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Quantitative Assessment of Perfusion and Vascular Compromise in Perforator Flaps Using a Near-Infrared Fluorescence-Guided Imaging System

Matsui, Aya M.D.; Lee, Bernard T. M.D.; Winer, Joshua H. M.D.; Laurence, Rita G. B.S.; Frangioni, John V. M.D., Ph.D.

Plastic and Reconstructive Surgery: August 2009 - Volume 124 - Issue 2 - p 451-460
doi: 10.1097/PRS.0b013e3181adcf7d
Experimental: Original Articles

Background: Techniques currently used to determine flap perfusion are mainly subjective, with the majority of reconstructive surgeons still relying on clinical examination. In this study, the authors demonstrate the use of near-infrared fluorescence angiography to directly quantify normal and abnormal perfusion in perforator flaps.

Methods: Indocyanine green was injected intravenously into anesthetized adult pigs (n = 38). A custom near-infrared fluorescence imaging system was used for image acquisition and quantitation. Thirty-nine flaps were designed based on identified perforators, and postoperative imaging was performed for comparison. In select flaps, isolated occlusion of the arterial and venous pedicle was performed. In select flaps, vascular spasm was induced by local irrigation of the vessels with epinephrine. The fluorescence intensities of select regions of interest were quantified. From these data, the authors defined two indices for abnormal perfusion: the Tmax ratio and the drainage ratio.

Results: The authors identified a normal pattern of perfusion before flap elevation, composed of a distinct fluorescence intensity peak at maximal arterial inflow followed by a smooth drop representing venous drainage. Delay of this peak after flap elevation, as indicated by the Tmax ratio, identified vascular spasm and arterial occlusion (p < 0.0001). Abnormal fall of fluorescence intensities after this peak, as indicated by the drainage ratio, identified venous occlusion (p < 0.0001).

Conclusions: Quantitation of fluorescence intensities by near-infrared angiography accurately characterizes arterial and venous compromise. The authors’ technique can assess perfusion characteristics during the intraoperative and postoperative periods and therefore complements clinically based subjective criteria now used for flap assessment.

Boston, Mass.; and Sapporo, Japan

From the Division of Hematology/Oncology, Department of Medicine, the Department of Radiology, and the Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center; the Division of Cancer Diagnostics and Therapeutics, Hokkaido University Graduate School of Medicine; and the Department of Surgery, Brigham & Women’s Hospital.

Received for publication November 20, 2008; accepted January 8, 2009.

Drs. Matsui, Lee, and Frangioni contributed equally to this work.

Poster presented at the World Molecular Imaging Conference, in Nice, France, September 10 through 13, 2008.

Disclosure: All intellectual property for the intraoperative near-infrared fluorescence imaging system is owned by Dr. Frangioni’s employer, the Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School. The patent rights have been licensed nonexclusively by the Beth Israel Deaconess Medical Center to GE Healthcare. As inventor of the technology, Dr. Frangioni may someday receive royalties if a product is ever developed. Dr. Frangioni has no real or deferred equity interests, whatsoever, in this or any other technology. Dr. Frangioni does not consult for any company. GE Global Research sponsors unrelated research in Dr. Frangioni’s laboratory. The other authors have no conflicts of interest to disclose.

John V. Frangioni, M.D., Ph.D., Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Room SL-B05, Boston, Mass. 02215,

©2009American Society of Plastic Surgeons