. Therefore, it is important to prevent skin-flap

* Corresponding author.
E-mail address: nakagawa.srg2@tmd.ac.jp (T. Nakagawa).

https://doi.org/10.1016/j.pdpdt.2021.102401
Received 24 March 2021; Received in revised form 15 May 2021; Accepted 8 June 2021
Available online 11 June 2021
1572-1000/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Ogawa et al.
necrosis because it delays other postoperative treatments. Tissue hypo­
perfusion is one of the mechanisms underlying necrosis [18], irre­
spective of the surgical technique used or organ involved. Indocyanine
green can help visualize blood flow and prevent skin-flap necrosis.
Indocyanine green has been prominently used to test liver function
for 50 years [19]. Moreover, in recent years, indocyanine green fluo­
rescence [20] has been used in clinical applications in surgical imaging
based on a technique that detects the fluorescence produced by
near-infrared light illuminating the indocyanine green bound to plasma
proteins [21, 22]. Indocyanine green fluorescence depicts blood vessels
and lymphatic vessels at depths of up to 10 mm below the body’s surface
in real-time. Therefore, indocyanine green fluorescence can aid surgical
decision-making and prevent complications in surgical fields where
good tissue perfusion is required.
In 2010, Komorowska-Timek et al. reported that indocyanine green
angiography in breast reconstruction, including tissue expander and
autologous tissue reconstruction, reduced the incidence rate of mas­
tectomy flap necrosis and partial necrosis of autologous tissue from
15.1% to 4% [4].
Consequently, the usefulness of indocyanine green for the assess­
ment of skin-flap perfusion and prediction of flap viability in the field of
breast reconstruction has been widely reported. One of the reasons for
this is the improvement in the laser-assisted indocyanine green imaging
system. The SPY Fluorescence Imaging System (SPY system, Novadaq
Technologies) used in numerous facilities possesses a built-in quantifi­
cation software known as SPY-Q, which can quantify the imaging data
captured by the near-infrared camera. This evolution has led to multiple
studies that evaluated and compared the perfusion value among in­
dividuals. A systematic review conducted by Driessen et al. in 2020
reported that indocyanine green-based imaging was a promising method
for assessing skin perfusion [15]. Moreover, the SPY devices have been
used to predict flap necrosis [4-9, 14] and establish cut-off values [6, 9,
14].
However, based on studies from several facilities, a negative view of
this method has emerged. In 2018, Chattha et al. reported that 3% of
breast reconstructions were assessed for skin-flap perfusion using
indocyanine green; they observed a gradual increase in the number of
patients who underwent indocyanine green imaging every year, but
with a corresponding increase in unnecessary debridement procedures
[13]. Mattison et al. were similarly concerned about overestimating the
area of necrosis and did not recommend its use in patients at low risk for
necrosis [11]. Both studies attempted to establish the cut-off values
required to predict the area of potential intraoperative necrosis in real
time, but they failed to attain consensus for clinical application.
Therefore, the problem with indocyanine green angiography is the
lack of an established protocol. To obtain good fluorescence images and
facilitate analysis and comparison among individuals, it is important to
understand the light absorption and scattering characteristics of indoc­
yanine green in vivo. For example, the indocyanine green concentration
and fluorescence intensity are not always commensurate with each
other. Indocyanine green fluorescence intensity varies greatly depend­
ing on the measurement environment, such as the surrounding bright­
ness and the distance between the target and light source [23].
We believe that accurate evaluation cannot be performed unless a
protocol is established based on the understanding of the characteristics
of indocyanine green [24]. To date, few studies have focused on the
characteristics of indocyanine green to establish their protocols. More­
over, no studies have described the three image evaluation modes of
SPY-Q: single frame, average, and max.
We think that skin-flap necrosis in breast reconstruction essentially
differs from that in simple mastectomy in terms of skin tension and
vascular regeneration because breast reconstruction involves inserting
artificial or autologous tissue under the skin or pectoral muscle. Hence,
it is worthwhile to make a new assessment of blood flow in total mas­
tectomies without reconstruction. We first measured skin-flap perfusion
for total mastectomies without reconstruction according to our protocol.
