Prediction of post-operative necrosis after mastectomy: A pilot study utilizing optical diffusion imaging spectroscopy
© Rao et al; licensee BioMed Central Ltd. 2009
Received: 23 September 2009
Accepted: 25 November 2009
Published: 25 November 2009
Flap necrosis and epidermolysis occurs in 18-30% of all mastectomies. Complications may be prevented by intra-operative detection of ischemia. Currently, no technique enables quantitative valuation of mastectomy skin perfusion. Optical Diffusion Imaging Spectroscopy (ViOptix T.Ox Tissue Oximeter) measures the ratio of oxyhemoglobin to deoxyhemoglobin over a 1 × 1 cm area to obtain a non-invasive measurement of perfusion (StO2).
This study evaluates the ability of ViOptix T.Ox Tissue Oximeter to predict mastectomy flap necrosis. StO2 measurements were taken at five points before and at completion of dissection in 10 patients. Data collected included: demographics, tumor size, flap length/thickness, co-morbidities, procedure length, and wound complications.
One patient experienced mastectomy skin flap necrosis. Five patients underwent immediate reconstruction, including the patient with necrosis. Statistically significant factors contributing to necrosis included reduction in medial flap StO2 (p = 0.0189), reduction in inferior flap StO2 (p = 0.003), and flap length (p = 0.009).
StO2 reductions may be utilized to identify impaired perfusion in mastectomy skin flaps.
In this pilot study of ten patients, increased mastectomy flap length, a significant drop in medial and inferior StO2 measurements by Optical Diffusion Imaging Spectroscopy (ViOptix T.Ox Tissue Oximeter) intra-operatively predicted post-operative mastectomy skin flap necrosis.
Breast cancer is diagnosed in approximately 200,000 women in the United States every year. Surgical treatment for breast cancer involves either breast conserving surgery (BCT) or total mastectomy. Although recent studies  indicate that the majority of patients diagnosed with breast cancer receive BCT, 33% of patients continue to undergo mastectomy . There also appears to be a significant improvement in the utilization of post-mastectomy reconstruction across the country . Although the benefits of immediate reconstruction after mastectomy are well-documented , it has also been demonstrated that immediate reconstruction does increase the rate of post-operative wound complications . Wound complications following mastectomy are estimated to be between 18-30% [5, 6]. Common complications include partial flap necrosis, epidermolysis and eschar formation.
Overall cosmetic outcome is highly dependent on the viability of mastectomy skin flaps. There is currently no accepted standard for evaluating skin flaps in the intra-operative setting. Techniques which are utilized include the injection of fluorescein, evaluation of "bleeding edges", and subjective assessment of capillary refill. Near Infrared Spectroscopy is a non-invasive method used to monitor blood perfusion to skin flaps. The unit of measurement is StO2. This is a measurement of the ratio of oxyhemoglobin (HgbO2) and deoxyhemoglobin (Hgb) in order to obtain noninvasive, real-time measurement of tissue pO2. This technique has previously been validated and is commonly used by plastic and reconstructive surgeons to assess the perfusion and viability of donor digital implants and microsurgical free tissue transfers [7–9]. The current pilot study evaluates the ability of near infrared spectroscopy to predict post-mastectomy skin flap necrosis in 10 patients.
Approval for the protocol was obtained from the Institutional Review Board at the University of Texas Southwestern Medical Center. Ten patients undergoing mastectomy at a single institution were selected for the study. Data recorded included patient age, height/weight, co-morbidities, smoking history, medical history, tumor size, pathology and stage.
The ViOptix T.Ox Tissue Oximeter Tissue Oximeter® made by ViOptix, Inc. (Fremont, CA) was used to obtain tissue oxygen saturation (StO2) measurements. Near-infrared lights of 690-nm and 830-nm wavelengths are emitted at a scan rate of up to 40 Hz and are transmitted to the tissue through a special quartz fiberglass cable. The light is absorbed, scattered, and reflected in the layers of the tissue up to 10 mm deep, including the capillary loops and dermal plexus. The light is absorbed by biological compounds known as chromophores, whose absorption properties are oxygen-dependent. Common chromophores include hemoglobin, myoglobin, and cytochrome c oxidase. The volume of tissue under investigation is determined by the depth of near infrared light penetration (10 mm). The amount of light recovered from tissues is dependent on the intensity of incident light, separation of the optodes, degree of light scattering in tissues, and amount of absorption by chromophores. Since the intensity, distance between the optodes and light scattering are controlled, the changes in recovered light can be attributed to the variation in the concentration of chromophores. The recovered light is then processed by an integrated computer performing a fingerprint analysis of the spectral data. The data is then displayed in real-time, numerically, on a monitor.
