Download PDF
J Reconstr Microsurg 2023; 39(05): 383-391
DOI: 10.1055/a-1939-5606
Original Article

Utility of Indocyanine Green Angiography for Preventing Pre-expanded Extended Lower Trapezius Myocutaneous Flap Necrosis: How to Make the Correct Decision for Hypoperfused Areas

Miao Wang 
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Mengqing Zang
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Shan Zhu
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Bo Chen
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Shanshan Li
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Tinglu Han
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Zixiang Chen
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
,
Yuanbo Liu
1   Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
› Author Affiliations Funding CAMS Innovation Fund for Medical Sciences, 2021-I2M-C&T-B-077; Science Foundation of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, YS202013
› Further Information
    Permissions and Reprints

Abstract

Background Designing a skin flap that perfectly covers the anatomical and dynamic territories is challenging. Tissues capturing territories beyond may be insufficiently perfused, and these hypoperfused areas can lead to partial flap necrosis. Indocyanine green angiography (ICGA) is an effective tool for identifying hypoperfused areas. This retrospective study proposes a standardized strategy for managing the hypoperfused areas identified by ICGA in pre-expanded extended lower trapezius myocutaneous (e-LTMC) flaps.

Methods Patients who underwent pre-expanded e-LTMC flap surgery with perfusion assessment using ICGA between June 2016 and January 2022 were identified. A standardized protocol was applied, and patients were divided into four groups according to different management options for hypoperfused areas detected by ICGA. Preoperative and operative variables of interest and postoperative outcomes, including flap necrosis and flap survival length, were collected and analyzed.

Results Sixty-nine flaps were included in the study. No total flap necrosis was observed. Partial necrosis occurred in 10 flaps. Significant differences were observed in the incidence of full-thickness necrosis between the management groups. The incidence of flap necrosis in cases where management relied on ICGA findings was significantly lower than that of cases where management did not rely on ICGA findings. There were no differences in the relative survival length of the flap between cases with and without intervention for the hypoperfused areas.

Conclusion The proposed standard strategy effectively reduced the necrosis rate of the pre-expanded e-LTMC flap, thus it is sensible to act on the ICGA findings. Prophylactic resection of the hypoperfused area should be recommended. Where resection may lead to poor reconstructive outcomes, flap trimming or a second flap should be the preferred option.