2
Photodiagnosis and Photodynamic Therapy 35 (2021) 102401
The data were quantitatively evaluated by SPY-Q to determine whether
postoperative flap necrosis could be predicted from the intraoperative
images.
2. Materials and methods
The participants were 30 patients diagnosed with breast cancer be­
tween October 2019 and July 2020 at Tokyo Medical and Dental Uni­
versity Hospital. The patients underwent mastectomy, mastectomy plus
sentinel node biopsy, mastectomy plus additional axillary node dissec­
tion due to positive for sentinel node biopsy, or mastectomy plus axillary
node dissection, without tissue expander insertion and simultaneous
breast reconstruction. One of the six members of the breast surgery
department performed the surgery. Our department’s policy is to always
include the skin directly above the tumor in the area to be resected. The
evaluation of skin-flap perfusion was performed once per patient; only
one measurement was performed per side, even in patients with bilateral
breast cancer. Patients allergic to iodine were excluded because indoc­
yanine green contains iodine. All patients provided full informed con­
sent, and the study was approved by the university’s ethics committee
(ID:MD2020–190).
The following is the indocyanine green protocol used in our
department.
2.1. Measurement methods
2.1.1. Establishing the observation environment
Areas with clinically obvious poor perfusion and potential for ne­
crosis were excised before observation at the surgeon’s discretion. Ob­
servations were made after breast tissue excision and insertion of
drainage and at the time of completion of the dermal sutures but not the
subcutaneous sutures. The operative field was observed using the SPY
Fluorescence Imaging System SP3000 (Novadaq Technologies). Images
acquired using the near-infrared observation camera, which is fixed to a
movable arm, were stored in the system and could be analyzed using the
on-board SPY-Q. During the observation, the room’s lights were
switched on, and only the surgical lights were switched off. The imaging
head was fixed parallel to the chest wall and 30 cm away from the body
to observe an area measuring approximately 12 × 18 cm.
2.1.2. Preparation for indocyanine green administration
The solution was prepared by dissolving 25 mg of powdered indoc­
yanine green dye in 10 mL of distilled water at a 2.5 mg/mL concen­
tration. Indocyanine green 0.05 mg/kg of body weight was injected
through a peripheral vein, and the rate of administration was kept
constant by boosting with 20 mL of saline. Unless there were specific
contraindications, all drugs were administered through a peripheral
vein in the forearm contralateral to the breast being observed.
2.2. SPY-Q evaluation methods
The wound was observed with the near-infrared camera for
approximately 2 min after intravenous injection of indocyanine green.
The assessment of perfusion was performed retrospectively using the
stored images. The black and white videos stored in SPY-Q can be used
to visualize the perfusion in color at a specified time. The evaluation was
performed using images observed 100 s after the indocyanine green
reached the skin within the observation area in a single frame. Indoc­
yanine green timing reaching the skin was determined by the rise of the
fluorescence curve, which is described later in the results.
We designated a point on the caudal side of the wound, where there
was no clinically apparent surgical invasion, as the healthy area. The
fluorescence luminance of the healthy area was designated as 100
(reference value), and the perfusion value of any part within the
observation range was denoted as a relative value and compared among
individuals.
A. Ogawa et al. Photodiagnosis and Photodynamic Therapy 35 (2021) 102401

2.3. Necrosis definitions and comparison Table 1

Details of the patient factors.
