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

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          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.

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          Most cited references34

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          In vivo mechanisms of cutaneous vasodilation and vasoconstriction in humans during thermoregulatory challenges.

          Mark D Kellogg (2006)
          This review focuses on the neural and local mechanisms that have been demonstrated to effect cutaneous vasodilation and vasoconstriction in response to heat and cold stress in vivo in humans. First, our present understanding of the mechanisms by which sympathetic cholinergic nerves mediate cutaneous active vasodilation during reflex responses to whole body heating is discussed. These mechanisms include roles for cotransmission as well as nitric oxide (NO). Next, the mechanisms by which sympathetic noradrenergic nerves mediate cutaneous active vasoconstriction during whole body cooling are reviewed, including cotransmission by neuropeptide Y (NPY) acting through NPY Y1 receptors. Subsequently, current concepts for the mechanisms that effect local cutaneous vascular responses to direct skin warming are examined. These mechanisms include the roles of temperature-sensitive afferent neurons as well as NO in causing vasodilation during local heating of skin. This section is followed by a review of the mechanisms that cause local cutaneous vasoconstriction in response to direct cooling of the skin, including the dependence of these responses on intact sensory and sympathetic, noradrenergic innervation as well as roles for nonneural mechanisms. Finally, unresolved issues that warrant further research on mechanisms that control cutaneous vascular responses to heating and cooling are discussed.
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            Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined.

            Brian Moyer, Albert Losken (2012)
            Preservation of breast skin during mastectomy has improved the cosmetic results of breast reconstruction. Unfortunately, the incidence of mastectomy skin flap necrosis remains high using conventional evaluation methods; therefore, accurate prediction of flap viability is an important component of postmastectomy reconstruction. The authors studied a prospective cohort of women who underwent skin-sparing mastectomy and breast reconstruction over a 2-year period at Emory University. Mastectomy skin flap perfusion was measured intraoperatively using indocyanine green angiography. Once necrosis matured postoperatively, digital images were taken and superimposed over the intraoperative scan. Perfusion percentages were measured in healthy and nonviable skin. One hundred eighteen patients were included, and 14 patients (15 breasts) with postoperative skin necrosis and sufficient image data were analyzed. The average woman's age was 49.7 years (range, 28 to 73 years) and the average body mass index was 27.7 (range, 21.2 to 42.2). Skin with 25 percent or less perfusion (perfusion score, ≤ 25) was not viable 90 percent of the time, and areas with greater than or equal to 45 percent perfusion survived 98 percent of the time. A 33 percent perfusion score had a positive predictive value of removing nonviable skin of 88 percent and a negative predictive value of removing healthy skin of 16 percent. Indocyanine green angiography is a useful adjunct to assess mastectomy skin flap viability. A gray zone exists between 25 and 45 percent of maximal skin perfusion in which the ultimate viability remains in question. By designating the cutoff perfusion score of 33 percent, the surgeon can expect to more accurately remove nonviable skin. Diagnostic, III.
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              Indocyanine green applications in plastic surgery: A review of the literature.

              Pierre Burnier, Jeremy Niddam, Romain Bosc … (2017)
              Use of indocyanine green (ICG) near-infrared fluorescence as a dye to assess tissue vascularization is now well standardized. The aim of this literature review was to review and resume the most recent recommendations for ICG use in its plastic surgery applications.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Plast Surg
                Journal ID (iso-abbrev): Indian J Plast Surg
                Journal ID (doi): 10.1055/s-00042863
                Title: Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India
                Publisher: Thieme Medical and Scientific Publishers Pvt. Ltd. (A-12, 2nd Floor, Sector 2, Noida-201301 UP, India )
                ISSN (Print): 0970-0358
                ISSN (Electronic): 1998-376X
                Publication date (Electronic): 24 April 2023
                Publication date Collection: June 2023
                Publication date PMC-release: 1 April 2023
                Volume: 56
                Issue: 3
                Pages: 208-217
                Affiliations
                [1 ]Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
                Author notes
                Address for correspondence Sunil Choudhary, MS, FRCSEd Fellow of EBOPRAS, Max Institute of Reconstructive, Aesthetic, Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital Saket, 1,2 Press enclave Marg, New Delhi 100017India plasticsurgerymax@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-0875-809X
                Article
                Publisher ID: IJPS-22-10-1919
                DOI: 10.1055/s-0043-57270
                PMC ID: 10332904
                SO-VID: 4b0f39ac-9ef5-48f9-8307-e8f28acb6e87
                Copyright © 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/ )
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

                History
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Surgery
                Keywords: indocyanine green angiography,spy angiography,free flap outcomes,partial flap loss,flap warming,head and neck flaps,whole-body surface warming
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: indocyanine green angiography, spy angiography, free flap outcomes, partial flap loss, flap warming, head and neck flaps, whole-body surface warming

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