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9 Use of Fluorescence Guidance in Plastic and Reconstructive…
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of poor and no perfusion [3], (level of evidence 4). The adverse
reactions reported from ICG are uncommon and occur in 0.34%
of patients, based on a study by Obana etal. with mild reactions
of nausea, skin rash, and itchiness, and with very rare instances of
anaphylactic shock (level of evidence 5) [1, 4].
Plastic surgery has beneted from systemic ICG perfusion
angiography use in many aspects. One of its classic uses is for
evaluation of tissue perfusion in pedicled aps, free aps, and perforator aps. Holm etal. (level of evidence 2) described a rsttime use of intraoperative ICG imaging in free ap tissue perfusion
[1]. Patients were prospectively evaluated with ICG angiography
performed intraoperatively after ap inset. Postoperatively, monitoring was done exclusively by clinical means without the use of
ICG. The authors found 2/10 (20%) of complications with one
partial and one total ap loss that had been detected intraoperatively by ICG imaging. The study was able to show cases of arterial spasms, venous congestion, and tissue hypoperfusion with
intraoperative ICG imaging [5]. These ndings are supported by
other studies (level of evidence 4) investigating the use of ICG
angiography in free ap operations [3, 6, 7]. However, since then,
other aspects of plastic surgery have also beneted from use of
ICG perfusion angiography guidance.
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Indications: Use inExtremity Reconstruction
The use of NIR technologies in extremities, specially by consulting services in anticipation of tissue coverage, allows better coordination of care and preservation of tissue with subsequent
improvement of post-reconstruction function (Figs.9.1, 9.2, 9.3,
and 9.4).
Dietz etal. (level of evidence 5) described the utilization of
SPY-Q system technology to determine tissue viability in trauma
allowing for more thoughtful debridement, especially in orthopedic surgery, when preservation of certain tissues may signify
functional preservation [1, 8]. Moreover, it allows evaluation of
levels of amputation and perfusion of avulsed tissues and vessels
in trauma.
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Z. A. Koenig et al.
Fig. 9.1 Preoperative defect with concern for poor perfusion
As described by Green etal. (level of evidence 4), the use of
SPY-Q system technology minimizes perfusion-related complications by allowing intraoperative modications and revisions that
will decrease poor tissue perfusion [1, 9]. Fluorescence angiography allows intraoperative modications, such as excision of distal
ap segments with poor perfusion, angiosome or persome mapping (which is especially useful in random aps and propeller
9 Use of Fluorescence Guidance in Plastic and Reconstructive…
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261
Fig. 9.2 Exposure of the underlying defect
aps), ap inset modications to salvage reconstruction, release
of sutures during closure if the tissue is noted to be ischemic or
under excess tension, and evaluation of free ap anastomosis as
described by Lohman et al. These intraoperative adjustments
improve reconstructive outcomes.
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Z. A. Koenig et al.
Fig. 9.3 Fluorescence angiography to identify ap regions of poor perfusion
The described decisions can be crucial in designing axial pattern
aps or pedicled aps. These aps, unlike free aps, can be a challenge in extremity reconstruction due to the limited amount of available tissue, limited reach, and the need for advancement of tissue
without potentially sacricing tissue perfusion. The use of intraoperative ICG assists with tissue mapping during harvest of the ap, insetting of the ap, and the decision to delay a ap or add a second ap.
9 Use of Fluorescence Guidance in Plastic and Reconstructive…
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Fig. 9.4 Debridement of devitalized tissue and coverage with a skin substitute
Indications: Use inSkin Flaps
Skin aps are utilized in plastic surgery as a primary method of
reconstruction for soft tissue defects and coverage of wounds.
There are many types of skin aps based primarily on the tissue
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Z. A. Koenig et al.
included in the ap or based on the source of blood supply to
the ap.
Skin aps may include the skin, subcutaneous fat, fascia, tendon, muscle, nerves, and bones. Flaps are often named based on
the contents of the ap, such as skin ap (skin and subcutaneous
tissue), fasciocutaneous ap (skin, subcutaneous fat, and fascia),
myocutaneous ap (skin, subcutaneous fat, fascia, and muscle), or
osteocutaneous ap (skin, subcutaneous fat, and bone). Flaps are
sometimes described based on the pattern of movement of the tissue, specically whether the tissue is rotated, advanced, or transposed to cover the defect. In addition, aps can be described based
on the pattern and source of blood supply to the ap. Random
pattern aps are based on blood supply through the subdermal
plexus and do not have a named blood vessel supplying the ap,
such as in axial patterned aps. Flaps can be used to cover defects
locally, regionally, and in distant locations or used as free aps
anywhere in the body.
One of the major challenges with skin aps is maintaining
adequate perfusion to tissue to ensure viability. There have been
many methods to assess skin aps, which includes axial pattern
aps and pedicled aps, as described earlier. The use of indocyanine green has been a major asset to the armamentarium of tools
used preoperatively, intraoperatively, and postoperatively to
design and evaluate skin aps. Random pattern aps are designed
based on length to width ratios typically of 2:1, and axial patterned aps are based on known anatomical regions of perfusions
surrounding the named vessels. Although several factors contribute to complications of ap healing such as nicotine, obesity, diabetes, radiation, and vascular insufciency, uorescence
angiography allows us to assess real-time perfusion of aps as we
aim to limit tissue necrosis and improve tissue survivability and,
therefore, improve outcomes.