Keywords

indocyanine green angiography - flap necrosis - hypoperfused area


Publication History

Received: 10 June 2022

Accepted: 14 August 2022

Accepted Manuscript online:
08 September 2022

Article published online:
19 October 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Pruimboom T, van Kuijk SMJ, Qiu SS. et al. Optimizing Indocyanine Green Fluorescence Angiography in Reconstructive Flap Surgery: A Systematic Review and Ex Vivo Experiments. Surg Innov 2020; 27 (01) 103-119
    CrossrefPubMedGoogle Scholar
  • 2 Cormack GC, Lamberty BGH. Concepts of territories. In: Cormack GC, Lamberty BGH eds, The Arterial Anatomy of Skin Flaps. Edinburgh and New York: Churchill Livingstone; 1994: 6-9
    Google Scholar
  • 3 Lin CT, Wu SZ, Chen LW. Strategy of harvesting extended thoracodorsal artery perforator flaps for resurfacing the large soft-tissue defects of extremities. J Plast Reconstr Aesthet Surg 2022; 75 (03) 1064-1072
    CrossrefPubMedGoogle Scholar
  • 4 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Li K, Zhang Z, Nicoli F. et al. Application of Indocyanine Green in Flap Surgery: A Systematic Review. J Reconstr Microsurg 2018; 34 (02) 77-86
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 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; 26 (07) 487-492
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Cruz-Segura A, Cruz-Domínguez MP, Jara LJ. et al. Early Detection of Vascular Obstruction in Microvascular Flaps Using a Thermographic Camera. J Reconstr Microsurg 2019; 35 (07) 541-548
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Bai W, Guo H, Ouyang W. et al. Intramuscular Near-Infrared Spectroscopy for Muscle Flap Monitoring in a Porcine Model. J Reconstr Microsurg 2022; 38 (04) 321-327
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Han T, Khavanin N, Wu J. et al. Indocyanine Green Angiography Predicts Tissue Necrosis More Accurately Than Thermal Imaging and Near-Infrared Spectroscopy in a Rat Perforator Flap Model. Plast Reconstr Surg 2020; 146 (05) 1044-1054
    CrossrefPubMedGoogle Scholar
  • 10 Still J, Law E, Dawson J, Bracci S, Island T, Holtz J. Evaluation of the circulation of reconstructive flaps using laser-induced fluorescence of indocyanine green. Ann Plast Surg 1999; 42 (03) 266-274
    CrossrefPubMedGoogle Scholar
  • 11 Abdelwahab M, Patel PN, Most SP. The Use of Indocyanine Green Angiography for Cosmetic and Reconstructive Assessment in the Head and Neck. Facial Plast Surg 2020; 36 (06) 727-736
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Nassar AH, Maselli AM, Manstein S. et al. Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery. J Reconstr Microsurg 2022; 38 (03) 170-180
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Khavanin N, Qiu C, Darrach H. et al. Intraoperative Perfusion Assessment in Mastectomy Skin Flaps: How Close are We to Preventing Complications?. J Reconstr Microsurg 2019; 35 (07) 471-478
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Rudy SF, Abdelwahab M, Kandathil CK, Most SP. Paramedian forehead flap pedicle division after 7 days using laser-assisted indocyanine green angiography. J Plast Reconstr Aesthet Surg 2021; 74 (01) 116-122
    CrossrefPubMedGoogle Scholar
  • 15 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 (01) 59-65
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Han T, Khavanin N, Zang M. et al. Use of Indocyanine Green Imaging for Perforator Identification in Preexpanded Brachial Artery Perforator Flaps. Facial Plast Surg 2020; 36 (05) 650-658
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 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
    CrossrefPubMedGoogle Scholar
  • 18 Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg 1985; 75 (03) 318-327
    CrossrefPubMedGoogle Scholar
  • 19 Can A, Orgill DP, Dietmar Ulrich JO, Mureau MA. The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions. J Plast Reconstr Aesthet Surg 2014; 67 (12) 1669-1679
    CrossrefPubMedGoogle Scholar
  • 20 Baghaki S, Yalcin CE, Khankishiyev R. et al. Propeller and Pre-expanded Propeller Use of a Transversely Oriented Upper Trapezius Perforator Flap in Head and Neck Reconstruction: Clinical Experience and Review of Vascular Anatomy of the Supraspinal Trapezius Muscle. J Plast Reconstr Aesthet Surg 2021; 74 (07) 1534-1543
    CrossrefPubMedGoogle Scholar
  • 21 Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L, Baş L. Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure. Plast Reconstr Surg 2004; 114 (02) 339-350
    CrossrefPubMedGoogle Scholar
  • 22 Snider KT, Kribs JW, Snider EJ, Degenhardt BF, Bukowski A, Johnson JC. Reliability of Tuffier's line as an anatomic landmark. Spine 2008; 33 (06) E161-E165
    CrossrefPubMedGoogle Scholar
  • 23 Burm JS, Yang WY. Distally extended tensor fascia lata flap including the wide iliotibial tract for reconstruction of trochanteric pressure sores. J Plast Reconstr Aesthet Surg 2011; 64 (09) 1197-1201
    CrossrefPubMedGoogle Scholar
  • 24 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; 125 (04) 1065-1073
    CrossrefPubMedGoogle Scholar
  • 25 Gorai K, Inoue K, Saegusa N. et al. Prediction of Skin Necrosis after Mastectomy for Breast Cancer Using Indocyanine Green Angiography Imaging. Plast Reconstr Surg Glob Open 2017; 5 (04) e1321
    CrossrefPubMedGoogle Scholar
  • 26 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
    CrossrefPubMedGoogle Scholar
  • 27 Chen WL, Zhang B, Wang JG, Yang ZH, Huang ZQ, Zhang DM. Reconstruction of large defects of the neck using an extended vertical lower trapezius island myocutaneous flap following salvage surgery for neck recurrence of oral carcinoma. J Plast Reconstr Aesthet Surg 2011; 64 (03) 319-322
    CrossrefPubMedGoogle Scholar
  • 28 Zenga J, Sharon JD, Santiago P. et al. Lower Trapezius Flap for Reconstruction of Posterior Scalp and Neck Defects after Complex Occipital-Cervical Surgeries. J Neurol Surg B Skull Base 2015; 76 (05) 397-408
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Ou KL, Dai YH, Wang HJ. et al. The lower trapezius musculocutaneous flap for head and neck reconstruction: two decades of clinical experience. Ann Plast Surg 2013; 71 (1, Suppl 1) S48-S54
    CrossrefPubMedGoogle Scholar
  • 30 Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery. Plast Reconstr Surg 2000; 105 (05) 1758-1763
    CrossrefPubMedGoogle Scholar
  • 31 Munabi NC, Olorunnipa OB, Goltsman D, Rohde CH, Ascherman JA. 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; 67 (04) 449-455
    CrossrefPubMedGoogle Scholar
  • 32 Francisco BS, Kerr-Valentic MA, Agarwal JP. Laser-assisted indocyanine green angiography and DIEP breast reconstruction. Plast Reconstr Surg 2010; 125 (03) 116e-118e
    CrossrefPubMedGoogle Scholar
  • 33 Wu C, Kim S, Halvorson EG. Laser-assisted indocyanine green angiography: a critical appraisal. Ann Plast Surg 2013; 70 (05) 613-619
    CrossrefPubMedGoogle Scholar
  • 34 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
    CrossrefPubMedGoogle Scholar
  • 35 Valerio I, Green III JM, Sacks JM, Thomas S, Sabino J, Acarturk TO. Vascularized osseous flaps and assessing their bipartate perfusion pattern via intraoperative fluorescence angiography. J Reconstr Microsurg 2015; 31 (01) 45-53
    PubMedGoogle Scholar
  • 36 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
    CrossrefPubMedGoogle Scholar
  • 37 Beckler AD, Ezzat WH, Seth R, Nabili V, Blackwell KE. Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction: Comparison of Clinical Findings, Fluorescein, and Indocyanine Green Angiography. JAMA Facial Plast Surg 2015; 17 (06) 422-426
    CrossrefPubMedGoogle Scholar