Review Article| Volume 23, ISSUE 3, P249-254, April 2023

Download started.


Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques

Published:January 03, 2023DOI:


      • Mastectomy skin-flap necrosis (MSFN) after immediate implant-based breast reconstruction represents a dreaded complication, with a reported incidence up to 41%.
      • Preoperative techniques such as mammography, ultrasound, and MRI can provide useful information especially when combined together and compared with intraoperative findings.
      • Indocyanine angiography showed better prediction of MSFN than other intraoperative mastectomy flap assessment, however both thermal imaging and spectroscopy demonstrated novel and promising results.


      Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons’ clinical experience. Even though numerous studies have already addressed the patients’ risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Albornoz CR
        • Cordeiro PG
        • Pusic AL
        • et al.
        Diminishing relative contraindications for immediate breast reconstruction: a multicenter study.
        J Am Coll Surg. 2014; 219: 788-795
        • Panchal H
        • Matros E.
        Current trends in postmastectomy breast reconstruction.
        Plast Reconstr Surg. 2017; 140: 7S-13S
        • Jahkola T
        • Asko-Seljavaara S
        • von Smitten K.
        Immediate breast reconstruction.
        Scand J Surg. 2003; 92: 249-256
        • Antony AK
        • Mehrara BM
        • McCarthy CM
        • et al.
        Salvage of tissue expander in the setting of mastectomy flap necrosis: a 13-year experience using timed excision with continued expansion.
        Plast Reconstr Surg. 2009; 124: 356-363
        • Patel KM
        • Hill LM
        • Gatti ME
        • Nahabedian MY.
        Management of massive mastectomy skin flap necrosis following autologous breast reconstruction.
        Ann Plast Surg. 2012; 69: 139-144
        • 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
        • Matsen CB
        • Mehrara B
        • Eaton A
        • et al.
        Skin flap necrosis after mastectomy with reconstruction: a prospective study.
        Ann Surg Oncol. 2016; 23: 257-264
        • Diep GK
        • Hui JY
        • Marmor S
        • et al.
        Postmastectomy reconstruction outcomes after intraoperative evaluation with indocyanine green angiography versus clinical assessment.
        Ann Surg Oncol. 2016; 23: 4080-4085
        • Peled AW
        • Stover AC
        • Foster RD
        • McGrath MH
        • Hwang ES.
        Long-term reconstructive outcomes after expander-implant breast reconstruction with serious infectious or wound-healing complications.
        Ann Plast Surg. 2012; 68: 369-373
      1. Miller, TJ, GR. Sue and GK. Lee. Mastectomy skin necrosis: risk factors, prevention, and management. 2016.

