Intraoperative flap design using ICG monitoring of a conjoined fabricated anterolateral thigh/tensor fasciae latae perforator flap in a case of extensive soft tissue reconstruction at the lower extremity

Abstract

In this report, we present a case of the use of a conjoined fabricated free anterolateral thigh (ALT)/tensor fascia latae (TFL) perforator flap for reconstruction of the lower extremity with intraoperative flap design using intraoperative indocyanine green (ICG) monitoring. The flap was used for reconstruction of a 16 cm × 28 cm sized defect of the lower leg in a 24-year-old man. The defect was caused by a third degree open fracture to the tibia. Upon dissection of the ALT perforators, ICG monitoring showed that both dominant ALT perforators did not yield a sufficient perforasome (∼16 cm × 17 cm) for the larger flap needed. An adjacent TFL perforator also supplied a large perforasome (∼15 cm × 11 cm), so a conjoined fabricated flap was harvested and transplanted to cover an extensive lower leg defect. The artery of the TFL perforator pedicle was being in-flap anastomosed to a side branch of the ALT pedicle. Postoperative course was uneventful and there were no complications. Length of follow-up was 6 months, aesthetic and functional outcome was good. The patient was very satisfied with the aesthetic outcome. Both legs were fully mobile after intensive physiotherapy for the reconstructed leg. The leg where the flap had been harvested showed full strength in knee joint flexion. This case could show that identification of the supplying vessels may be possible by ICG monitoring. © 2015 Wiley Periodicals, Inc. Microsurgery 36:684-688, 2016.

Intraoperative Mapping of the Subfascial Plexus Using the Transillumination Method for Head and Neck Reconstruction with Free Style Anterolateral Thigh Flaps

“…In a series of 15 patients, Sacks et al 22 used laserassisted near-infrared indocyanine green angiography intraoperatively to localize the perforator perfusion zones for assisting immediate ALT flap design. In a case of a conjoined ALT and tensor fascia lata perforators, Buehrer et al 23 proposed a similar modality using intraoperative indocyanine green monitoring to identify a sufficient perforasome before flap harvesting and also to assess the vascular flow after anastomosis. Sacks et al 22 stated that laser-assisted indocyanine green angiography can provide real-time, intraoperative, and quantitative information to optimize ALT flap design, and they did not use the handheld Doppler to identify the perforator preoperatively.…”

Der sichere Lappen – Präoperatives Gefäß-Mapping und intraoperative Perfusionsmessung zur Reduktion der lappenbedingten Morbidität

“…So kann zum Beispiel das Lappendesign an die Gewebedurchblutung, sprich das Perforasom angepasst werden. Buehrer et al beschrieben einen klinischen Fall, bei dem ein ausgedehnter Weichteildefekt am Unterschenkel mit einem freien ALT-Lappen der Gegenseite rekonstruiert werden sollte [37]. Nach der Präparation zweier ALT-Perforatoren evaluierten die Autoren das ALT-Perforasom mittels ICG-Fluoreszenzangiographie und realisierten, dass dieses nicht die gesamte Lappenfläche versorgen konnte.…”

Application of Indocyanine Green in Flap Surgery: A Systematic Review

“…ICG may be used to design the flap, to assess flap perfusion, to evaluate the patency of microvascular anastomoses, to monitor the flap postoperatively, and to check lymphatic system function. 1,[10][11][12] The aim of this study is to summarize the utility of ICG in tissue transfer surgery and to evaluate the maximum safe dose, routine dose, pre-operative allergy testing protocols, relevant contraindications, and the potential adverse effects in flap surgery; all of which will assist clinicians in applying ICG safely and efficiently.…”