Flap thickness was measured by allowing the skin to lie in a neutral position against the chest wall and then utilizing an intra-operative ruler to measure the skin flap at its most distal aspect. Flap length was defined as the superior flap length, this area was measured since this is typically the longest flap in a mastectomy. It was measured by allowing all skin to lie in a neutral position and measuring the distance, in cm, from the edge of the superior portion of the incision at the 12 o'clock position to the clavicle, care was taken to ensure that a straight line was maintained during this measurement. All complications were noted; presence and total area of epidermolysis was noted and recorded. Patients were followed for four weeks post-operatively to estimate the area of necrosis, evaluate for wound infection, and seroma formation. De-identified data was entered into a Microsoft Excel® database. Statistical analysis was performed using Wilcoxon Rank Sum test and Student's t-test.
Analysis of patients with and without necrosis
Flap Length (cm)
Thickness of flap (mm)
Pre-operative Tissue Oxygenation (StO2)
Post-operative Tissue Oxygenation (StO2)
Changes in Tissue Oxygenation
StO2 percent change (absolute StO2 change)
Body Mass Index (BMI)
Clinical T Size
Radiation to Chest Wall
One commonly used tool to evaluate mastectomy flap viability intra-operatively is the intravenous sodium fluorescein test (Wood's lamp method). This involves intravenous injection of fluorescein followed by intra-operative evaluation with a Wood's lamp. Although it has been available since 1931, its application is prone to subjective errors, and is limited to over/under reading by as much as 30% . It is also a test of vascularity - not viability, and subject to changes in vascularity such as vasospasm, intravascular clotting, or alterations in the distribution of the microcirculation. Alternatively the use of infrared spectroscopy takes into account metabolic changes of the dissected tissue, and potentially allows trends to be followed for flap evaluation post-operatively.
The arterial supply of the breast is generally defined as an anastomotic plexus of vessels originating from the axillary artery, the internal mammary artery, the intercostal arteries, and lateral thoracic artery. The contribution of each individual artery and the consequences of vascular interruption are poorly understood, but the course of the nerves and vessels may be related to the ligamentous apparatus . One such horizontal ligamentous suspension originates from the pectoral fascia along the 5th rib . Our finding that the decrease in perfusion from the inferior portion of the breast most accurately predicted post-operative epidermolysis may be supportive of this finding.
In addition, there currently does not exist any standardized method for measuring mastectomy skin flap thickness during an operation, further refinements in this technique-i.e. the use of calipers, may be helpful for future trials.
Traditionally, surgeons are careful to avoid transection of medial perforators. Consistent with this, our data demonstrate an increased likelihood of necrosis in the patient who had a significant decrease in medial StO2 measurements. This may be particularly important in those patients who undergo disruption of the medial perforators secondary to internal mammary node dissection.
There are significant limitations to this study. Most notable is the small sample size. Contributions from underlying co-morbidities (coronary artery disease, diabetes) may be more readily apparent with a larger sample size. In addition, this study population was predominately a minority population; there is an under-representation of Caucasian patients. Although the ViOptix T.Ox Tissue Oximeter system has been validated in several racial groups, there may be variability in StO2 measurements between races which can only be further elucidated with a large sample size. For further studies, assuming a 10% necrosis rate, a sample of 40 patients will provide more than 90% power to detect a two standard deviation difference of the mean StO2 measures (significance level is held at 0.05, two sided). Clearly a group of patients undergoing skin-sparing mastectomy with immediate reconstruction would provide the most useful clinical information as these patients are more likely to have difficulties with wound healing and face the greatest consequences (implant extrusion, flap failure) from poor wound healing.
It is known that the perfusion to the subdermal plexus of the skin is controlled by the autonomic nervous system in response to variations in metabolic demands and environment. All patients in this study were stable intra-operatively. However, the actual oxygen saturation and blood pressure measurements at the time of StO2 measurement were not evaluated, the influence of these factors will be examined in future studies. The patient with necrosis had drops in StO2 measurement, which also may be an indicator of failure to compensate for injury, whereas the patients who did not have necrosis, for the most part, had increased StO2 levels after dissection, potentially indicating an ability to increase perfusion appropriately to the area of injury.
Similarly, wound healing is a complicated process. Factors contributing to or complicating the wound healing process include body habitus, age, co-morbidities, prolonged operative time, collagen disorders, infection, history of radiation exposure, immune status, and steroid use [13–15].
Lastly, a review of the patient response to the ViOptix T.Ox Tissue Oximeter system indicates that the patient having necrosis also had a longer flap length. This would appear to be consistent with the concept that the blood supply of longer flaps is more tenuous, likely due to the greater area of vascular disruption required when a mastectomy is performed.
