The Use of Indocyanine Green Angiography for Cosmetic and Reconstructive Assessment in the Head and Neck

Abstract

Reconstructive procedures in the head and neck can be a surgical challenge owing to the complex anatomical and physiological structure. Different locoregional and microvascular flaps are used for various defects to improve both function and cosmesis. Subjective clinical findings have been the mainstay for perfusion monitoring; however, areas of borderline perfusion are much more difficult to assess clinically. Multiple technologies that offer objective perfusion assessment have been developed to improve surgical outcomes. Indocyanine green (ICG) angiography has gained popularity owing to its minimal invasiveness and increased sensitivity and specificity in assessing flap perfusion particularly in the head and neck. It has been extensively used in free flaps, pedicled flaps (including nasal reconstruction), facelift procedures, random flaps, skull base reconstruction, and pharyngocutaneous fistula prediction. Its perioperative use has provided valuable qualitative and quantitative data that aid our understanding of flap hemodynamics. Clinically, this impacted decision-making in flap design, harvest, inset, and precocious salvage interventions. Though increased cost and intraoperative time could be limitations, cost-effectiveness studies have supported its use, particularly in high-risk individuals. Limitations include the lack of standardized dosing and consistent methodology agreement for data analysis. Future studies should involve larger cohorts and multi-institute studies to overcome such limitations.

Hyperintensity of integrin‐targeted fluorescence agent IntegriSense750 accurately predicts flap necrosis compared to Indocyanine green

“…Close monitoring of the pedicled flap is critical to its success, as early signs of flap failure could alter the clinical management course of patient care. Perfusion assessment of a pedicled flap is usually based on subjective clinical findings such as skin turgor, color, capillary refill, and dermal bleeding 5 . Areas of borderline perfusion and watershed areas that cross adjacent angiosomes are more difficult to assess with these subjective clinical strategies.…”

“…Indocyanine green (ICG) fluorescence angiography is an established and objective tool to assess flap perfusion. ICG has gained popularity for its minimal invasiveness and good sensitivity (95%–100%) and specificity (98.8%–100%) in assessing flap perfusion 5,6 . ICG is a water‐soluble, tricarbocyanine dye that absorbs light in the near‐infrared spectral range and fluoresces maximally at 835 nm 7 .…”

“…Perfusion assessment of a pedicled flap is usually based on subjective clinical findings such as skin turgor, color, capillary refill, and dermal bleeding. 5 Areas of borderline perfusion and watershed areas that cross adjacent angiosomes are more difficult to assess with these subjective clinical strategies.…”

“…ICG has gained popularity for its minimal invasiveness and good sensitivity (95%-100%) and specificity (98.8%-100%) in assessing flap perfusion. 5,6 ICG is a water-soluble, tricarbocyanine dye that absorbs light in the near-infrared spectral range and fluoresces maximally at 835 nm. 7 It demonstrates strict occupancy to the intravascular space and has a short half-life of 2.5-4 min.…”

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

“…9 Since Still et al 10 first used ICGA to evaluate flap perfusion in 1999, this technique has been adapted for plastic and reconstructive surgeries. 11,12 The benefits of ICGA in assessing tissue perfusion to aid clinical decision-making have been demonstrated in mastectomy skin flaps, 13 free flaps, 12 and pedicle flaps. 14 ICGA uses a dedicated near-infrared digital camera to record the fluorescence of ICG in real-time for perfusion assessment, and can directly demonstrate flap perfusion by the intensity of fluorescence.…”