ASK THE EXPERT: GLYN JONES, MD
ASK THE EXPERT
Dr. Glyn Jones, MD, FACS is the Chief Medical Officer of Surgery at Kent Imaging. He is dedicated to excellence in reconstructive and cosmetic surgery as a member of the American Society of Plastic Surgeons & American Association of Plastic Surgeons. Dr. Jones was a full-time faculty member and an Associate Professor of Plastic Surgery at Emory University for fifteen years, serving as the Department of Plastic Surgery Interim Chair, and was a recipient of the ‘Teacher of the Year’ award. He was then a Professor at the University of Illinois College of Medicine at Peoria (UICOMP) for 15 years while concurrently running a private practice. His primary focus as a surgeon has been on breast reconstruction for cancer, cosmetic surgery, and the management of complex wounds.
KI: From your experience, how does SnapshotNIR enhance intra-operative clinical decision-making, especially when determining flap viability or closure planning?
Dr. Jones: Prior to the advent of imaging techniques, clinical judgment and fluorescein injection, such as indocyanine green (ICG), were the only modalities available to assess skin viability. Near-infrared spectroscopy (NIRS) imaging with SnapshotNIR has largely overcome this issue and enables surgeons to proceed with confidence given perfusion data generated by the camera regarding the viability of the mastectomy skin envelope.
The ability to perform an immediate reconstruction under a fresh mastectomy skin flap is predicated on the viability of the overlying mastectomy skin. Advances in the management of breast cancer and breast reconstruction have seen a rapid embrace of both skin- and nipple-sparing mastectomies as a means of conserving the breast skin envelope for subsequent reconstruction. This has been paralleled by increasing acceptance of direct-to-implant reconstruction in either the pre-pectoral or sub-pectoral planes.
The use of SnapshotNIR enabled me to convert almost exclusively to immediate pre-pectoral reconstruction without having to resort to expanders or delayed techniques. This was a major step forward for both patient and surgeon and saves considerable healthcare dollars at a time when medical expenses have been under scrutiny.
KI: How does the objective, non-contact nature of SnapshotNIR imaging enhance your ability to assess tissue viability compared to traditional visual inspection or ICG assessment?
Dr. Jones: ICG injection is used intra-operatively, with subsequent near-infrared imaging of laser fluorescence of the injected dye. While this created quite a dramatic visual effect, the technique was soon found to be associated with a relatively high incidence of over-read of necrosis of up to 25% in multiple studies. The dye would also have to egress from the operative site with an elapsed time of about 20 minutes before a study can be repeated on the same patient.
In addition to the invasiveness of the technique, the equipment was cumbersome and expensive, and even handheld devices were tethered to a computer and endoscopic tower, making mobility difficult.
By contrast, SnapshotNIR is a handheld, portable device completely untethered and fully self-contained. It costs a fraction of the price of ICG-based devices and can be used in operating room recovery, the ICU or in a surgeon’s office. The device also allows for analytic informatics concerning venous congestion and the status of oxyhemoglobin and deoxyhemoglobin concentrations within the capillary bed, helping guide intra-operative decisions and post-operative patient monitoring.
KI: In oncologic breast reconstruction, regions like the nipple-areola complex often contain two different skin tones within the same imaging field. How does SnapshotNIR (KD205) help you navigate this?
Dr. Jones: Nipple-sparing mastectomy is an increasingly commonly used technique for preserving the skin envelope prior to reconstruction of the breast following mastectomy. Given the preservation of the nipple-areolar complex, as well as the entire breast skin envelope, this approach offers unparalleled opportunities for the creation of a very realistic breast mound with either implants or autologous tissue.
One of the problems associated with this technique, apart from that of skin necrosis, is the difficulty of assessing the viability of the nipple-areola complex, particularly in pigmented patients.
The dual tones of lighter breast skin combined with the darker pigmentation of the nipple-areola complex renders tissue perfusion assessment difficult to the naked eye, particularly in Fitzpatrick Skin Type Scale 5 and 6 skin tones. Techniques like capillary refill assessment simply do not work in these patients.
SnapshotNIR is able to differentiate these skin tones, even in darker pigmented patients, allowing the surgeon incomparable ability to assess perfusion in both the mastectomy skin, as well as the darker nipple-areola tissue. This gives surgeons considerable confidence to move ahead with an immediate reconstruction without fear of losing these critical structures.
KI: Are there examples where early identification of compromised tissue helped you intervene sooner or avoid complications?
Dr. Jones: SnapshotNIR has enabled me to identify skin suspected of being poorly perfused, leading to a clinical decision to perform a resection prior to continuing with the breast reconstruction. This allowed for an uneventful post-operative course without fear of skin loss and implant exposure placing a reconstruction at risk for total loss.
I’ve also used the device to assess skin flap perfusion in the head and neck following oncologic procedures with considerable success.
Specifically, on one occasion I used SnapshotNIR to identify the extent of tension on a tight skin closure following a bilateral latissimus flap for delayed breast reconstruction. Decompression of the pressure, with subsequent imaging 24 hours later, allowed for an uneventful post-operative course with excellent healing and outcome for the patient.
KI: How does incorporating SnapshotNIR help standardize tissue assessment and documenting changes or justifying treatment direction?
Dr. Jones: In plastic surgery, most procedures depend upon well perfused skin flaps in order to achieve satisfactory outcomes whether reconstructive or cosmetic in nature. The incorporation of SnapshotNIR allows for cost effective skin perfusion assessment which can be repeated as often as necessary during a procedure whether in a main hospital operating room or ambulatory surgery center, including office ORs. This provides a surgeon with a considerable level of confidence to proceed even in the face of complex tissue manipulations.
KI: Beyond breast reconstructive surgery, where else do you see SnapshotNIR having a strong impact in the surgical field?
Dr. Jones: NIRS imaging, particularly SnapshotNIR, has the potential to be extremely helpful in numerous other areas:
In neurosurgery, the assessment of skin flap viability can help prevent the use of compromised skin for scalp flap closure.
In cardiothoracic surgery, the assessment of the skin margins in open sternotomy cases is immensely helpful in reducing marginal skin necrosis leading to suppurative mediastinitis.
In orthopedic plastic cases, the assessment of skin and muscle flap viability and perfusion at the time of reconstruction after complex orthopedic salvage procedures can substantially reduce the risk of complications and extremely costly revisions.
The device can be used for gynecological reconstructions after oncologic procedures.
It has value in open colorectal procedures where the viability of the distal colonic segment can be evaluated prior to a colo-anal anastomosis for low anterior resections.
In cosmetic surgery, skin perfusion is critically important for a successful outcome and for limiting poor scarring. Imaging devices are almost never used in this arena given the cost of the materials being added to what is often already an expensive self-pay procedure.
To assess a facelift skin flap or mastopexy flap or abdominoplasty skin flaps would be cost-effective and highly advantageous.
Plastic surgery, in general, almost always requires adequate perfusion to skin or tissue flaps for a successful reconstructive or cosmetic surgical outcome.
Having an inexpensive, mobile perfusion device to use in the hospital operating room, ambulatory surgery center, or even in the office dramatically increases the value of such a device.
GAME CHANGERS: If you would like to share your experience with SnapshotNIR through an Ask the Expert Interview, fill out this form.