Download PDF
CC BY-NC-ND 4.0 · Indian J Plast Surg 2023; 56(03): 208-217
DOI: 10.1055/s-0043-57270
Original Article

Role of Indocyanine Green Angiography in Free Flap Surgery: A Comparative Outcome Analysis of a Single-Center Large Series of 877 Consecutive Free Flaps

Sunil Choudhary 
1   Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
,
Soumya Khanna
1   Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
,
Raghav Mantri
1   Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
,
Prateek Arora
1   Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Purpose This study aims to assess and validate the role and cost-effectiveness of indocyanine green angiography (ICGA) in free flap surgery outcomes. A new intraoperative protocol of whole-body surface warming (WBSW) for all free flap surgeries during the strategic “microbreaks” is also described.

Methods A retrospective analysis of 877 consecutive free flaps, performed over 12 years, is presented. The results of the ICGA group (n = 438) were compared with the historical No-ICGA group (n = 439), and statistical significance was calculated for three crucial flap-related adverse outcomes and cost-effectiveness. ICGA was also used as a tool to show the effect of WBSW on free flaps.

Results ICGA showed a notably strong statistical significance in decreasing two outcome parameters, namely, partial flap loss and re-exploration rate. It was also cost-effective. ICGA also demonstrated the positive role of WBSW in increasing flap perfusion.

Conclusions Our study shows that the usage of ICGA for intraoperative assessment of flap perfusion can significantly reduce the partial flap loss and re-exploration rate in free flap surgeries in a cost-effective manner. A new protocol of WBSW is also described and recommended to increase flap perfusion in all free flap surgeries.

Keywords

indocyanine green angiography - SPY angiography - free flap outcomes - partial flap loss - flap warming - head and neck flaps - whole-body surface warming

The paper has not been presented at any meetings.