        • Jallali N
        • Ridha H
        • Butler PE.
        Postoperative monitoring of free flaps in UK plastic surgery units.
        Microsurgery. 2005; 25: 469-472
        • Moyer HR
        • Losken A.
        Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined.
        Plast Reconstr Surg. 2012; 129: 1043-1048
        • Komorowska-Timek E
        • Gurtner GC.
        Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction.
        Plast Reconstr Surg. 2010; 125: 1065-1073
        • Olivier WA
        • Hazen A
        • Levine JP
        • Soltanian H
        • Chung S
        • Gurtner GC.
        Reliable assessment of skin flap viability using orthogonal polarization imaging.
        Plast Reconstr Surg. 2003; 112: 547-555
        • Santanelli F
        • Longo B
        • Sorotos M
        • Farcomeni A
        • Paolini G.
        Flap survival of skin-sparing mastectomy type IV: a retrospective cohort study of 75 consecutive cases.
        Ann Surg Oncol. 2013; 20: 981-989
        • Phillips BT
        • Lanier ST
        • Conkling N
        • et al.
        Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.
        Plast Reconstr Surg. 2012; 129: 778e-788e
        • Robertson SA
        • Jeevaratnam JA
        • Agrawal A
        • Cutress RI.
        Mastectomy skin flap necrosis: challenges and solutions.
        Breast Cancer (Dove Med Press). 2017; 9: 141-152
        • Mlodinow AS
        • Fine NA
        • Khavanin N
        • Kim JY.
        Risk factors for mastectomy flap necrosis following immediate tissue expander breast reconstruction.
        J Plast Surg Hand Surg. 2014; 48: 322-326
        • McCarthy CM
        • Mehrara BJ
        • Riedel E
        • et al.
        Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk.
        Plast Reconstr Surg. 2008; 121: 1886-1892
        • Carlson GW.
        Trends in autologous breast reconstruction.
        Semin Plast Surg. 2004; 18: 79-87
        • Alderman AK
        • Wilkins EG
        • Kim HM
        • Lowery JC.
        Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study.
        Plast Reconstr Surg. 2002; 109: 2265-2274
        • Hultman CS
        • Daiza S.
        Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome.
        Ann Plast Surg. 2003; 50 (discussion 255): 249-255
        • Pinsolle V
        • Grinfeder C
        • Mathoulin-Pelissier S
        • Faucher A.
        Complications analysis of 266 immediate breast reconstructions.
        J Plast Reconstr Aesthet Surg. 2006; 59: 1017-1024
        • Abedi N
        • Ho AL
        • Knox A
        • et al.
        Predictors of mastectomy flap necrosis in patients undergoing immediate breast reconstruction: a review of 718 patients.
        Ann Plast Surg. 2016; 76: 629-634
        • Davies K
        • Allan L
        • Roblin P
        • Ross D
        • Farhadi J.
        Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction.
        Breast. 2011; 20: 21-25
        • Garwood ER
        • Moore D
        • Ewing C
        • et al.
        Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients.
        Ann Surg. 2009; 249: 26-32
        • Chun YS
        • Verma K
        • Rosen H
        • et al.
        Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction.
        Am J Surg. 2011; 201: 160-165
        • Khavanin N
        • Jordan S
        • Lovecchio F
        • Fine NA
        • Kim J.
        Synergistic interactions with a high intraoperative expander fill volume increase the risk for mastectomy flap necrosis.
        J Breast Cancer. 2013; 16: 426-431
        • Habermann EB
        • Abbott A
        • Parsons HM
        • Virnig BA
        • Al-Refaie WB
        • Tuttle TM.
        Are mastectomy rates really increasing in the United States?.
        J Clin Oncol. 2010; 28: 3437-3441
        • Page MJ
        • McKenzie JE
        • Bossuyt PM
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71
        • Rancati AO
        • Angrigiani CH
        • Hammond DC
        • et al.
        Direct to implant reconstruction in nipple sparing mastectomy: patient selection by preoperative digital mammogram.
        Plast Reconstr Surg Glob Open. 2017; 5: e1369
        • Luze H
        • Nischwitz SP
        • Wurzer P
        • et al.
        Assessment of mastectomy skin flaps for immediate reconstruction with implants via thermal imaging-a suitable, personalized approach?.
        J Pers Med. 2022; 12: 740
        • Sbitany H.
        Important considerations for performing prepectoral breast reconstruction.
        Plast Reconstr Surg. 2017; 140: 7S-13S
        • Agochukwu NB
        • Huang C
        • Zhao M
        • et al.
        A novel noncontact diffuse correlation spectroscopy device for assessing blood flow in mastectomy skin flaps: a prospective study in patients undergoing prosthesis-based reconstruction.
        Plast Reconstr Surg. 2017; 140: 26-31
        • De Vita R
        • Buccheri EM.
        Nipple sparing mastectomy and direct to implant breast reconstruction, validation of the safe procedure through the use of laser assisted indocyanine green fluorescent angiography.
        Gland Surg. 2018; 7: 258-266
        • Sood M
        • Glat P.
        Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction.
        Ann Surg Innov Res. 2013; 7: 9
        • Newman MI
        • Jack MC
        • Samson MC.
        SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis.
        Ann Plast Surg. 2013; 70: 595-598
        • Kanuri A
        • Liu AS
        • Guo L.
        Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction.
        Plast Reconstr Surg. 2014; 133: 448e-454e
        • Yang CE
        • Chung SW
        • Lee DW
        • Lew DH
        • Song SY.
        Evaluation of the relationship between flap tension and tissue perfusion in implant-based breast reconstruction using laser-assisted indocyanine green angiography.
        Ann Surg Oncol. 2018; 25: 2235-2240
        • Radu M
        • Bordea C
        • Noditi A
        • Blidaru A.
        Assessment of mastectomy skin flaps for immediate implant-based breast reconstruction.
        J Med Life. 2018; 11: 137-145
        • Salibian AA
        • Frey JD
        • Karp NS.
