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Original Investigation |

Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction Comparison of Clinical Findings, Fluorescein, and Indocyanine Green Angiography

Andrew D. Beckler, MD1; Waleed H. Ezzat, MD1,2; Rahul Seth, MD1,3; Vishad Nabili, MD1; Keith E. Blackwell, MD1
[+] Author Affiliations
1Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles
2currently with the Department of Otolaryngology–Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts
3currently with the Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco
JAMA Facial Plast Surg. 2015;17(6):422-426. doi:10.1001/jamafacial.2015.0961.
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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 Measures  The rates of partial skin paddle necrosis and revision reconstructive surgery.

Results  The 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 Relevance  The 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.

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Intraoperative Indocyanine Green Angiography Shows Poor Perfusion of the Margin of a Fibula Flap Skin Paddle Harvested From the Proximal Leg

The entire skin paddle appeared to be viable according to clinical findings. Using the quantification software that is available with the SPY Elite Imaging System (Novadaq Technologies Inc), a perfusion intensity of less than 33% of maximal perfusion was chosen as an indicator of hypoperfusion, and the flap was trimmed according to these findings. This line of demarcation corresponds to the black line. The flap did not develop partial necrosis. The percentages represent perfusion compared with the green 100, which was selected as the maximal area of perfusion in the flap.

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