Quantitative Evaluation of Blood Perfusion to Nerves Included in the Anterolateral Thigh Flap using Indocyanine Green Fluorescence Angiography: A Different Contrast Pattern between the Vastus Lateralis Motor Nerve and Femoral Cutaneous Nerve

Abstract

Background Better postoperative results can be expected in nerve reconstruction when vascularized nerve grafts are used. Previous studies reported reconstruction with flaps including “vascularized” nerves; however, few have evaluated blood supply to these nerves. The aim of this study was to quantitatively assess blood perfusion to nerves included in anterolateral thigh (ALT) flaps by indocyanine green (ICG) fluorescence angiography.

Patients and Methods Participants comprised eight patients who underwent reconstructive surgery with nerve defects using free ALT flaps, including the vastus lateralis motor nerve and/or femoral cutaneous nerve. Intraoperative ICG fluorescent angiography was performed. Time after the drug injection and the intensity of fluorescence in these nerves were analyzed as time–intensity curves. Maximum intensity (Imax), time to Imax (Tmax), and time at the beginning of intensity elevation (Te) were measured at three points: Point C, the central portion of the flap-attached region of the nerve; Point P, 2 cm from the proximal flap-attached edge; and Point D, 2 cm from the distal edge.

Results Imax and Te at point C and Imax/Tmax-Te at point P were significantly different between these two nerves (p = 0.03125, p = 0.02895, p = 0.03125, respectively). Fluorescence in the vastus lateralis motor nerve was slightly quicker and stronger than that in the femoral cutaneous nerve, and also exhibited an axial pattern of fluorescence.

Conclusion Intraoperative ICG fluorescent angiography can be used to determine which nerve is better for nerve reconstruction. The indexes of Imax, Te, and Imax/Tmax-Te may be the suitable criteria for decision making regarding donor nerve selection.

Keywords

vascularized nerve graft - vastus lateralis motor nerve - femoral cutaneous nerve - anterolateral thigh flap - indocyanine green fluorescent angiography

Note

Partial results from this study were presented at the 6th Congress of the World Society for Reconstructive Microsurgery, WSRM 2011, June 29 through July 2, 2011, Helsinki, Finland.

