[ca] El verd d'indocianina (ICG) és un contrast que permet la valoració de la perfusió dels teixits de manera intraoperatòria i dinàmica, aportant informació d'interès en el camp de la reconstrucció mamària. Aquest treball es focalitza en l'estudi del seu ús en reconstrucció microquirúrgica de mastectomia amb penjoll DIEP (Deep Inferior Epigastric Perforator). L'objectiu principal és optimitzar el rendiment d'aquesta prova a l'hora de dissenyar el penjoll, i estableix en quin moment durant la intervenció quirúrgica és més efectiu valorar la seva perfusió, i demostrar que amb el seu ús és possible reduir la taxa de esteatonecrosis postoperatòria, una de les complicacions més freqüents en aquest tipus de reconstruccions. Per a això es van plantejar 2 estudis: - En el primer estudi es va valorar si existien diferències en la taxa d'esteatonecrosis postoperatòria en els penjalls DIEP per mastectomia oncològica en funció de si es va emprar (grup d'estudi) o no (grup control) l'ICG durant la intervenció quirúrgica. - En el segon estudi es va comparar la perfusió de l'penjall DIEP amb ICG en dos moments de la cirurgia, quan la vascularització depenia de l'pedicle original (zona donant) i després de la anastomosi microquirúrgica als gots receptors mamaris interns (zona receptora). A més, es van valorar els avantatges i inconvenients associats a la realització de la prova en cada moment. Els resultats d'ambdós estudis van mostrar que amb l'angiografia amb ICG intraoperatòria és possible disminuir la esteatonecrosis postoperatòria, tant la seva incidència com el seu grau i la necessitat de tractaments quirúrgics secundaris, sent major la seva efectivitat a l'hora de dissenyar el penjoll DIEP quan es realitza en la zona donant (abans de la secció de l'pedicle en què es basa).

[en] Background and objectives: The Deep Inferior Epigastric Perforator (DIEP) flap is the first option for autologous microsurgical reconstruction for oncological mastectomy, with great results. However, one of its most frequent complications is fat necrosis (up to 62.5%), as a consequence of a deficient regional perfusion of the flap, which could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs. The indocyanine green angiography (ICGA) has been successfully used for years in the assessment of perfusion in free flaps surgeries, and the aim of this study was to demonstrate the intraoperative use of ICGA to reduce fat necrosis in DIEP flap. Besides, it has not yet been established when the ICGA should be performed during the surgery, so the second main aim of this study is to evaluate whether it is better to perform the test on the donor or recipient sites of the DIEP flap. Methods: Two studies have been conducted. In the first one, 61 patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed. In the second study, the intraoperative perfusion of 46 DIEP flaps was assessed twice, on the donor and recipient sites. Differences between both ischemic areas of each flap were statistically analyzed. In addition, perforator location and risk factors were evaluated in order to assess whether they are associated with changes in the perfusion of the flap between both sites. Results: In the first article, the incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25- 0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q. In the second study, differences between ischemic areas on the donor and recipient sites were statistically significant (p = 0.012). In all cases in which there was a change of area between both zones, it was always less in the donor site. That means that in all cases the flap was the same or better perfused in the recipient site. The final flap design only changed in two cases (4.3%) because of the ICGA findings on the recipient site. Besides, performing the ICGA on the donor site facilitated the identification of the best perfused areas, allowed a better planning of its placement into the recipient site, and also can be useful to choose the best perforator. Bilateral DIEP flap, lateral location of the perforator and tobacco use had a statistically significant association with lower probability to increase the perfusion area between both sites Conclusions: Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade and the number of secondary surgeries. In addition, several advantages have been found in performing the ICGA on the donor site to assess the perfusion of the DIEP flap. In addition, performing the ICGA in the donor site (before the flap pedicle section) allowed to achieve a flap design based on the best perfused areas with greater precision.