The drains were removed when the drainage was less than 30 ml/day Value (%) Value (%)
or on postoperative day 14, even if the drainage did not decrease. The Patient factor cM
day after the drain was removed, the patient was discharged. The pa­ Age, years 61.0 M0 28 (93)
Average (SD) 13.4 M1 2 (7)
tient’s skin was evaluated every day during hospitalization and at the
Range 30–83 Operation type
first outpatient visit within one week of discharge. No postoperative BMI, kg/m2 24.4 Bt 4 (13)
prophylactic antibiotics were administered unless infection was Average (SD) 4.6 Bt+SNB (-) 14 (47)
suspected. Range 14.2–37.3 Bt+SNB(+)→axe 4 (13)
Skin-flap necrosis is defined as clinically apparent poor skin tone Patient characteristics, no. of breasts (%) Bt+axe 8 (27)
Total number of breasts 30 Previous treatment
around the wound. It encompasses various conditions ranging from
cT Chemotherapy 4 (13)
wound edge necrosis to relatively large areas of necrosis requiring Tis 4 (13) Endocrine therapy 2 * (7)
topical medications or debridement. The results were compared by T1 8 (27) Underlying comorbidities
dividing the patients into two groups: those with skin-flap necrosis, T2 15 (50) Obesity (BMI≥25) 11 (37)
T3 0 (0) Smoking 8 (27)
including wound margin necrosis (necrosis group), and those who
T4 3 (10) Hypertension 13 (43)
showed good healing without necrosis (non-necrosis group). cN Diabetes mellitus 4 (13)
The postoperative course of the two groups was compared using the N0 20 (67)
SPY-Q images obtained intraoperatively. N1 8 (27)
N2 0 (0)
N3 2 (7)
3. Results
The stage of breast cancer: Tumor size (cT); Tis, ductal carcinoma in situ (DCIS);
All patients included in this study were Japanese women. There were T1, ≤20 mm; T2, >20 to 50 mm; T3, >50 mm; T4, with skin invasion; regional
no cases of suspected side-effects of indocyanine green. The mean pa­ lymph nodes (cN); N0, no lymph node metastasis; N1, axillary lymph node
metastasis; N2, including endothoracic lymph node metastasis; N3, including
tient age was 61.0 years (SD: 13.4, range: 30 to 83 years), and the stage
supraclavicular lymph node metastasis; distant metastasis (cM); M0, no distant
of breast cancer in the study population ranged from ductal carcinoma in
metastasis; M1, with distant metastasis.
situ to axillary lymph node metastasis with skin invasion and/or distant Operation type: Bt, mastectomy; Bt+SNB(-), mastectomy and sentinel node bi­
metastasis. The mean body mass index was 24.4 kg/m2 (SD: 4.6, range opsy; Bt+SNB(+)→axe, mastectomy and sentinel node biopsy with axillary
14.2 to 37.3 kg/m2). Four patients underwent mastectomy, 14 patients lymph node dissection due to positive metastasis; Bt+axe, mastectomy with
underwent mastectomy and sentinel node biopsy, 4 patients underwent axillary lymph node dissection planned in advance.
mastectomy and sentinel node biopsy with axillary lymph node dissec­ * The patient who underwent preoperative endocrine therapy experienced
tion due to positive metastasis, and 8 patients underwent mastectomy recurrence after partial mastectomy and radiation.
with axillary lymph node dissection planned. Four patients had under­ BMI: body mass index.
gone chemotherapy preoperatively, 2 patients underwent preoperative
endocrine therapy, including one patient who experienced recurrence luminance (arterial phase), and once the peak was reached (same time-
after partial mastectomy and radiation. Eight patients were current or phase as Fig. 2d), it gradually descended (venous phase) to a plateau
former smokers, 13 patients had been diagnosed with hypertension, and (same time-phase as Fig. 2f).
