The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional Negative Pressure Wound Therapy on Mastectomy Skin Flap Perfusion-Related Problems
Phase: PHASE2
Conditions: Perfusion; Complications
Sponsor: Wake Forest University Health Sciences

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
 
 
Principal Investigator:  
 
Ivo A. Pestana, MD 
 
 
 
 
 
Plastic and Reconstructive Surgery 
 
 
 
 
 
Wake Forest School of Medicine 
Winston-Salem, NC 27157 
336-716-4171 
ipestana@wakehealth.edu 
 
 
Co-Investigator(s): 
 
 
Austin M. Bond, MD 
Plastic and Reconstructive Surgery 
Wake Forest School of Medicine 
abond@wakehealth.edu 
 
Christine Velazquez, MD 
General Surgery 
Wake Forest School of Medicine 
cvelazq@wakehealth.edu 
 
Malcolm W. Marks, MD 
Plastic and Reconstructive Surgery 
Wake Forest School of Medicine 
mmarks@wakehealth.edu 
 
Lisa R. David, MD 
Plastic and Reconstructive Surgery 
Wake Forest School of Medicine 
ldavid@wakehealth.edu 
 
Anthony J. DeFranzo, MD 
Plastic and Reconstructive Surgery  
Wake Forest School of Medicine 
adefranzo@wakehealth.edu 
 
Christopher M. Runyan, MD. PhD 
Plastic and Reconstructive Surgery 
Wake Forest School of Medicine 
crunyan@wakehealth.edu 
 
Marissa Howard-McNatt, MD 
General Surgery 
Wake Forest School of Medicine 
mmcnatt@wakehealth.edu 
 
Biostatistician: 
Greg Russell 
Department of Biostatistical Sciences 
Division of Public Health Sciences 
336-716-5449 
grussell@wakehealth.edu 
 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
 
 
Study Coordinator: 
 
 
Renea Jennings 
Plastic and Reconstructive Surgery 
Wake Forest School of Medicine 
rjenning@wakehealth.edu 
 
Regulatory Contact: 
 
 
TBD 
 
Protocol Editor: 
 
 
Bonny Morris, MSPH, BSN, RN 
Comprehensive Cancer Center of Wake Forest University 
 
 
 
 
 
336-713-6180 
 
 
 
 
 
bemorris@wakehealth.edu 
 
 
Participating Institution(s): 
 
Wake Forest Baptist Medical Center 
 
 
Version Date:  
 
 
05/07/2019 
Amended: 
 
 
 
Confidential
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 3 of 19 
 
 
Table of Contents 
SCHEMA ................................................................................................................................... 4 
1.0 
Introduction and Background ............................................................................................. 5 
2.0 
Objectives ........................................................................................................................ 5 
3.0 
Patient Selection ............................................................................................................... 5 
3.1 Inclusion Criteria ................................................................................................................. 5 
3.2 Exclusion Criteria ................................................................................................................ 6 
3.3 Inclusion of Women and Minorities .................................................................................... 6 
4.0 Study Outcomes and Study Measures ........................................................................................ 7 
4.1 Primary Outcomes ............................................................................................................... 8 
5.0 
Treatment Plan ................................................................................................................. 9 
5.1 Study Related Activities .................................................................................................... 9 
5.2 Duration of Follow-up .........................................................................................................10 
6.0 
Adverse Events List and Reporting Requirements ................................................................10 
6.1 Adverse Event Characteristics ...........................................................................................10 
6.2  
WFUHS IRB AE Reporting Requirements ......................................................................10 
7.0 
Data Management ............................................................................................................11 
8.0 
Statistical Considerations ..................................................................................................11 
8.1 Estimated Accrual Rate ....................................................................................................11 
8.2 Estimated Study Length ....................................................................................................12 
9.0 
Registration Procedures ....................................................................................................13 
References ..................................................................................................................................13 
 
 
 
 
 
 
 