The use of uorescence angiography for evaluation of skin
aps in breast reconstruction has been discussed in another chapter. However, uorescence angiography is also utilized for the
evaluation of skin aps of the head and neck, trunk, and extremities. Laser-induced uorescence of ICG has been used by several
studies to evaluate skin viability in skin aps. Graham etal. laid
9 Use of Fluorescence Guidance in Plastic and Reconstructive…
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the framework for use of uorescein as an injectable marker in
rats to assess random ap perfusion [10]. The rst human study
using ICG angiography for evaluation of pedicled skin ap perfusion was done by Still etal. (level of evidence 3), and this showed
promising results in that wound healing was accurately predicted
by ICG angiography [1, 11]. Another prospective study by Holm
etal. (level of evidence 3) corroborated these ndings by suggesting that ICG angiography is a sensitive tool for assessing nutritive
blood ow in pedicled skin aps with and without an axial vessel
[1, 5]. Other studies support the ndings listed above for use of
uorescence angiography in pedicled skin aps (levels of evidence 3–5) [1, 12–14].
265
Indications: Use inAbdominoplasty
andPanniculectomy
Abdominoplasty and panniculectomy are two common operations
performed by plastic surgeons for functional and cosmetic
improvements particularly in patients with excess skin. One complication of any abdominal procedure is delayed wound healing
caused by poor circulation to the skin. Complications like wound
dehiscence, skin necrosis, and wound infection can be related to
decreased perfusion of the skin ap and are inherent to these surgical procedures secondary to undermining of large skin aps.
When compounded with underlying patient comorbidities which
affect the microcirculation, the likelihood of poor perfusion to
localized areas of the skin during wound healing increases exponentially. As adequate tissue perfusion is crucial for normal
wound healing, a better understanding of abdominal skin perfusion after these procedures may contribute to reducing wound
healing problems (Figs.9.5, 9.6, 9.7, and 9.8).
Standard abdominoplasty and panniculectomy can have a
signicant impact on abdominal skin perfusion. Nergård etal.
(level of evidence 2) were the rst to quantify abdominal skin
perfusion following abdominoplasty using DIRT where they
identied the least perfusion occurring at Hager zone II near the
lower transverse incision line [1, 15]. Patel etal. (level of evi-
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Fig. 9.5 Intraoperative angiography used during brachioplasty
Z. A. Koenig et al.
Fig. 9.6 Intraoperative angiography used during brachioplasty
9 Use of Fluorescence Guidance in Plastic and Reconstructive…
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Fig. 9.7 Intraoperative image of panniculectomy, indocyanine green visible
in overlay mode
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Fig. 9.8 Intraoperative angiography shows excellent perfusion of aps in
uorescence mode
dence 4) showed that ICG angiography can accurately detect
perfusion abnormalities to decrease wound healing complications in patients undergoing complex hernia repair with concomitant panniculectomy [1, 16]. Numerous other studies
support the use of ICG angiography to identify perfusion abnor-
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malities in patients with risk factors such as obesity, current
tobacco use, prior wound infection, and hypertension (levels of
evidence 2–5) [1, 17–19].
Z. A. Koenig et al.
Technique
In our institution, we use indocyanine green (ICG) to assess
tissue perfusion. ICG is a water-soluble dye that binds to
plasma proteins in the blood or tissue and emits an energy in
the NIR spectrum of 750–810nm. It has been utilized for evaluation of retinal angiography, cardiovascular function, and
hepatic clearance for over 50years [8, 20]. The use of NIR
uorescence is well-known and reproducible and provides
good diagnostic accuracy. It can be used with a handheld camera or a microscope. ICG can be injected systemically (angiography) when looking for ap, composite graft, or bone
perfusion, or subcutaneously when looking for lymph nodes or
lymphatic perfusion. When utilized systemically, the administered dose range is 0.025 to 0.50mg/kg and 0.03 to 0.25mg/kg
when injected subcutaneously [21] (level of evidence 3). There
are some differences in dosages depending on indications and
surgeon’s habits. As an example, for sentinel node mapping,
the dosage is 25mg ICG diluted in 5ml of distilled water with
doses of 0.4 to 1.2ml; lymphography for lymphedema evaluation is usually 0.1 to 0.3ml and for evaluation of tissue perfusion, the dose is 5mg or 0.5mg/kg [22], (level of evidence 4).
There are many laser-assisted uorescence angiography cameras, and one of the most common NIR uorescence tools utilizing ICG is performed with SPY-Q imaging analysis software.
SPY-Q system is an analytical software that provides quantiable
data that can be used preoperatively, intraoperatively, or postoperatively. ICG can show perfusion in tissue to a depth of 1–1.5cm.
In general, a dose of 7.5 mg (ICG concentration 2.5 mg/ml) is
administered systemically, and the area of interest is visualized
directly with the use of a handheld camera and a screen with capability of video recording.
The images provided by SPY-Q system can be analyzed with
two techniques:
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