four were currently taking medication for diabetes (Table 1). Patient 2 is a representative case from the necrosis group. She was a
Skin-flap necrosis was observed in only 5 of the 30 cases, including 4 57-year-old woman who had left breast cancer, axillary lymph node
cases that required topical medication, debridement, and re-suturing, metastasis, and liver metastasis. After chemotherapy (pertuzumab,
and 1 case with wound crusting, which improved with follow-up only. trastuzumab, and docetaxel), the primary tumor decreased in size,
Univariate analysis of patients’ background characteristics in necrosis lymph node metastasis and liver metastasis disappeared, and mastec­
and non-necrosis groups revealed significant differences in obesity tomy was performed for local control. The tumor was located in the
(body mass index ≥25 kg/m2) (p = 0.047) and weight of the resected lower inner quadrant of the breast. The skin incision included the skin
specimens (483.6 g versus 929.2 g, p<0.01). directly above the tumor (Fig. 4a). Fig. 4b depicts a photograph of the
Patient 1 is a representative case from the non-necrosis group. She flap perfusion measurement. Ulceration was observed on the cephalic
was a 50-year-old woman who underwent mastectomy for a 5-cm large side of the wound on postoperative day 6 (Fig. 4c), which was treated
tumor in the inner area of the left breast. The mammary gland was with the application of a topical (ointment) medication. The extent of
dissected along the incision line, which was determined preoperatively necrosis was determined on postoperative day 10 (Fig. 4d). Debridement
(Fig. 1a). Indocyanine green was administered intravenously after was performed at the first outpatient visit after discharge.
completing the dermal sutures and before the subcutaneous sutures All measurements were performed before placing the subcutaneous
(Fig. 1b). The indocyanine green reached the observation area within sutures so that the area of poor perfusion could be excised depending on
approximately 5 to 30 s after the saline flush. Blood flow from the sternal the SPY results. However, none of the cases required intraoperative
side was observed first through the near-infrared camera (Fig. 2a), fol­ debridement. SPY-Q analysis showed good cephalic and caudal blood
lowed by blood flow from the cephalic and caudal aspects of the wound flow in the single frame/plateau phase in patient 1, and the relative
(Fig. 2b). Subsequently, the blood flow was observed from the axillary value was greater than 75% in most regions (Fig. 5a, 5b). On the other
direction (Fig. 2c), and the fluorescence intensity within the observation hand, in the single frame/plateau phase, the flap perfusion on the ce­
area reached its highest value (peak) during the observation time phalic side was clearly lower than that on the caudal side in patient 2. An
(Fig. 2d). After reaching the peak, the indocyanine green dye washed out area with a relative value of less than 12.5% was observed along the
slowly (Fig. 2e) and plateaued (Fig. 2f). A similar blood flow pattern was cephalic edge of the wound. The areas with a relative value below 12.5%
observed in most cases. corresponded roughly to the necrotic areas (Fig. 6a, 6b). The lowest
In all cases, the skin within the observation area was depicted rela­ perfusion rate within the observation range was 10% (Fig. 6c).
tively uniformly within the observation time. The fluorescence lumi­ The lowest relative rates for the necrosis group were all observed
nance curve seen in patient 1 was typical and was similar to that in most within the necrotic region, with a mean of 11.2%. The mean of the
cases (Fig. 3). Fig. 3 shows the fluorescence intensity over the entire lowest relative rates for the non-necrosis group was 27.6%, and the
observation area for approximately 130 s after the intravenous admin­ difference between the necrosis and non-necrosis groups was statisti­
istration of indocyanine green. First, there was a rapid increase in cally significant (p = 0.014).

3
A. Ogawa et al.
4. Discussion
To the best of our knowledge, this protocol is the first to consider
indocyanine green and the performance of SPY-Q characteristics and the
first report of a mastectomy without reconstruction in which skin
perfusion was measured.
There have been several attempts to quantitatively evaluate skin-flap
perfusion using the SPY system, especially in the area of breast recon­
struction [10]. We extracted papers that reported quantitatively
assessed skin-flap perfusion in breast reconstruction using indocyanine
green between 2010 and 2020, published in Open Access, and for which
the full text was available (Table 2) [5-7, 9, 12, 14]. All these studies
included patients undergoing breast reconstruction. However, each
study employed unique and unsubstantiated methods of reconstruction
and measurement, which rendered comparisons among individuals and
4
Photodiagnosis and Photodynamic Therapy 35 (2021) 102401
Fig. 1. Representative case from the non-
necrosis group (patient 1)
A 50-year-old woman underwent mastectomy
for a 5-cm breast tumor in the inner area
(within the dotted line). The mammary gland
was dissected along the incision line, as deter­
mined preoperatively (1a). The photograph was
obtained when indocyanine green was admin­
istered intravenously after completing the
dermal sutures and before placing the subcu­
taneous sutures (1b).