 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 4 of 19 
SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ensure subject fulfills inclusion/ exclusion criteria, obtain pre-
operative consent, and then obtain pre-operative pictures 
Randomization
1.
Group 1  
a.
 Clinical Examination 
b.
No therapy applied 
2.
Group 2  
a.
Clinical Examination 
b.
Nitroglycerin Cream applied 
3.
Group 3 
a.
Clinical Examination 
b.
Incisional Negative Pressure Wound 
Therapy applied 
4.
Group 4 
a.
Clinical Examination 
b.
Incisional Negative Pressure Wound 
Therapy + Nitroglycerin Cream 
applied 
CRF form completed and post-
operative photos taken at week 1 
(7 days after surgery), week 2, 
week 3 and week 4. 
Intraoperatively, perfusion of flap will be assessed by criteria a above to 
determine if subject is able to tolerate implant/tissue expander 
If plastic surgeon determines that 
the subject cannot tolerate 
implant/tissue expander, then no 
implant will be placed. Subject 
will continue to be followed for 
30 days but randomized therapy 
will be irrelevant. Thus a new 
envelope will be introduced to 
the pre-made envelopes 
5.
Group 5 
a.
Fluorescent Angiography 
b.
No therapy applied 
6.
Group 6 
a.
Fluorescent Angiography 
b.
Nitroglycerin Cream Applied 
7.
Group 7 
a.
Fluorescent Angiography 
b.
Incisional Negative Pressure Wound 
Therapy Applied 
8.
Group 8  
a.
Fluorescent Angiography 
b.
Incisional Negative Pressure Wound 
Therapy +Nitroglycerin Cream 
applied  
Subject continues with the study and 
randomized therapy if the surgeon 
determines perfusion is sufficient to 
support implant/tissue expander and 
intraoperative pictures will be taken 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 5 of 19 
1.0 
Introduction and Background 
 
Breast cancer changes the lives of more and more women each year.  Despite its oncologic benefits, 
mastectomy results in disfigurement of the chest and women who undergo breast reconstruction 
demonstrate a profound psychosocial benefit.  The outcome of breast reconstruction is highly dependent on 
the remnant soft tissues and skin after mastectomy.  Unfortunately, vascular perfusion-related problems 
(PRPs) after mastectomy are common and may manifest as skin loss, wound dehiscence, delayed wound 
healing, or wound/ implant infections.  These, in turn, may result in significant patient morbidity as they 
undergo the process of breast reconstruction. Medications and technologies have been developed to aid in 
perfusion assessment (fluorescent angiography-FA), perfusion augmentation (nitroglycerin paste-NTG), 
and wound healing (incisional negative pressure wound therapy-iVAC), but their use and effect in 
minimizing mastectomy flap skin loss remains unclear.  
 
Indocyanine-green fluorescent angiography (FA) is a safe and efficient technology which implements laser 
excitation of indocyanine green (ICG) fluorescent dye to provide real-time angiography and assessment of 
tissue perfusion.  Our plastic and reconstructive surgery department and others have utilized FA since it is 
an accepted technique employed to identify perfusion-related problems in breast and free tissue transfer 
surgery.   
 
Nitroglycerin ointment exerts a vasodilatory effect on the soft tissue to which it is applied.  Thus, nitro paste 
may help to prevent perfusion-related problems when used in a prophylactic fashion after immediate breast 
reconstruction.  Most recently, a Level 1 evidenced randomized-controlled trial comparing nitroglycerin 
ointment to placebo in patients undergoing mastectomy with immediate reconstruction has shed new light 
on the use of this non-invasive treatment to decrease the incidence of potential ischemia-related 
complications postoperatively. 
 
Vacuum-assisted closure (VAC) dressings, also referred to as negative-pressure wound therapy (NPWT), 
have been employed since the early 1990’s to treat difficult open wounds, and recent evidence has 
elucidated their role in decreasing complications when placed over surgical closure sites (in which setting 
they are often referred to as “incisional NPWT” or iVAC).  A recent study has demonstrated decreased 
rates of mastectomy skin flap necrosis when incisional NPWT was placed over the surgical closure 
compared to no dressing placed over the incision.   
2.0 
Objectives 
 
Our aim is to evaluate and to compare the above described interventions and their effect on the incidence 
of PRPs in patients with breast cancer undergoing mastectomy and implant-based immediate breast 
reconstruction (IBR).  The ability to identify, prevent and treat these PRPs can help maximize aesthetic 
results after breast surgery, improve patient satisfaction with both mastectomy and breast reconstruction, 
and reduce healthcare cost associated with mastectomy and reconstruction complications. 
3.0 
Patient Selection 
 
3.1 Inclusion Criteria  
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 6 of 19 
3.1.1 
Patients must be female. 
 
3.1.2 
Patients must be between the ages of 18 and 99 years. 
 
 
 
3.1.3 
Patients must undergo mastectomy with our attending breast oncology surgeons 
followed by possible implant-based immediate breast reconstruction (IBR) performed 
by our attending plastic surgeons at WFBMC. 
 