• References

• 1 Koshima I, Harii K. Experimental study of vascularized nerve grafts: morphometric study of axonal regeneration of nerves transplanted into silicone tubes. Ann Plast Surg 1985; 14 (3) 235-243
• 2 Koshima I, Harii K. Experimental study of vascularized nerve grafts: multifactorial analyses of axonal regeneration of nerves transplanted into an acute burn wound. J Hand Surg Am 1985; 10 (1) 64-72
• 3 Best TJ, Mackinnon SE, Evans PJ, Hunter D, Midha R. Peripheral nerve revascularization: histomorphometric study of small- and large-caliber grafts. J Reconstr Microsurg 1999; 15 (3) 183-190
• 4 Iwai M, Tamai S, Yajima H, Kawanishi K. Experimental study of vascularized nerve graft: evaluation of nerve regeneration using choline acetyltransferase activity. Microsurgery 2001; 21 (2) 43-51
• 5 Hatoko M, Tada H, Tanaka A, Kuwahara M, Yurugi S. The differential expression of N-cadherin in vascularized and nonvascularized nerve grafts: a study in a rat sciatic nerve model. Ann Plast Surg 2001; 47 (3) 322-327
• 6 Hatoko M, Tanaka A, Kuwahara M, Yurugi S, Iioka H, Niitsuma K. Expression of alpha, beta, and gamma catenins in vascularized and nonvascularized nerve grafts during the regeneration process. J Reconstr Microsurg 2003; 19 (4) 271-278
• 7 Kashiwa K, Kobayashi S, Ogino K, Kashiwaya G, Higuchi H. Inferolateral extension of the groin flap based on the artery accompanying the lateral femoral cutaneous nerve. J Reconstr Microsurg 2009; 25 (3) 181-189
• 8 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Kawai A. Vascularized femoral nerve graft with anterolateral thigh true perforator flap for massive defects after cancer ablation in the upper arm. J Reconstr Microsurg 2003; 19 (5) 299-302
• 9 Hyodo I, Ozawa T, Hasegawa Y, Ogawa T, Terada A, Torii S. Management of a total parotidectomy defect with a gastrocnemius muscle transfer and vascularized sural nerve grafting. Ann Plast Surg 2007; 58 (6) 677-682
• 10 Iida T, Nakagawa M, Asano T, Fukushima C, Tachi K. Free vascularized lateral femoral cutaneous nerve graft with anterolateral thigh flap for reconstruction of facial nerve defects. J Reconstr Microsurg 2006; 22 (5) 343-348
• 11 Koshima I, Moriguchi T, Soeda S. Reinnervation of denervated Pacinian corpuscles: ultrastructural observations in rats following free nerve grafts. Plast Reconstr Surg 1993; 92 (4) 728-735
• 12 Schultes G, Gaggl A, Kleinert R, Kärcher H. Vascularized versus non-vascularized nerve transfers: histologic study in rats. J Reconstr Microsurg 2001; 17 (8) 637-642
• 13 Bianchi B, Ferri A, Ferrari S , et al. The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: one surgeon's experience in 92 cases. Microsurgery 2012; 32 (2) 87-95
• 14 Tanaka K, Okazaki M. Visualization of blood supply to the 'vascularized nerve' with anterolateral thigh flap using indocyanine green fluorescence angiography. J Plast Reconstr Aesthet Surg 2013; 66 (1) 146-147
• 15 Okazaki M, Tanaka K, Kodaira S, Homma T, Miyashita H. One-stage transfer of 2 paddles of thoracodorsal artery perforator flap with 1 pair of vascular anastomoses for Barraquer-Simons syndrome. J Craniofac Surg 2012; 23 (3) 883-885
• 16 Azuma R, Morimoto Y, Masumot o K , et al. Detection of skin perforators by indocyanine green fluorescence nearly infrared angiography. Plast Reconstr Surg 2008; 122 (4) 1062-1067
• 17 Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg 2009; 123 (4) 1239-1244
• 18 Betz CS, Zhorzel S, Schachenmayr H , et al. Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited Indocyanine Green: preliminary results. J Plast Reconstr Aesthet Surg 2009; 62 (12) 1602-1608
• 19 Onoda S, Azumi S, Hasegawa K, Kimata Y. Preoperative identification of perforator vessels by combining MDCT, Doppler flowmetry, and ICG fluorescent angiography. Microsurgery 2013; 33 (4) 265-269
• 20 Liu DZ, Mathes DW, Zenn MR, Neligan PC. The application of indocyanine green fluorescence angiography in plastic surgery. J Reconstr Microsurg 2011; 27 (6) 355-364
• 21 Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV. Quantitative assessment of perfusion and vascular compromise in perforator flaps using a near-infrared fluorescence-guided imaging system. Plast Reconstr Surg 2009; 124 (2) 451-460
• 22 Lee BT, Matsui A, Hutteman M , et al. Intraoperative near-infrared fluorescence imaging in perforator flap reconstruction: current research and early clinical experience. J Reconstr Microsurg 2010; 26 (1) 59-65
• 23 Nguyen JT, Ashitate Y, Buchanan IA , et al. Face transplant perfusion assessment using near-infrared fluorescence imaging. J Surg Res 2012; 177 (2) e83-e88
• 24 Ashitate Y, Lee BT, Ngo LH , et al. Quantitative assessment of nipple perfusion with near-infrared fluorescence imaging. Ann Plast Surg 2013; 70 (2) 149-153
• 25 Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV. Predictive capability of near-infrared fluorescence angiography in submental perforator flap survival. Plast Reconstr Surg 2010; 126 (5) 1518-1527