Fig. 2. Entry of indocyanine green into the skin
of the observation area over time in patient 1
Blood flow from the sternal side (*) was
observed first (2a), followed by blood flow from
the cephalad and caudal sides (arrows) of the
wound (2b). Thereafter, blood flow from the
axillary direction (within the dotted line) was
observed (2c), and the fluorescence intensity
within the observation area reached its highest
value during the observation time (peak) (2d).
After reaching the peak, indocyanine green was
slowly expelled (2e) and the fluorescence in­
tensity reached a plateau (2f).
institutions difficult. Hence, to evaluate skin-flap perfusion accurately, it
was first necessary to define the imaging protocol. In establishing the
protocol, we considered three factors related to the characteristics of
indocyanine green and the performance of SPY-Q.
1) Indocyanine green concentration and dosage
In general, the luminescence of a fluorescent material depends on the
solute concentration. The intensity of luminescence increases as the
solute concentration increases at low concentrations. As the solute
concentration increases, the luminescence reaches a maximum value,
and then, a decrease in luminescence called the “quenching phenome­
non” is often observed [25]. In other words, it is important to note that a
highly concentrated solution that seems to give good results may
decrease luminescence. Therefore, Table 2 shows that many facilities set
the concentration at 2.5 mg/ml, and we referred to them. Moreover, if
the dose of indocyanine green is equal for all patients, it will be affected
A. Ogawa et al.
Fig. 3. Fluorescence curve for patient 1
First, there is a rapid increase in luminance (arterial phase), and once the peak is reached (same time-phase as Fig. 2d), it gradually descends (venous phase) to a
plateau (same time-phase as Fig. 2f).
by the amount of circulating plasma because it binds rapidly to plasma
proteins [22].
Previous studies (Table 2) administered indocyanine green at con­
centrations of 2.5 mg/mL, 5 mg/mL, or 12.5 mg/mL. The dose was in­
dependent of the body weight, and the total amount administered
ranged from 10 to 25 mg, which is higher than that used this study.
When we administered 6.25 mg (0.125 mg per body weight) of indoc­
yanine green at a concentration of 2.5 mg/mL in this study, ICG
remained in the entire observation area during the peak and the plateau
phase, making accurate evaluation difficult. When performing an
5
Photodiagnosis and Photodynamic Therapy 35 (2021) 102401
Fig. 4. Photographs of a representative patient
from the necrosis group (patient 2)
A 57-year-old woman underwent mastectomy
for local control of the tumor. The tumor was
located in the lower-inner quadrant of breast
(within the circle). The skin incision was made
such that it included the skin directly above the
tumor (4a). Photograph of the flap perfusion
measurement (4b). Ulceration was observed on
the cephalic side of the wound on postoperative
day 6 (4c). The extent of necrosis was deter­
mined on postoperative day 10 after topical
medication (4d).
anatomical evaluation, such as running blood vessels, a dose of 0.1 mg/
kg or higher is easier to observe. However, when evaluating the relative
luminance of blood flow, a higher dose makes it impossible to evaluate.
Thus, we decided to prepare a 2.5 mg/mL solution of indocyanine green
and administered 0.05 mg/kg of body weight dose.
Since cardiac function also affects the circulating plasma volume, the
body temperature and blood pressure at the time of measurement under
general anesthesia were examined and controlled at 36–37 ◦ C, while the
systolic blood pressure was maintained at 90–100 mmHg and diastolic
blood pressure at 50–60 mmHg [26].
A. Ogawa et al.
Fig. 5. Analysis using SPY-Q in Patient 1
Both cephalic and caudal blood flow was good in the single frame/plateau phase, and most of the regions were above 75% (within the dotted line) of the relative
perfusion rate (a, b).