3.1.4 
Patients must have the ability to understand and the willingness to sign an IRB-
approved informed consent document. 
 
3.2 Exclusion Criteria  
 
3.2.1 
Patients who are under the age of 18 or over the age of 99. 
 
3.2.2 
Patients who are undergoing mastectomy without immediate breast reconstruction 
including immediate breast reconstruction with autologous tissue (or combination of 
autologous tissue with tissue expanders or implants), or patients with a history of 
mastectomy presenting for delayed breast reconstruction. 
 
3.2.3 
Patients with pre-existing conditions in which use of indocyanine-green is 
contraindicated or must be used with caution, including those with a history of allergy 
to iodides or iodinated dye, those with chronic kidney disease, those with hepatic 
failure or cirrhosis of the liver, and females who are nursing, pregnant, or may become 
pregnant. 
 
3.2.4 
Pregnant women are excluded from this study because pregnancy precludes immediate 
breast reconstruction in our patient population. 
 
3.2.5 
Patients with pre-existing conditions in which use of nitroglycerin paste is 
contraindicated, including those with a history of cardiac insufficiency, hypotension, 
sensitivity to nitrites, severe liver impairment, glaucoma, hyperthyroidism, recent head 
trauma, severe anemia, or taking certain medication (i.e. alteplase, aspirin, beta-
blocker, calcium channel blocker, diuretics or thiazides). 
 
3.2.6  
Patients with pre-existing conditions in whom use of incisional negative pressure 
wound therapy is contraindicated including those with evidence of surgical site 
infection ( i.e. erythema, purulent drainage), clinical signs of hematoma (i.e. wound 
swelling, fluctuance, blood drainage), history of persistent cancer, exposed blood 
vessel on site of proposed therapeutic use, or allergy to acrylics and adhesives.   
 
3.3 Inclusion of Women and Minorities 
 
Females of any race or ethnicity who meet the above-described inclusion criteria are 
eligible to participate in this study.  

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 7 of 19 
4.0 Study Outcomes and Study Measures 
 
We will perform a randomized pilot study comprised of eight groups. All of these groups employ accepted 
techniques, medications and dressings and therefore are not experimental.   
 
Group 1: Breast skin after mastectomy will be clinically examined by the surgeon to determine if there is 
adequate blood flow to the skin to allow safe coverage of the breast implant. No dye study, ointment, or 
vacuum dressing will be applied to the breast after implant placement. 
 
Group 2 - Breast skin after mastectomy will be clinically examined by the surgeon, and nitroglycerin (NTG) 
cream will be applied to the breast skin after implant placement.  This cream does not have systemic effects 
but may improve blood flow to the remnant breast skin after mastectomy. 
 
Group 3 - Breast skin after mastectomy will be clinically examined by the surgeon, and an incisional 
vacuum-assisted dressing (iVAC) will be placed over the breast incisions after implant placement, which 
may improve blood flow to the skin and help wound healing. 
 
Group 4 - Breast skin after mastectomy will be clinically examined by the surgeon, and both NTG cream 
will be applied to the breast skin and an iVAC will be placed over the incisions after implant placement. 
 
Group 5 - Blood flow to breast skin after mastectomy will be examined using a fluorescent dye study called 
fluorescent angiography (FA) to determine if there is adequate blood flow to the skin to allow safe coverage 
of the breast implant.  No further intervention will be used after implant placement.   
 
Group 6 - Blood flow to breast skin breast skin will be examined using FA, and NTG cream will be applied 
to the skin after the implant is placed. 
 
Group 7 - Blood flow to breast skin breast skin will be examined using FA, and an iVAC will be placed 
over breast skin incisions after the implant is placed. 
 
Group 8 - Blood flow to breast skin breast skin will be examined using FA, and both NTG cream and iVAC 
will be used as interventions after the implant is placed.   
 
The dosage of indocyanine-green (IC-green) to be used for assessment of mastectomy flaps will be in 10 
mg boluses, not to exceed 5 mg/kg. 
 
Nitro-Bid® (nitroglycerin ointment, 2%) at a dose of 45 mg (equal to 7.5 cm on the measuring strip 
provided with packaging) will be used.  The paste will be applied to remnant breast skin after skin closure 
and surgical dressings placed over top. 
 
Incisional negative pressure wound therapy will consist of a standard sponge dressing with adhesive drape, 
either Ioban® 2 (3M ™) or KCI-V.A.C.® Drape (KCI®), to continuous suction at 125 mm Hg while the 
patient is in hospital and not to exceed 4 days. 
 
