Use of Indocyanine Green Imaging for Perforator Identification in Preexpanded Brachial Artery Perforator Flaps

Abstract

The tissues of the medial arm as a donor site for perforator flap design have several advantages. However, they are relatively underused with limited reports, partly due to unreliable perforator anatomy. Therefore, we aimed to review our preliminary experience using indocyanine green (ICG) angiography to design and elevate preexpanded pedicled brachial artery perforator (BAP) flaps for regional reconstruction. All patients underwent soft tissue reconstructions using a preexpanded BAP flap in two or three stages. ICG angiography was used to localize perforators during both expander insertion and flap elevation. The pedicle was divided at the third stage 3 weeks following flap elevation for head and neck cases. Sixteen patients underwent reconstructions of the head and neck (n = 13) or shoulder/trunk (n = 3) using 14 perforator-plus and 2 propeller BAP flaps. In total, 50 perforators were identified using ICG imaging, all of which were appreciable during both expander placement and flap elevation. Thirty-five perforators were directly visualized during flap elevation, and an additional 15 perforators were not explored but incorporated into the flap. All flaps survived without necrosis, and the donor sites healed uneventfully without complications. The medial arm provides thin and pliable skin for the resurfacing of regional defects with relatively minimal donor-site morbidity. With the assistance of ICG angiography, perforators of the brachial artery can be reliably identified, facilitating the preexpansion and elevation of pedicled BAP flaps for use in head–neck and trunk reconstruction.

Use of Serial Flap Transfer Technique in En Bloc Reconstruction of Extensive Soft Tissue Defects in the Head and Neck

“…4 A full-length medial arm flap can be safely harvested with a single pulsatile perforator from the brachial artery and applied to head and neck defects as a perforator-plus flap based on a proximal or distal pedicle without the need for microsurgery. 6 When combined with tissue expansion, a maximum size of 27 Â 14 cm medial arm skin could be transferred without the risk of ischemia. Most donor sites were closed with skin grafting, and the circumference of the medial arm remarkably decreased, resulting in apparent contour deformity and bilateral asymmetry.…”

“…4,5 Thus, a large flap can be harvested from these sites as a perforator-plus flap to achieve en bloc reconstruction of hemifacial defects. 6,7 This technique respects the principle of like-withlike tissue reconstruction and results in minimal scars. However, the donor site is often closed under tension or with skin grafting after a significant amount of tissue is excised, even combined with tissue expansion.…”

Imaging for thinned perforator flap harvest: current status and future perspectives

“…Tissue expansion, a popular approach to create perforator flaps with decreased adipose and dermal thicknesses that simultaneously match the colour and texture of recipient sites [ 46 ], tends to evoke haemodynamic changes through choke anastomosis opening and neovascularization [ 47 ]. ICGA is beneficial in perforator localization of such thin flaps of <8 mm thickness and with greatly augmented vascularity [ 48 , 49 ].…”

“…Thus, apart from direct thin flap elevation, this feature of ICGA has also contributed to its feasibility in flap defatting after elevation where the degree of flap thinning can still be continually adjusted according to perfusion mapping during the procedure [ 17 ]. Its application could also be further broadened to include flaps where vascularization has been augmented through prefabrication, supercharging or tissue expansion, to assist in tailoring optimal flap designs based on the perfusion territories of the pedicle [ 49 ]. The efficacy of ICGA as a haemodynamic analysis tool for quantitative measurements of arterial inflow and venous outflow, has been further proven by our previous work on challenging cervicofacial reconstruction with pre-expanded multipedicled perforator flap with augmented blood supply, prefabricated and/or supercharging, which demands an even thinner and larger flap yet with secured vascularization [ 51 ].…”

“…The efficacy of ICGA as a haemodynamic analysis tool for quantitative measurements of arterial inflow and venous outflow, has been further proven by our previous work on challenging cervicofacial reconstruction with pre-expanded multipedicled perforator flap with augmented blood supply, prefabricated and/or supercharging, which demands an even thinner and larger flap yet with secured vascularization [ 51 ]. Reliable flap necrosis prediction has helped to avoid unfortunate vascular-related flap outcomes particularly in the distal end due to in-time flap salvage [ 12 , 49 ]. Moreover, ICGA could even be used for expansion capsule pressure optimization during the expansion period, helping to eradicate expansion-related complications, as demonstrated in our previous work [ 52 ].…”