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Maintaining a Healthy Degree of Suspicion: Utilizing SPY Angiography in High-risk Patients

Li, Xingchen, BA; Parcells, Alexis L., MD; Lee, Edward S., MD

Plastic and Reconstructive Surgery – Global Open: December 2016 - Volume 4 - Issue 12 - p e1172
doi: 10.1097/GOX.0000000000001172
United States

From the Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, N.J.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Xingchen Li, BA, Division of Plastic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Ambulatory Care Center, E1620, Newark, NJ 07103, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Laser-assisted indocyanine green angiography (most often using the SPY Elite System [LifeCell Corp., Branchburg, N.J.]) is a recent technology that is frequently described in the literature as a method useful for assessing flap viability and preventing flap failure. Although most of the attention on angiography surrounds breast reconstruction, fewer studies have focused on facial reconstruction and even fewer on high-risk patients.

A 68-year-old white woman underwent a paramedian forehead flap after excision of a basal cell carcinoma on her nose. Because of her extensive smoking history, we used SPY angiography 3 weeks after the initial procedure. There was evidence of minimal perfusion of the central portion of our flap, and as such, we sectioned half of it for secondary delay (Fig. 1). Two weeks later, we again performed SPY angiography that demonstrated excellent inflow from her nasal bed, and her pedicle was divided (Fig. 2).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Existing studies on high-risk facial reconstruction patients use SPY angiography to safely attempt reducing the wait time before pedicle division. This is particularly important with paramedian forehead flaps as the externalized pedicle can cause significant distress to the patient by preventing eyeglass use, obstructing vision, and affecting personal appearance.1 Christensen et al2 described a case involving a 65-year-old female smoker with history of hepatitis C and polycythemia vera in which pedicle division of a paramedian flap was successfully performed at 3 weeks after angiography showed good perfusion. They successfully implanted a flap that otherwise would have been delayed had clinical judgment, based on visual examination of the flap after pedicle occlusion and pinprick, been the sole determinant. Lee et al3 used angiography to map flap perfusion over time and also found it useful in turning a subjective decision, based on a surgeon’s clinical judgment and experience, to proceed with pedicle division in smokers into an objective one.

Although most studies have focused on angiography as a supplement to clinical judgment in proceeding with pedicle division, our report records the first instance in the literature in which SPY angiography led to delay of pedicle division and prevention of an incipient serious complication. Although early division of the pedicle may be preferable and could be supported even in high-risk patients, the plastic surgeon should still be wary of signs that the flap is ill suited for transfer, especially in high-risk patients. By maintaining a high suspicion for insufficient perfusion in this population, the surgeon can avoid the pitfalls of premature division of the pedicle. Not only would this be responsible practice, but as Kanuri et al4 noted in their study on the cost-effectiveness of SPY angiography in prosthesis-based breast reconstruction, substantial costs can be avoided because the treatment of flap necrosis is expensive and occurs more frequently in these complicated cases. Although many factors may be considered in deciding when to transfer a flap, our experience is a reminder that patient safety must always be the priority, especially in risky patients, and that SPY angiography can assist in maintaining it.

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1. Surowitz JB, Most SP. Use of laser-assisted indocyanine green angiography for early division of the forehead flap pedicle. JAMA Facial Plast Surg. 2015;17:209214.
2. Christensen JM, Baumann DP, Myers JN, et al. Indocyanine green near-infrared laser angiography predicts timing for the division of a forehead flap. Eplasty 2012;12:e41.
3. Lee LN, Smith DF, Boahene KD, et al. Intraoperative laser-assisted indocyanine green imaging for objective measurement of the vascular delay technique in locoregional head and neck flaps. JAMA Facial Plast Surg. 2014;16:343347.
4. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg. 2014;133:448e454e.
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.