A physician will see the subjects on a regular weekly basis for up to 30 days once the procedure has been 
completed. These clinical visits are standard of care and the subject’s health and well-being will be 
monitored rigorously during these visits. If during any of these visits, the physician deems a therapy 
necessary to prevent impairment/damage and improve well-being, the subject will be treated appropriately. 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 8 of 19 
At no point during this study will the needs of the randomized arm/research take priority over the subject’s 
health and well-being. 
 
Study Risks 
 
Risks of surgery may include bleeding, infection, hematoma/seroma formation, risks of anesthesia, 
implant/tissue expander failure, extrusion, or tissue necrosis. 
 
Risks with ICGLA may include a potential risk for anaphylaxis/urticarial reaction.   Caution must be taken 
with patients with iodine/iodinated contrast allergy.  There have been no studies performed to evaluate 
carcinogenicity, mutagenicity, or impairment of fertility. 
 
Risks associated with the use of nitroglycerin paste may include dizziness, light-headedness, blurred vision, 
fainting, increased risk of alcohol toxicity if consumed in conjunction with nitroglycerin use, headaches, 
severe allergic reactions (rash, hives, itching, difficulty breathing, tightness in chest, swelling of mouth, 
face, lips, throat or tongue), flushing and red, swollen, blistered or peeling skin. 
 
Vacuum-assisted closure is routinely used in the medical setting for various types of traumatic, surgically-
created, or chronic wounds.  The use of NPWT therapy is contraindicated when the system is in direct 
contact with vital structures (i.e. exposed vessels, anastomoses, organs, or nerves), or when the following 
are present in the wound: malignancy, untreated osteomyelitis, non-enteric and unexplored fistulas, or 
necrotic tissue with eschar present.Use of Ioban® drape is contraindicated in patients with a known 
sensitivity to iodine.  In these instances, the KCI-V.A.C.® drape will be used.  Patients with known allergy 
to acrylics or adhesives may develop an adverse hypersensitivity reaction to the KCI drape and will be 
excluded from the study.   
 
4.1 Primary Outcomes 
 
4.1.1 
The primary outcomes will be the following perfusion-related problems:  
 
 
Soft tissue ischemia/loss (i.e. partial and full thickness soft tissue defects 
identified postoperatively in clinic follow up) 
 
Surgical site infection (i.e. soft tissue cellulitis or abscess identified 
postoperatively either clinically or with wound culture) 
 
Delayed wound healing (manifesting as suture dehiscence and opening of 
an incisional wound) 
 
4.2 Secondary Outcomes 
 
 
4.2.1 
The secondary outcomes will be the following: 
 
 Rate of operative intervention secondary to perfusion related problems 
as listed in “Primary Outcomes” above, and surgical outcome with 
regards to mastectomy flaps 
 Rate of prescribing of outpatient antibiotics or admission for inpatient 
IV antibiotics for treatment of surgical site infection 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 9 of 19 
 Wound care management modalities for treatment of delayed wound 
healing complications as listed in “Primary Outcomes” above, and 
wound healing outcomes 
 
5.0 
Treatment Plan 
 
 
Pre-
Operative 
Visit 
Day of 
Surgery 
Week 1 
Postop 
Week 2 
Postop 
Week 3 
Postop 
Week 4 
Postop 
Enrollment and informed consent 
X 
 
 
 
 
 
Clinical assessment to determine 
whether implant/tissue expander can be 
placed without compromising perfusion 
 
X 
 
 
 
 
Clinical photos of surgical site 
X 
X 
X 
X 
X 
X 
Data sheet documenting outcome 
 
 
X 
X 
X 
X 
 
5.1 
Study Related Activities 
 
Potential subjects will be identified by the physician, advanced practice provider, or research 
coordinator. This individual will discuss the study with the patient and answer any questions or 
concerns they may have. This will take place in an exam room, hospital room, or by phone 
depending on whether or not the patient is inpatient or a clinic patient. 
 
Signed informed consent will be obtained from each subject who will be undergoing mastectomy 
with immediate breast reconstruction using breast implants during a pre-operative appointment in 
the General Surgery (Breast Oncology) or Plastic Surgery clinic.  After the subject has been 
identified as meeting the inclusion criteria by the clinician or research coordinator, the study 
coordinator will obtain the signed informed consent. A signed copy of the consent form will be 
given to the subject. Once the patient has agreed to take part in the study and sign the consent form, 
pre-operative photos of the breast will be taken. Pregnancy tests performed 15 days apart (prior to 
surgery) is done as standard of care for all women of childbearing age potentially undergoing this 
surgery.  
 
