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The most common complication of autologous breast reconstructions using a deep inferior epigastric artery (DIEP) flap after mastectomy is fat necrosis due to ischemia. DIEP flap perfusion assessment can be optimized by using nearinfrared fluorescence (NIRF) imaging with indocyanine green (ICG). Several studies demonstrated diminished incidence of fat necrosis, partial flap loss and other complications. Studies with large patient numbers and standardized outcomes are lacking. To determine the correlation of incidence of fat necrosis and NIRF imaging with ICG we performed: 1) a review to evaluate relevant literature, and 2) a pilot study of NIRF imaging. With the aim to decide whether a randomized controlled trial (RCT) should be started. Seven studies were included in the review, showing NIRF imaging was feasible and incidence of fat necrosis was diminished. However, most studies were retrospective and with small patient numbers. In the pilot study, 18 flaps, assessed with NIRF imaging were prospectively included and compared to 18 retrospectively included flaps solely assessed based on clinical findings. There were no significant differences in patient and surgery characteristics. Incidence of complications and fat necrosis decreased from 30% to 6% (p-value: 0.07) in the NIRF imaging group. No strong conclusions can be drawn from the pilot study given the low patient number, neither from the reviewed studies. But based on the results a multicenter RCT would be recommended to determine the actual value of NIRF imaging for perfusion assessment of DIEP flaps. An RCT could also aid in wider implementation of this accessible technique in a standardized matter.
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