Fig. 6. SPY-Q evaluation of Patient 2
The area with a relative perfusion rate of 12.5% or less in the single frame/plateau phase corresponds to the necrotic area at the head of the wound margin (a, b). The
lowest value within the observation range was 10 (c).
Of the six studies described in Table 2, only the one by Moyer et al.
mentioned ethnicity: they reported no significant difference in perfusion
scores between African-American and Caucasian populations [6].
2) Method of acquisition and timing of evaluation
The observation environment influences the light scattering in the
target tissue. Because the wavelengths of the surgical lights and indoc­
yanine green are similar, we turned off only the surgical lights and left
the room lights on during observation to standardize the surrounding
environment. The imaging head was placed parallel to the chest wall
and fixed 30 cm away from the chest wall for imaging. Skin-flap
perfusion can vary greatly depending on the timing of the assessment.
Previous studies have reported two main phases, i.e., around the peak
area (30 or 60 s) and around the plateau area (90 or 120 s) (Table 2).
Moreover, although the SPY-Q quantification software can change the
analysis pattern (such as ① single frame: single luminance analysis at
the specified timing, ② average: the mean luminance up to the specified
timing, and ③ maximum: the maximum luminance value up to the
specified timing), we could not find any studies that described the
analysis patterns. We combined the following “three” different analysis
patterns at “two” points during the observation time to ascertain the
evaluation method that reflected the extent of postoperative skin-flap
6
Photodiagnosis and Photodynamic Therapy 35 (2021) 102401
necrosis most accurately: when the luminance value of the imaging
area was the highest (peak) and 100 s after indocyanine green reached
the skin within the observation area (plateau phase) for a total of “six”
images and a clinical necrosis photograph (Fig. 6a) for comparison
(Fig. 7). As shown in the results, the lowest mean relative rates for the
necrosis group was 11.2%, so we compared the six images using a cut-off
value of 12.5% as a coordinate, as was the closest value shown. Because
regions with a relative perfusion rate of 12.5% or less measured in the
single frame/plateau phase most accurately reflected the necrotic re­
gion, we decided to adopt this evaluation method.
3) Analysis of the captured images
SPY-Q can quantify the perfusion obtained from the images in ab­
solute or relative values. The SPY system can compare the relative
luminance (intensity of fluorescent coloration) of indocyanine green in
any specific area as 100% (reference value). Gorai et al. installed plate-
shaped luminance controls in which ICG was embedded in 16 different
concentrations and measured luminance in a constant environment.
They reported that the variation in the measured intensity among in­
dividuals was large, and it was difficult to predict perfusion using the
absolute value of the intensity [27]. Newman et al. compared the ab­
solute and relative values for the prediction of mastectomy flap necrosis
A. Ogawa et al. Photodiagnosis and Photodynamic Therapy 35 (2021) 102401

Table 2
Summary of clinical studies that quantitatively assessed skin-flap perfusion in breast reconstruction using indocyanine green.
Author Reconstruction Mean Type of Total Indocyanine Indocyanine Timing of Devices Software Analysis Absolute
(Year) Type Number of BMI Mastectomy Green Green Dose Evaluation Pattern value or
Cases (Breasts) Concentration Relative
value
Newman TE (15 cases, 20 25.3 N/A 2.5 mg/mL 10 mg 30 s SPY not SPY-Q Single Relative
[5] breasts) specified Frame
(2010)
Moyer [6] TE (6 cases) LD/TE (6 27.7 SSM 5 mL (? mg/mL) 5 mL (? mg/ 60 s N/A SPY-Q N/A Relative
(2012) cases) TRAM (2 cases) mL)
Phillips TE (32 cases, 51 26.9 mastectomy N/A 17.5 mg 120 s SPY 2001 SPY-Q Single Absolute
[7] breasts) Frame
(2012)
Munabi TE (48 breasts) TRAM N/A Mastectomy 2.5 mg/mL 10 mg 90 s SPY Elite SPY-Q N/A Absolute
[9] (6 breasts) DIEP (6 or SSM or System
(2014) breasts) direct-to- NSM
implant (2 breasts)
Gorai TE (83 breasts, 81 N/A simple ellipse 12.5 mg/mL 25 mg 120 s PDE ROI N/A Relative
[12] cases) incision analysis
(2017) software
Kim [14] TE (5 cases) direct-to- 22.74 NSM 5 mg/mL 15 mg plateau SPY not SPY-Q Single Relative
(2019) implant (25 cases) specified Frame

TE, tissue expander; LD, latissimus dorsi; TRAM, transverse rectus abdominis muscle; DIEP, deep inferior epigastric perforator; SSM, skin-sparing mastectomy; NSM,
nipple-sparing mastectomy; ROI: region of interest; BMI: body mass index.