Twenty subjects will be randomized to each arm of the study using sealed instructions provided by 
the study coordinator who will inform the clinician of the arm prior to surgery. The envelopes will 
be filled prior to the study with envelopes containing a document indicating to which group the 
patient will be a part of. The envelopes will be sealed and shuffled and then labeled from subject 1 
through 160.  
 
Once the subject is randomized to an arm of the study, the operating surgeon will be informed of 
the arm prior to the surgery. On the day of surgery, the surgeon will decide intraoperatively whether 
an implant/tissue expander can be safely placed without compromising perfusion of the flap. If the 
surgeon determines that an implant/tissue expander cannot be safely placed, they will continue to 
be followed as that indicates a perfusion related problem. At that point, another envelope will be 
introduced into the pre-made envelopes with that subject’s assigned arm. Pictures will be take pre-

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 10 of 19 
operatively, intraoperatively, and at week 1,2,3, and 4 post-operatively. In addition to these 
pictures, the data collecting sheet will be completed  by the physician, advanced practice provider 
or study coordinator at week 1, 2,3 and 4 post-operatively. 
 
This is not an intent-to-treat trial. In order to ensure that we are able to gather the most information 
from this study, we want to be able to closely monitor our enrolled subjects and remove any subjects 
that are non-compliant with their randomized arm. The study coordinator will be responsible for 
keeping a detailed Excel spreadsheet of the enrolled subjects and their respective arms of the study. 
If a subject comes off the study prematurely, another envelope will be introduced to the pre-made 
envelopes with the withdrawn subject’s arm – in this way the arms will never be unbalanced. 
 
This study will be monitored by the Cancer Center’s Safety and Toxicity Review (STRC) for 
SAEs and will also be monitored for accrual by the Clinical Research Oversight Committee 
(CROC) since this is an institutional intervention study. The standard operating procedures for the 
STRC can be found below in appendix c. 
 
 
5.2 Duration of Follow-up 
 
Patients will be followed for a minimum of 30 days after the procedure. Clinical assessments will 
occur weekly. 
6.0 
Adverse Events List and Reporting Requirements 
 
Any unanticipated problems, serious and unexpected adverse events, deviations or protocol changes will 
be promptly reported by the principal investigator or designated member of the research team to the IRB 
and sponsor or appropriate government agency if appropriate. 
6.1 Adverse Event Characteristics 
 
Adverse events may include, but are not limited to: anaphylaxis/urticarial reaction, dizziness, light-
headedness, blurred vision, fainting, severe allergic reactions (rash, hives, itching, difficulty 
breathing, tightness in chest, swelling of mouth, face, lips, throat or tongue), flushing and red, 
swollen, blistered or peeling skin, intraoperative or immediately postoperative/post-procedure 
death. 
6.2  
WFUHS IRB AE Reporting Requirements 
 
Any unanticipated problems involving risks to subjects or others and adverse events shall be 
promptly reported to the IRB, according to institutional policy. Reporting to the IRB is required 
regardless of the funding source, study sponsor, or whether the event involves an investigational or 
marketed drug, biologic or device. Reportable events are not limited to physical injury, but include 
psychological, economic and social harm. Reportable events may arise as a result of drugs, 
biological agents, devices, procedures or other interventions, or as a result of questionnaires, 
surveys, observations or other interactions with research subjects. 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 11 of 19 
All members of the research team are responsible for the appropriate reporting to the IRB and other 
applicable parties of unanticipated problems involving risk to subjects or others. The Principal 
Investigator, however, is ultimately responsible for ensuring the prompt reporting of unanticipated 
problems involving risk to subjects or others to the IRB. The Principal Investigator is also 
responsible for ensuring that all reported unanticipated risks to subjects and others which they 
receive are reviewed to determine whether the report represents a change in the risks and/or benefits 
to study participants, and whether any changes in the informed consent, protocol or other study-
related documents are required. 
 
Any unanticipated problems involving risks to subjects or others occurring at a site where the study 
has been approved by the WFUHS IRB (internal events) must be reported to the WFUHS IRB 
within 7 calendar days of the investigator or other members of the study team becoming aware of 
the event. 
 
Any unanticipated problems involving risks to subjects or others occurring at another site 
conducting the same study that has been approved by the WFUHS IRB (external events) must be 
reported to the WFUHS IRB within 7 calendar days of the investigator or other members of the 
study team becoming aware of the event. 
 
