Surgeon Reports

Cost Savings Associated with SPY Use in Breast Reconstruction Surgery

SPY angiography is a new technology that aides the reconstructive surgeon in assessing tissue perfusion intraoperatively. The information can be valuable to the surgeon and assist in intraoperative decision-making to limit complications, which ultimately leads to cost savings for the hospital system. Most importantly, the procedure has minimal morbidity and adds little time to the operation.

Examples of SPY angiography use that would improve patient outcomes and reduce hospitals costs include: (1) evaluation of mastectomy flaps, (2) evaluation of tissue perfusion, and (3) evaluation of microscopic anastomoses.

Evaluation of mastectomy flaps - after mastectomy, the skin of the breast is used for reconstruction of the new breast. Because the blood supply to the breast skin comes mainly from the resected breast, skin loss or necrosis can result. Any skin loss on the reconstruction necessitates prolonged hospitalization, and reoperation for revisions or skin grafting. Because these complications fall within the global period for the original surgery, reimbursement can be limited. SPY angiography allows the surgeon to directly visualize the perfusion of the skin prior to reconstruction so poorly perfused skin can be eliminated, greatly reducing the possibility of later loss.

Evaluation of tissue perfusion - the most common tissue-based breast reconstruction performed today is the TRAM or abdominal flap procedure. This operation uses the lower abdominal skin and fat to rebuild a breast after mastectomy. The blood supply to the flap may be either via the rectus muscle (a “pedicle” flap) or by blood vessels only (a microsurgical “free” flap). No matter the source of blood supply, the perfusion of the transferred tissue is variable and transfer of poorly perfused tissue results in fat necrosis (tissue loss) that prolongs hospitalization and requires further unplanned surgery to correct. As noted above, reimbursement for these extra procedures or hospital days may be poorly reimbursed. SPY angiography can greatly reduce the incidence of this problem (from 20% to 5% or less) by equipping the surgeon with an intraoperative tool to directly evaluate the perfusion of a flap angiographically. Limits of perfusion can be identified and poorly vascularized tissues can be eliminated prior to use in the reconstruction.

Evaluation of microsurgical anastomoses - when “free” flap surgery is performed, blocks of tissue are completely removed from the body and reattached to blood vessels in a new location to successfully complete a reconstruction. These transferred tissues are completely reliant on the microsurgically created anastomoses (reconnection). Sometimes during this surgery, flow can be interrupted by kinking of the vessels or clot within the vessels but this may not be readily apparent at surgery. If this is determined postoperatively, the tissue may be completely lost and a new surgery required to salvage the situation. If determined quickly, a reoperation may be able to save the ischemic flap. Both of these situations can be costly to the patient due to increased risk of further major surgery in the acute operative setting. They are also costly to the institution due to unreimbursed costs for reoperation and loss of elective time for fully reimbursed surgeries bumped due to these unscheduled emergencies. The solution to the problem is prevention and recognition of the problem before leaving the OR. When flow within the artery and vein of the flap is questionable, direct visualization of the blood flow by SPY angiography can be extremely helpful in confirming flow or alerting the surgeon to the possible need for intervention.

In conclusion, SPY angiography is a safe and cost-saving technology that can be used today to limit patient morbidity and improve clinical outcomes. While examples of cost savings have been provided for breast reconstruction, SPY’s benefits extend to all free tissue transfers and any reconstructive procedure where determination of perfusion of the tissue is critical. - Dr. Michael R. Zenn, M.D.

Dr. Zenn is an Associate Professor of Plastic Surgery at Duke University Medical Center. He has been in Plastic Surgery in North Carolina for over a decade, having received his medical training at Cornell University Medical College, his surgery training at The New York Hospital in New York City, and his plastic surgery training at Harvard’s Massachusetts General Hospital in Boston. He also completed the prestigious microsurgery fellowship at The Memorial Sloan-Kettering Cancer Center in New York City. Dr. Zenn is an active member of the American Society of Plastic Surgery, the American Society of Aesthetic Plastic Surgery, the American Association of Plastic Surgery, the American College of Surgeons, the American Medical Association, the Plastic Surgery Research Council, the American Society of Reconstructive Microsurgery, the World Society of Reconstructive Microsurgery, and is Past President of the North Carolina Society of Plastic Surgery.