        Strategies and considerations in selecting between subpectoral and prepectoral breast reconstruction.
        Gland Surg. 2019; 8: 11-18
        • Pagliara D
        • Montella RA
        • Garganese G
        • et al.
        Improving decision-making in prepectoral direct-to-implant reconstruction after nipple sparing mastectomy: the key role of flap thickness ratio.
        Clin Breast Cancer. 2022;
        • Larson DL
        • Basir Z
        • Bruce T.
        Is oncologic safety compatible with a predictably viable mastectomy skin flap?.
        Plast Reconstr Surg. 2011; 127: 27-33
        • Robertson SA
        • Rusby JE
        • Cutress RI.
        Determinants of optimal mastectomy skin flap thickness.
        Br J Surg. 2014; 101: 899-911
        • Frey JD
        • Salibian AA
        • Choi M
        • Karp NS.
        The importance of tissue perfusion in reconstructive breast surgery.
        Plast Reconstr Surg. 2019; 144: 21S-29S
        • Baker BG
        • Irri R
        • MacCallum V
        • Chattopadhyay R
        • Murphy J
        • Harvey JR.
        A prospective comparison of short-term outcomes of subpectoral and prepectoral strattice-based immediate breast reconstruction.
        Plast Reconstr Surg. 2018; 141: 1077-1084
        • Bernini M
        • Calabrese C
        • Cecconi L
        • et al.
        Subcutaneous direct-to-implant breast reconstruction: surgical, functional, and aesthetic results after long-term follow-up.
        Plast Reconstr Surg Glob Open. 2016; 3: e574
        • Sigalove S
        • Maxwell GP
        • Sigalove N
        • et al.
        Prepectoral implant-based breast reconstruction: rationale, indications, and preliminary results.
        Plast Reconstr Surg. 2017; 139: 287-294
        • Vidya R
        • Masià J
        • Cawthorn S
        • et al.
        Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: first multicenter European report on 100 cases.
        Breast J. 2017; 23: 670-676
        • Sbitany H
        • Piper M
        • Lentz R.
        Prepectoral breast reconstruction: a safe alternative to submuscular prosthetic reconstruction following nipple-sparing mastectomy.
        Plast Reconstr Surg. 2017; 140: 432-443
        • Sigalove S
        • Maxwell GP
        • Sigalove NM
        • et al.
        Prepectoral implant-based breast reconstruction and postmastectomy radiotherapy: short-term outcomes.
        Plast Reconstr Surg Glob Open. 2017; 5: e1631
        • Casella D
        • Kaciulyte J
        • Lo Torto F
        • et al.
        "To Pre or Not to Pre": introduction of a prepectoral breast reconstruction assessment score to help surgeons solving the decision-making dilemma. Retrospective results of a multicenter experience.
        Plast Reconstr Surg. 2021; 147: 1278-1286
        • Rancati A
        • Angrigiani C
        • Hammond D
        • et al.
        Preoperative digital mammography imaging in conservative mastectomy and immediate reconstruction.
        Gland Surg. 2016; 5: 9-14
        • Frey JD
        • Salibian AA
        • Choi M
        • Karp NS.
        Mastectomy flap thickness and complications in nipple-sparing mastectomy: objective evaluation using magnetic resonance imaging.
        Plast Reconstr Surg Glob Open. 2017; 5 (e1439)
        • Benya R
        • Quintana J
        • Brundage B.
        Adverse reactions to indocyanine green: a case report and a review of the literature.
        Cathet Cardiovasc Diagn. 1989; 17: 231-233
        • Rübben A
        • Eren S
        • Krein R
        • Younossi H
        • Böhler U
        • Wienert V.
        Infrared videoangiofluorography of the skin with indocyanine green-rat random cutaneous flap model and results in man.
        Microvasc Res. 1994; 47: 240-251
        • May Jr., JW
        • Chait LA
        • O'Brien BM
        • Hurley JV.
        The no-reflow phenomenon in experimental free flaps.
        Plast Reconstr Surg. 1978; 61: 256-267
        • SPY: Kit Instructions for Use
        LifeCell Corp, Branchburg, NJ2011
        • O'goshi K
        • Serup J.
        Safety of sodium fluorescein for in vivo study of skin.
        Skin Res Technol. 2006; 12: 155-161
        • 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
        • Desai ND
        • Miwa S
        • Kodama D
        • et al.
        A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts.
        J Thorac Cardiovasc Surg. 2006; 132: 585-594
        • Newman MI
        • Samson MC
        • Tamburrino JF
        • Swartz KA.
        Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction.
        J Reconstr Microsurg. 2010; 26: 487-492
        • Liu DZ
        • Mathes DW
        • Zenn MR
        • Neligan PC.
        The application of indocyanine green fluorescence angiography in plastic surgery.
        J Reconstr Microsurg. 2011; 27: 355-364
        • Munabi NC
        • Olorunnipa OB
        • Goltsman D
        • Rohde CH
        • Ascherman JA.
        The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: a prospective trial.
        J Plast Reconstr Aesthet Surg. 2014; 67: 449-455
        • Holm C
        • Dornseifer U
        • Sturtz G
        • Ninkovic M.
        Sensitivity and specificity of ICG angiography in free flap reexploration.
        J Reconstr Microsurg. 2010; 26: 311-316
        • Brennan ME
        • Spillane AJ.
        Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy–systematic review.
        Eur J Surg Oncol. 2013; 39: 527-541
        • Woerdeman LA
        • Hage JJ
        • Hofland MM
        • Rutgers EJ.
        A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria.
        Plast Reconstr Surg. 2007; 119: 455-463
        • Duggal CS
        • Madni T
        • Losken A.
        An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction.
        Aesthet Surg J. 2014; 34: 61-65
        • Singer R
        • Lewis CM
        • Franklin JD
        • Lynch JB.
        Fluorescein test for prediction of flap viability during breast reconstructions.
        Plast Reconstr Surg. 1978; 61: 371-375
        • Lin Y
        • Huang C
        • Irwin D
        • He L
        • Shang Y
        • Yu G.
        Three-dimensional flow contrast imaging of deep tissue using noncontact diffuse correlation tomography.
        Appl Phys Lett. 2014; 104121103