Any event, incident, experience, or outcome that alters the risk versus potential benefit of the 
research and as a result warrants a substantive change in the research protocol or informed consent 
process/document in order to insure the safety, rights or welfare of research subjects. 
7.0 
Data Management 
 
 
Race Verification Form 
ORIS 
Protocol registration form 
ORIS 
Data Collection 
REDCap 
8.0 
Statistical Considerations 
 
This investigation will be designed as a pilot study, in which patients will be randomized to one of the eight 
groups described.  Once enrollment goals are met, outcomes data will be calculated for each of the primary 
and secondary measures.  Using these estimates, a larger randomized clinical trial will be designed to assess 
differences between study groups.  It is anticipated that the rate of study completion will be uniformly high 
across the study groups, with low rates of attrition.  For use in designing a future trial, we will calculate the 
rate of dropout for each group.  Reasons for dropout will be recorded and reported. 
 
 
8.1 
Estimated Accrual Rate 
8.1.1   We anticipate enrolling approximately 70-80 patients per year; With 8 study 
groups, with 20 subjects per group, the study will need 160 subjects to meet 
recruitment goals.  We will allow for attrition in our enrollment estimates, as our 
goal is to have 20 completed subjects in each arm.  Assuming a 15% dropout rate, 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 12 of 19 
the study would need approximately 184 subjects.  Study recruitment should be 
completed within 2.5 years.   
 
 
8.2 
Estimated Study Length 
8.2.1 
The time Follow up time for each patient will be thirty days, which will allow 
enough time for mastectomy flap necrosis to develop.   
 
8.3 
Statistical Analyses 
8.3.1 
Estimates of all primary outcomes  (Soft tissue ischemia/loss, surgical site 
infection, delayed wound healing) and secondary outcomes (rate of operative 
intervention, rate of prescribing antibiotics or admission for IV antibiotic therapy, 
wound care management modalities and outcomes) will be calculated.  These data 
will provide estimates of rates for each outcome that will allow planning for future 
studies.  The rates of the primary outcomes will be reported, along with 
corresponding 95% confidence intervals.  With an anticipated sample size of 20 in 
each group, the width of the exact 95% confidence interval would be 
approximately +/- 22.8 if the observed rate was 50%.  The table below shows the 
power for testing against an observed rate of 10% (the anticipated average rate in 
the 8 study groups) in group 1 versus 20%, 30%, 40%, and 50% in other groups 
with an alpha of 0.20.  With group sample sizes of 20 in each of the 2 groups, the 
study would have 84% power to detect a difference of 30%. 
 
Numeric Results of Tests Based on the Difference: P1 - P2 
H0: P1 - P2 = 0.   H1: P1 - P2 = D1 ≠ 0.   Test Statistic: Z test with pooled variance 
  
                                                 
 
 
                  Trt|H1   Cntrl    Diff       Target       Actual 
Power              N1           N2             N          P1       P2        D1        Alpha        Alpha 
0.36453             20           20            40       0.10      0.20      -0.10       0.2000       0.1966 
0.62930             20           20            40       0.10      0.30      -0.20       0.2000       0.2228 
0.84713             20           20            40       0.10      0.40      -0.30       0.2000       0.2172 
0.95746             20           20            40       0.10      0.50      -0.40       0.2000       0.1920 
 
 
 
 
The table below shows the target and actual alpha and power if groups are 
combined to have 80 subjects in each one.  
 
Numeric Results of Tests Based on the Difference: P1 - P2 
H0: P1 - P2 = 0.   H1: P1 - P2 = D1 ≠ 0.   Test Statistic: Z test with pooled variance 
 
                                                                   
 
 
 Trt|H1     Cntrl     Diff      Target     Actual 
Power              N1           N2            N         P1          P2          D1      Alpha      Alpha 
0.42287             80           80           160       0.10      0.20      -0.10       0.05       0.0503 
0.71633             80           80           160       0.10      0.25      -0.15       0.05       0.0518 
0.90284             80           80           160       0.10      0.30      -0.20       0.05       0.0513 
0.97682             80           80           160       0.10      0.35      -0.25       0.05       0.0507 
0.99617             80           80           160       0.10      0.40      -0.30       0.05       0.0472 
 
With group sample sizes of 80 in each of the 2 groups, being compared, the study 
would have 90% power to detect a difference of 20%. 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 13 of 19 
8.3.2  The rate of attrition and reason for dropout will be reported for each of the study 
groups; these data will be used in adjusting the needed sample size for a larger 
study.  The rate of attrition and its corresponding 95% confidence interval will be 
calculated; attrition will be defined as the number of subjects who do not attend 
the final assessment, divided by the number accrued into the treatment group. 
9.0 
Registration Procedures 
 
All patients entered on any CCCWFU trial, whether treatment, companion, or cancer control trial, must 
be registered with the CCCWFU Protocol Registrar or entered into ORIS Screening Log. Patients must 
be registered prior to the initiation of treatment.   
 