Commonly used intraoperative methods to determine flap viability include detection of skin discoloration, wound edge bleeding and intra-operative assessment with fluorescein and a Wood's Lamp. The use of near-infrared reflection spectroscopy to monitor myocutaneous flaps has been previously validated in humans . Our study indicates that ViOptix T.Ox Tissue Oximeter is a non-invasive method which may be utilized to identify impaired perfusion in mastectomy skin flaps. It could potentially add valuable information to clinical observation, and may be able to detect early vascular complications. Areas which demonstrate sub-optimal perfusion can therefore be excised intra-operatively to potentially decrease wound complications and improve cosmetic outcome, alternatively, reconstruction may also be postponed until a later date or potentially an autologous reconstruction may be considered. Further studies are planned with a larger sample size for validation, and to establish standards.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-In-Chief of this journal.
The authors are grateful to the invaluable assistance of our colleagues: William Brooks MD, Fiemu Nwariaku MD, Lisa Lilley NP, William Lodrigues NP, Victoria Warren RN, and Fatemah Youssefi PhD.
Presented at the 24th Annual Miami Breast Cancer Conference, February 21st-24th, 2007. Miami, FL.
Presented at the 9th Annual University of Texas Southwestern Department of Surgery Surgical Research Forum, June 6, 2007. Dallas, TX.
- Malin JL, Schneider EC, Epstein AM, Adams J, Emanuel EJ, Kahn KL: Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States?. J Clin Oncol. 2006, 24: 626-634. 10.1200/JCO.2005.03.3365.View ArticlePubMedGoogle Scholar
- Christian CK, Niland J, Edge SB, Ottesen RA, Hughes ME, Theriault R, Wilson J, Hergrueter CA, Weeks JC: A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg. 2006, 243: 241-249. 10.1097/01.sla.0000197738.63512.23.PubMed CentralView ArticlePubMedGoogle Scholar
- Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA: Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. 2000, 92: 1422-1429. 10.1093/jnci/92.17.1422.View ArticlePubMedGoogle Scholar
- Mortenson MM, Schneider PD, Khatri VP, Stevenson TR, Whetzel TP, Sommerhaug EJ, Goodnight JE, Bold RJ: Immediate breast reconstruction after mastectomy increases wound complications: however, initiation of adjuvant chemotherapy is not delayed. Arch Surg. 2004, 139: 988-991. 10.1001/archsurg.139.9.988.View ArticlePubMedGoogle Scholar
- Margulies AG, Hochberg J, Kepple J, Henry-Tillman RS, Westbrook K, Klimberg VS: Total skin-sparing mastectomy without preservation of the nipple-areola complex. Am J Surg. 2005, 190: 907-912. 10.1016/j.amjsurg.2005.08.019.View ArticlePubMedGoogle Scholar
- Garwood ER, Moore D, Ewing C, Hwang ES, Alvarado M, Foster RD, Esserman LJ: Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann Surg. 2009, 249: 26-32. 10.1097/SLA.0b013e31818e41a7.View ArticlePubMedGoogle Scholar
- Scheufler O, Exner K, Andresen R: Investigation of TRAM flap oxygenation and perfusion by near-infrared reflection spectroscopy and color-coded duplex sonography. Plast Reconstr Surg. 2004, 113: 141-152. 10.1097/01.PRS.0000095940.96294.A5. discussion 153-145View ArticlePubMedGoogle Scholar
- Stranc MF, Sowa MG, Abdulrauf B, Mantsch HH: Assessment of tissue viability using near-infrared spectroscopy. Br J Plast Surg. 1998, 51: 210-217. 10.1054/bjps.1997.0088.View ArticlePubMedGoogle Scholar
- Mancini DM, Bolinger L, Li H, Kendrick K, Chance B, Wilson JR: Validation of near-infrared spectroscopy in humans. J Appl Physiol. 1994, 77: 2740-2747.PubMedGoogle Scholar
- Myers B, Donovan W: An evaluation of eight methods of using fluorescein to predict the viability of skin flaps in the pig. Plast Reconstr Surg. 1985, 75: 245-250. 10.1097/00006534-198502000-00017.View ArticlePubMedGoogle Scholar
- Wuringer E, Mader N, Posch E, Holle J: Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg. 1998, 101: 1486-1493. 10.1097/00006534-199805000-00009.View ArticlePubMedGoogle Scholar
- Wueringer E, Tschabitscher M: New aspects of the topographical anatomy of the mammary gland regarding its neurovascular supply along a regular ligamentous suspension. Eur J Morphol. 2002, 40: 181-189. 10.1076/ejom.184.108.40.20688.View ArticlePubMedGoogle Scholar
- Cruse PJ, Foord R: A five-year prospective study of 23,649 surgical wounds. Arch Surg. 1973, 107: 206-210.View ArticlePubMedGoogle Scholar
- Cruse PJ, Foord R: The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980, 60: 27-40.PubMedGoogle Scholar
- Nandi PL, Soundara Rajan S, Mak KC, Chan SC, So YP: Surgical wound infection. Hong Kong Med J. 1999, 5: 82-86.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.