Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction

Abstract

IMPORTANCE Complications of partial flap necrosis contribute substantially to morbidity in patients who undergo head and neck reconstructive surgery. OBJECTIVE To assess the usefulness of clinical findings, intraoperative fluorescein angiography, and intraoperative indocyanine green angiography (ICGA) for evaluation of flap skin paddle perfusion in patients undergoing oromandibular reconstruction who are at high risk of partial skin paddle necrosis. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review from May 21, 1996, to May 27, 2015, at a tertiary care academic medical center. Participants were 73 patients who underwent reconstruction of through-and-through defects of the mucosa, mandible, and skin using fibula free flaps that contained large bilobed skin paddles. MAIN OUTCOMES AND MEASURESThe rates of partial skin paddle necrosis and revision reconstructive surgery. RESULTSThe rates of partial flap necrosis were 8% (n = 2) among 25 patients in whom the skin paddle was trimmed based on ICGA and 33% (n = 16) among 48 patients in whom the skin paddle was trimmed according to clinical findings (P = .02). The rates of revision reconstructive surgery were 20% (5 of 25) when flap skin paddles were trimmed using ICGA and 42% (20 of 48) when trimmed per clinical findings (P = .06). CONCLUSIONS AND RELEVANCEThe use of ICGA may reduce the risk of partial skin flap necrosis in free flaps used in patients undergoing head and neck reconstruction who are at high risk of developing flap necrosis. Indocyanine green angiography imaging should be considered in any flap in which skin paddle viability is uncertain based on clinical findings and in patients in whom the skin paddle extends beyond the primary and adjacent angiosomes. LEVEL OF EVIDENCE 3.

Applications of intraoperative angiography in head and neck reconstruction

“…In cases of pharyngeal and oral cavity reconstructions, salivary fistulas cause delayed oral intake, and can result in lifethreatening conditions such as carotid blow-out syndrome. Reconstruction failures can also indirectly impact on patient prognosis as they may delay the initiation of adjuvant treatment 13,14 . Advocators for the use of LAIG highlight its ability to provide real-time intraoperative and objective assessment of areas of tissue perfusion that are not identified by the surgeon, serving as a superior clinical indicator compared with clinical intraoperative judgement alone 15 .…”

“…In free-flaps with high perforator variability such as the anterolateral thigh (ALT) free flap 20 , intraoperative angiography was described as an adjunct to select the most reliable skin perforator, as well as allowing reliable trimming prior to harvesting with good results 21 . Although we did not utilise LAIG for any fibula flap, Beckler et al 13 also had very promising results with the intraoperative angiography approach observing a reduction in partial skin flap necrosis of fibula flaps in a cohort of 73 patients that un- derwent oromandibular reconstructions with through and through defects. The reported post-laryngectomy pharyngocutaneous fistula rates range between 16% to 65% 22 .…”

Prediction of Flap Necrosis by Using Indocyanine Green Videoangiography in Cases of Venous Occlusion in the Epigastric Flap Model of the Rat

“…Intraoperative evaluation allows an assessment of the patency of microvascular anastomosis. 9 11 As stated consistently in the literature, the success of a free flap salvage operation is dependent on the early detection of vascular compromise and the subsequent short take-back time to the operating room. 12 The most common reason for flap failure is venous congestion, and congested flaps are more prone to fail than arterially compromised flaps.…”

“… 2 3 4 5 6 7 The use of indocyanine green (ICG) angiography can provide an early and accurate evaluation of flap perfusion. 8 9 ICG angiography is not restricted to vascular assessment but includes ICG lymphography to improve sentinel lymph node mapping and lymphovenous bypass surgery. 10 In the field of free flap surgery, the preoperative ICG angiography–assisted assessment of skin perfusion can help with flap design.…”

Multimodal Microvascular Mapping for Head and Neck, Skull Base Research and Education: An Anatomical Donor Study

“…14 15 16 17 Its significance is underscored by recent findings suggesting that incorporating fluorescence angiography into surgeries to evaluate the perfusion of free flaps might reduce the risk of flap necrosis by identifying areas of poor perfusion. 18 19 20 While fluorescence is one of the key modalities used for vascular imaging in the operating room or clinical setting, it is rarely used in anatomical dissection studies, where it could be used to identify and preserve vasculature via visualization of deeper vascular structures through tissue. A common fluorophore used in fluorescence imaging is fluorescein, which has a peak excitation at 494 nm (blue visible light) and emits fluorescence at a wavelength of approximately 520 nm which allows maximum visualization with a blue light filter.…”