You must perform the following steps in order to ensure prompt registration of your patient: 
 
1. Complete the Reduced Review Registration Form (Appendix A) 
2. Complete the Race Verification Form (Appendix B) 
3. Send the Reduced Review Protocol Registration Form and the Race Verification Form to the 
registrar, either by fax or email. 
 
 
Contact Information: 
Protocol Registrar PHONE (336) 713-6767 
Protocol Registrar FAX (336) 713-6772 
Protocol Registrar E-MAIL (registra@wakehealth.edu) 
            
*Protocol Registration is open from 8:30 AM - 4:00 PM, Monday-Friday. 
 
 
To complete the registration process, the Registrar will:   
 
 
register the patient on the study and assign the PID number 
 
References 
 
Burnier P, et al.  Indocyanine green applications in plastic surgery: A review of the literature.  J Plast 
Reconstr Aesthet Surg. 2017 Jun;70(6): 814-27. 
 
Dent BL, Small K, Swistel A, Talmor M.  Nipple-areolar complex ischemia after nipple-sparing 
mastectomy with immediate implant-based breast reconstruction: risk factors and the success of 
conservative treatment.  Aesth Surg J. 2014;34(4): 560-70. 
 
Duggal CS, Madni T, Losken A.  An outcome analysis of intraoperative angiography for postmastectomy 
breast reconstruction.  Aesthet Surg J. 2014 Jan;34(1): 61-5. 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 14 of 19 
Fan Z, He J.  Preventing necrosis of the skin flaps with nitroglycerin after radical resection for breast 
cancer.  J Surg Oncol.  1993 Jul;53(3): 210. 
 
Foglia E, et al.  Economic and organizational sustainability of a negative-pressure portable device for the 
prevention of surgical-site complications.  Clinicoecon Outcomes Res. 2017 Jun;12(9): 343-51. 
 
Gdalevitch P, et al.  Effects of nitroglycerin ointment on mastectomy flap necrosis in immediate breast 
reconstruction: a randomized controlled trial.  Plast Reconstr Surg.  2015 Jun;135(6): 1530-9. 
 
Gorai K, et al.  Prediction of skin necrosis after mastectomy for breast cancer using indocyanine green 
angiography imaging.  Plast Reconstr Surg Glob Open 2017 Apr;5(4): e1321. 
 
Griffiths M, Chae MP, Rozen WM.  Indocyanine green-based fluorescent angiography in breast 
reconstruction.  Gland Surg.  2016;5(2): 133-49. 
 
Harless CA, Jacobson SR.  Tailoring through technology: A retrospective review of a single surgeon’s 
experience with implant-based breast reconstruction before and after implementation of laser-assisted 
indocyanine green angiography.  Breast J.  2016 May;22(3): 274-81. 
 
Kim, DY, Park SJ, Bang SI, Mun GH, Pyon JK.  Does the use of incisional negative-pressure wound 
therapy prevent mastectomy flap necrosis in immediate expander-based breast reconstruction?  Plast 
Reconstr Surg.  2016 Sept;138(5): 558-66. 
 
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 Apr;125(4): 1065-73. 
 
Kutun S, et al.  Is transdermal nitroglycerin application effective in preventing and healing flap ischaemia 
after modified radical mastectomy?  S Afr J Surg. 2010 Nov;48(4): 119-21. 
 
Matsen CB, et al.  Skin flap necrosis after mastectomy with reconstruction: A prospective study.  Ann 
Surg Oncol.  2016 Jan;23(1): 257-64. 
 
Munabi NCO, et al.  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 Apr;67(4): 449-55. 
 
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 Sep;26(7): 487-92. 
 
Pestana IA, Campbell DC, Bharti G, Thompson JT.  Factors affecting complications in radiated breast 
reconstruction.  Ann Plast Surg. 2013 May;70(5):542-5. 
 