Publication History

Article published online:
24 April 2023

© 2023. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Phillips BT, Munabi NCO, Roeder RA, Ascherman JA, Guo L, Zenn MR. The role of intraoperative perfusion assessment: what is the current state and how can I use it in my practice?. Plast Reconstr Surg 2016; 137 (02) 731-741
    CrossrefPubMedSearch in Google Scholar
  • 2 Ono S, Hayashi H, Ohi H, Ogawa R. Imaging studies for preoperative planning of perforator flaps: an overview. Clin Plast Surg 2017; 44 (01) 21-30
    CrossrefPubMedSearch in Google Scholar
  • 3 Pafitanis G, Raveendran M, Myers S, Ghanem AM. Flowmetry evolution in microvascular surgery: a systematic review. J Plast Reconstr Aesthet Surg 2017; 70 (09) 1242-1251
    CrossrefPubMedSearch in Google Scholar
  • 4 Zenn MR. Fluorescent angiography. Clin Plast Surg 2011; 38 (02) 293-300
    CrossrefPubMedSearch in Google Scholar
  • 5 Green III JM, Thomas S, Sabino J. et al. Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction. J Oral Maxillofac Surg 2013; 71 (08) 1439-1449
    CrossrefPubMedSearch in Google Scholar
  • 6 Burnier P, Niddam J, Bosc R, Hersant B, Meningaud JP. Indocyanine green applications in plastic surgery: a review of the literature. J Plast Reconstr Aesthet Surg 2017; 70 (06) 814-827
    CrossrefPubMedSearch in Google Scholar
  • 7 Eguchi T, Kawaguchi K, Basugi A, Kanai I, Hamada Y. Intraoperative real-time assessment of blood flow using indocyanine green angiography after anastomoses in free-flap reconstructions. Br J Oral Maxillofac Surg 2017; 55 (06) 628-630
    CrossrefPubMedSearch in Google Scholar
  • 8 Phillips BT, Fourman MS, Rivara A. et al. Comparing quantitative values of two generations of laser-assisted indocyanine green dye angiography systems: can we predict necrosis?. Eplasty 2014; 14: e44
    PubMedSearch in Google Scholar
  • 9 Newman MI, Jack MC, Samson MC. SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis. Ann Plast Surg 2013; 70 (05) 595-598
    CrossrefPubMedSearch in Google Scholar
  • 10 Kim M, Lee S, Park JC. et al. Anaphylactic shock after indocyanine green video angiography during cerebrovascular surgery. World Neurosurg 2020; 133: 74-79
    CrossrefPubMedSearch in Google Scholar
  • 11 Ludolph I, Horch RE, Arkudas A, Schmitz M. Enhancing safety in reconstructive microsurgery using intraoperative indocyanine green angiography. Front Surg 2019; 6: 39
    CrossrefPubMedSearch in Google Scholar
  • 12 Jones GE, Garcia CA, Murray J. et al. Fluorescent intraoperative tissue angiography for the evaluation of the viability of pedicled TRAM flaps. Plast Reconstr Surg 2009; 124: 53
    PubMedSearch in Google Scholar
  • 13 Lee SK, Lee DW, Lew DH, Song SY. Determining the trimming layer in breast reconstruction with a free TRAM flap using intraoperative video-angiography. Plast Reconstr Surg Glob Open 2017; 5 (03) e1266
    CrossrefPubMedSearch in Google Scholar
  • 14 Momeni A, Sheckter C. Intraoperative laser-assisted indocyanine green imaging can reduce the rate of fat necrosis in microsurgical breast reconstruction. Plast Reconstr Surg 2020; 145 (03) 507e-513e
    CrossrefPubMedSearch in Google Scholar
  • 15 Varela R, Casado-Sanchez C, Zarbakhsh S, Diez J, Hernandez-Godoy J, Landin L. Outcomes of DIEP flap and fluorescent angiography: a randomized controlled clinical trial. Plast Reconstr Surg 2020; 145 (01) 1-10
    CrossrefPubMedSearch in Google Scholar
  • 16 Malagón-López P, Vilà J, Carrasco-López C. et al. Intraoperative indocyanine green angiography for fat necrosis reduction in the deep inferior epigastric perforator (DIEP) flap. Aesthet Surg J 2019; 39 (04) NP45-NP54
    CrossrefPubMedSearch in Google Scholar
  • 17 Mattison GL, Lewis PG, Gupta SC, Kim HY. SPY imaging use in postmastectomy breast reconstruction patients: preventative or overly conservative?. Plast Reconstr Surg 2016; 138 (01) 15e-21e
    CrossrefPubMedSearch in Google Scholar
  • 18 Phillips BT, Lanier ST, Conkling N. et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial. Plast Reconstr Surg 2012; 129 (05) 778e-788e
    CrossrefPubMedSearch in Google Scholar
  • 19 Muntean MV, Ardelean F, Strilciuc S, Pestean C, Georgescu AV, Muntean V. Flap warming improves intraoperative indocyanine green angiography (ICGA) assessment of perfusion. An experimental study. J Plast Reconstr Aesthet Surg 2019; 72 (07) 1150-1156
    CrossrefPubMedSearch in Google Scholar
  • 20 McNally R, Rimler J, Laurence V. Z Paydar K, A Wirth G. Comparative perfusion analysis of free muscle-sparing versus pedicle transverse rectus abdominis myocutaneous (TRAM) flaps in vivo in the perioperative and late postoperative periods. World J Plast Surg 2017; 6 (02) 144-151
    PubMedSearch in Google Scholar
  • 21 Krauss S, Rothenberger J, Mayer J. et al. Tissue conditioning – strategies to improve perfusion and reduce ischemia-reperfusion injury. Plast Aesthet Res 2018; 5: 39
    CrossrefSearch in Google Scholar
  • 22 Harder Y, Amon M, Schramm R. et al. Heat shock preconditioning reduces ischemic tissue necrosis by heat shock protein (HSP)-32-mediated improvement of the microcirculation rather than induction of ischemic tolerance. Ann Surg 2005; 242 (06) 869-878 , discussion 878–879
    CrossrefPubMedSearch in Google Scholar
  • 23 Wang BH, Ye C, Stagg CA. et al. Improved free musculocutaneous flap survival with induction of heat shock protein. Plast Reconstr Surg 1998; 101 (03) 776-784
    CrossrefPubMedSearch in Google Scholar
  • 24 Minh TC, Ichioka S, Nakatsuka T. et al. Effect of hyperthermic preconditioning on the survival of ischemia-reperfused skin flaps: a new skin-flap model in the mouse. J Reconstr Microsurg 2002; 18 (02) 115-119
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Kellogg Jr DL. In vivo mechanisms of cutaneous vasodilation and vasoconstriction in humans during thermoregulatory challenges. J Appl Physiol 2006; 100 (05) 1709-1718
    CrossrefPubMedSearch in Google Scholar
  • 26 Wilson TE, Crandall CG. Effect of thermal stress on cardiac function. Exerc Sport Sci Rev 2011; 39 (01) 12-17
    CrossrefPubMedSearch in Google Scholar
  • 27 Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg 2012; 129 (05) 1043-1048
    CrossrefPubMedSearch in Google Scholar
  • 28 Chang CS, Chu MW, Nelson JA. et al. Complications and cost analysis of intraoperative arterial complications in head and neck free flap reconstruction. J Reconstr Microsurg 2017; 33 (05) 318-327
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Taylor SR, Jorgensen JB. Use of fluorescent angiography to assess donor site perfusion prior to free tissue transfer. Laryngoscope 2015; 125 (06) E192-E197
    CrossrefPubMedSearch in Google Scholar
  • 30 Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J 2014; 34 (01) 61-65
    CrossrefPubMedSearch in Google Scholar
  • 31 Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg 2014; 133 (04) 448e-454e
    CrossrefPubMedSearch in Google Scholar
  • 32 Bigdeli AK, Thomas B, Falkner F, Gazyakan E, Hirche C, Kneser U. The impact of indocyanine-green fluorescence angiography on intraoperative decision-making and postoperative outcome in free flap surgery. J Reconstr Microsurg 2020; 36 (08) 556-566
    Thieme ConnectPubMedSearch in Google Scholar
  • 33 Lee KT, Lee JE, Nam SJ, Mun GH. Ischaemic time and fat necrosis in breast reconstruction with a free deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 2013; 66 (02) 174-181
    CrossrefPubMedSearch in Google Scholar
  • 34 Chang SY, Huang JJ, Tsao CK. et al. Does ischemia time affect the outcome of free fibula flaps for head and neck reconstruction? A review of 116 cases. Plast Reconstr Surg 2010; 126 (06) 1988-1995
    CrossrefPubMedSearch in Google Scholar