Fig. 7. Six images with three analysis patterns at two time-points were compared for areas below 12.5% (dotted box)
a, single frame/peak; b, average/peak; c, maximum/peak; d, single frame/plateau phase; e, average/plateau phase; f, maximum/plateau phase
The most accurate representation of the necrotic area (Fig. 6a) was observed during single frame/plateau phase (d).

in clinical practice and reported that the relative values were more
useful [5]. We also examined the use of absolute values and found that
absolute values were extremely low, especially in patients who had
undergone some kind of preoperative treatment, such as radiation or
chemotherapy, even though there was no evidence of necrosis. There­
fore, it was considered necessary to establish relative values to evaluate
the contrast effect quantitatively. We designated a relative value of
100% (reference value) to the clinically normal area without any sur­
gical invasion within the observation area and evaluated the perfusion
value within the observation area.
The persistent problem since the first publication regarding the
evaluation of skin-flap perfusion from the reconstructive breast area is
that this technique relies on the subjectivity of the surgeon. Although a
unified protocol seems to have increased objectivity, subjectivity cannot
be eliminated at the data processing stage. Gorai et al. predicted necrosis
based on the slope of the fluorescence curve to incorporate statistical
evaluation. However, it may not be easy to measure the slope intra­
operatively in actual clinical practice [12]. In the current protocol, a
color image using the single frame/plateau pattern can be displayed
only by pressing a button after observing the blood flow of the flap. We
believe that this method, which is relatively simple to implement and
allows relatively quick and easily interpretable results, is an outstanding
point.
It should be noted that this study used the SP3000 SPY system, which
is a relatively new model. Advancements in the SPY system may have
enhanced the performance of the laser and reduced the amount of
indocyanine green required. Moreover, the participants of this study
were all Japanese women with relatively lower body weight than
Western women (Table 2). A higher indocyanine green dose than that
used in this study may be required to obtain a good image, depending on
the device used and the thickness of the skin. It is also necessary to
change the protocol depending on the target patients, devices, and
software in practice.
As we continue to evaluate more cases with this protocol, we will
likely determine the cut-off value to reduce the frequency of skin-flap
necrosis and prevent unnecessary debridement. We believe that such
studies by breast surgeons will lead to the reevaluation of conventional
techniques and an improvement in the safety of breast surgery. We hope

7
A. Ogawa et al.
that these results will be applied to appropriate surgical techniques and
be useful to both breast and plastic surgeons.
5. Conclusion
This study focused on indocyanine green characteristics, established
a protocol for its angiography, and used laser-assisted indocyanine green
imaging (SPY system) to predict postoperative skin-flap necrosis from
intraoperative images in 30 patients who underwent mastectomy
without reconstruction retrospectively. The results were similar to those
of previous studies in breast reconstruction, showing decreased blood
flow perfusion in the area of necrosis at the time of intraoperative
measurement. Although the recommended protocol differs depending
on the patient’s demographic characteristics and the imaging system
used, we believe that establishing a unique, evidence-based protocol
within each institution will lead to accurate prediction of postoperative
flap necrosis.
Data statement
The data that support the findings of this study are available from the
corresponding author, T. Nakagawa, upon reasonable request.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
We would like to thank Editage (www.editage.jp) for editing this
paper.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.pdpdt.2021.102401.
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