Phillips BT, et al.  Intraoperative perfusion techniques can accurately predict mastectomy skin flap 
necrosis in breast reconstruction: Results of a prospective trial.  Plast Reconstr Surg. 2012 May;129(5): 
778e-788e. 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
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Robertson SA, Jeevaratnam JA, Agrawal A, Cutress RI.  Mastectomy skin flap necrosis: challenges and 
solutions.  Breast Cancer. 2017 Mar;9: 141-52. 
 
Xu K, Tzankova V, Li C, Sharma S.  Intravenous fluorescein angiography-associated adverse reactions.  
Can J Ophthalmol. 2016 Oct;51(5): 321-5. 
 
Zenn M, et al.  Optimizing outcomes of postmastectomy breast reconstruction with acellular dermal 
matrix: A review of recent clinical data.  Eplasty 2017;17(18): 156-71. 
 
 
 
 
 
 
 
 
 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 16 of 19 
The following Appendices are required for all CCCWFU cancer treatment protocols. 
 
Add additional appendices as needed. 
 
ALL data collection forms must be included as protocol appendices at the time the protocol is submitted 
to the CCCWFU Protocol Review Committee (PRC) for review. 
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 17 of 19 
APPENDIX A: REDUCED REVIEW** REGISTRATION FORM 
 
Protocol#: 00038262 
 
 
 
 
 
 
*Required Field  
 
Protocol Title: The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems     CCCWFU#00038262 
 
DEMOGRAPHICS 
 
Name (last, first) : ________________________, ________________________________ 
(or initials)  
 
UNIT # (MRN): _________________ (required if exists) 
Zip Code:__________ (required if no 
MRN) 
 
*SEX ﴾  ﴿ MALE 
(   ﴿ FEMALE  
 
*ETHNICITY (choose one): 
(   ﴿ HISPANIC ﴾   ﴿ NON-HISPANIC 
  
*RACE (choose all that apply):  WHITE 
 
 
 
 ASIAN 
 
  
 
 
 
 AFRICAN-AMERICAN 
 
 PACIFIC ISLANDER 
(HAWAIIAN) 
  
 
 
 
 
 NATIVE AMERICAN (ALASKAN) 
 Unknown (Other, Refused} 
 
*DIAGNOSIS : ____________________________________________________ 
 
 
BIRTH DATE: _______________________________(include if no MRN is provided) 
 
*MD Name (last, first): _________________________________ 
  
 
 
*DATE CONSENT WAS SIGNED: __________________ 
 
Date of Registration (if different): __________________________ 
 
PID#: ______________________ (to be completed by Registrar) 
 
The Comprehensive Cancer Center requires that all registrations be sent to the CCCWFU Centralized Registrar the 
day the patient is consented; if this is not possible we require that all registrations be communicated to the 
Centralized Registrar within 72 hours of consent. 
**Reduced review means eligibility and other review are not performed by CRM registrar. Questions: call 713-6767 
 
 
Submit by Email*** 
Print Form 
 
*** If not using the full wfubmc edu outlook client (full outlook, not web outlook), save this file and 
attach to an email to regjstra@wfubmc .edu  
Submitter  of this form is responsible for insuring that all regulatory and eligibility requirements are met 
for this registration. 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
Page 18 of 19 
Appendix B – Race Verification Form 
 
Thank you so much for helping us to verify your race and ethnicity to ensure the quality of our 
information. As a brief reminder, the information you provide today will be kept confidential. 
 
1. Are you: 
Hispanic or Latino/a   
Not Hispanic or Latino/a 
 
2. What is your race? One or more categories may be selected. 
White or Caucasian 
Black or African American American 
Indian or Alaskan Native Asian 
Native Hawaiian or Other Pacific Islander 
Other, Please Specify: _______________________________________ 
 
                                                            
Internal use only: 
Was the self-reported race and ethnicity of the participant verified at the time of consent? 
Yes       No 
 
Was a discrepancy found?       Yes        No 
If yes, please provide what is currently indicated in the EMR: 
 
Ethnicity: _____________________________   Race: _________________________________                                           
 
Additional comments:  ______________________________________________________________ 
___________________________________________________________________________________ 
___________________________________________________________________________________                             
 

 
 The Effect of Nitroglycerin Ointment, Fluorescent Angiography, and Incisional NPWT on 
Mastectomy Skin Flap Perfusion-Related Problems Comprehensive Cancer Center of Wake 
Forest University (CCCWFU)  
PI: Ivo Pestana, MD  IRB #00038262 NCT03716050   Date of Document: 05/07/2019  
Protocol version: 05/07/2019  
 
 
 
 
 
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