Application of intraoperative indocyanine green angiography for detecting flap congestion in the use of free deep inferior epigastric perforator flaps for breast reconstruction

Yoshimatsu, Hironobu; Karakawa, Ryo; Scaglioni, Mario F.; Fuse, Yuma; Tanakura, Kenta; Yano, Tomoyuki

doi:10.1002/micr.30734

Cited by 35 publications

(31 citation statements)

References 19 publications

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“…The skin flap was elevated above this fascia, and the deeper fat was saved ( Figure 1 ). After the elevation was completed, the flap perfusion was confirmed on indocyanine green angiography [ 18 ]. Recipient vessels were prepared within or in the adjacent of the defect after tumor excision.…”

Section: Methodsmentioning

confidence: 99%

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

et al. 2022

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Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: −1.6 days (95% confidence interval: −2.8 to −0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique.

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Section: Methodsmentioning

confidence: 99%

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

et al. 2022

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“…In this way we are able to identify the areas where the blood supply was lower and we usually resected them, thus reducing the risk of distal flap necrosis. Furthermore, a recent study showed also how the application of intraoperative ICG angiography can be safely used to predict venous congestion after free tissue transfer (Yoshimatsu et al, 2021).…”

Section: Surgical Techniquementioning

confidence: 99%

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases

et al. 2022

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Background Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases. Patients and Methods Eighty‐seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator‐based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21—87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm. Results The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm2 (range 12–80 cm2) for the pedicle flaps and 104 cm2 (range 24—200 cm2) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow‐up period was 8.4 months (range 3–12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life. Conclusions The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

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“…Its primary use has since switched to that of lymph node mapping, angiography and fluorescence-guided surgery. Intravenous administration allows quantitative assessment of tissue perfusion intraoperatively, allowing assessment of skin flap viability and congestion, prompting immediate revision, as opposed to future operations after flap failure [15][16][17] ; ICG angiography has also been demonstrated as a bedside tool to improve detection of reduced perfusion postoperatively 18 . Besides angiography for flap perfusion, ICG has also been described during intra-cranial aneurysm surgery 19 , coronary artery bypass graft surgery 20 , and is currently under investigation to evaluate whether it can reduce the anastomotic leak rate in colorectal cancer resection 21 .…”

Section: Introductionmentioning

confidence: 99%

Investigating the mechanisms of indocyanine green (ICG) cellular uptake in sarcoma

Chan

Brookes

Tanwani

et al. 2021

Preprint

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Introduction: Indocyanine green (ICG) is a near infrared (NIR) dye which has been used clinically for over 50 years and has recently been utilised for fluorescence guided surgery in a number of cancer types, including sarcoma. ICG is taken up and retained by sarcoma tumours to a greater extent than normal tissue, demonstrating its potential to aid in visualisation of tumour margins. However, the mechanisms surrounding preferential ICG uptake in tumours are poorly understood. Methods: In vitro ICG cellular uptake studies were performed across a panel of four sarcoma cell lines and one breast cancer cell line, exhibiting varying proliferation rates and phenotypes. The effects of ICG concentration, incubation time, inhibition of clathrin mediated endocytosis and cell line proliferation rate on the cellular uptake of ICG were investigated, using fluorescence microscopy and flow cytometry. The spatial orientation of ICG was also assessed in a patient specimen. Results: The level of ICG cellular uptake was dependent on ICG concentration and incubation time. Cell line proliferation rate correlated significantly to ICG uptake within 30 minutes (Rs = 1, p<0.001), whilst retention of ICG after 24hrs did not (Rs = 0.3, p=0.624). From our data, the primary mechanism of ICG uptake in sarcoma cells is via clathrin mediated endocytosis. Following the resection of a grade 3 leiomyosarcoma, ICG signal was detectable macroscopically and on 3um sections, whilst being negative on the muscle control. Conclusions: The use of ICG for tumour detection in sarcoma surgery may demonstrate higher utility in high grade tumours compared to low grade tumours, due to the observation of higher ICG uptake in more proliferative cell lines. It is likely that the enhanced permeability and retention (EPR) effect plays a significant role in the retention of ICG within tumours. Future work on the detection of ICG at the cellular level within human tissue sections is required, with the aid of purpose built NIR microscopes.

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Application of intraoperative indocyanine green angiography for detecting flap congestion in the use of free deep inferior epigastric perforator flaps for breast reconstruction

Cited by 35 publications

References 19 publications

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases

Investigating the mechanisms of indocyanine green (ICG) cellular uptake in sarcoma

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