Intraoperative near-infrared fluorescence imaging in perforator flap reconstruction: current research and early clinical experience

Abstract

Despite recent advances in perforator flap reconstruction, there can be significant variability in vessel size and location. Although preoperative evaluation may provide valuable information, real-time intraoperative methods have the potential to provide the greatest benefit. Our laboratory has developed the Fluorescence-Assisted Resection and Exploration (FLARE) near-infrared (NIR) fluorescence imaging system for intraoperative visualization of details of the underlying vasculature. The FLARE system uses indocyanine green, a safe and reliable NIR fluorophore already FDA-approved for other indications. The system has been optimized in large-animal models for the identification of perforator size, location, and perfusion and has also been translated to the clinic for use during breast reconstruction after mastectomy. In this article, we review our preclinical and clinical data, as well as literature describing the use of similar NIR fluorescence imaging systems in plastic and reconstructive surgery.

Figure 1. The FLARE™ (Fluorescence-Assisted Resection and Exploration) Near-Infrared Fluorescence Imaging System

The articulated arm has a reach of 50” laterally and 70” vertically, which permits positioning of the imaging head anywhere over the surgical field. The footswitch and satellite monitor are positioned according to surgeon preference.

Figure 2. Real-Time Quantitative Assessment of Flaps using NIR Fluorescence Angiography

Pre-operative assessment of an abdominal perforator flap. Shown are the color video (left) image, NIR fluorescence (middle) image, and a pseudo-colored (lime green) merge of the two (right). Images acquired at 8 sec post-injection of ICG. White arrow identifies the origin of a perforating vessel. N: nipple.

Figure 3. Assessment of Vessel Patency

After flap creation, the vessels on the undersurface of the flap (arrow) can also be evaluated. Shown are the color video image (left), NIR fluorescence image (middle), and a pseudo-colored (lime green) merge of the two (right). Images were acquired 10 sec post-injection of ICG.

Figure 4. Pilot Clinical Study

Evaluation of perforators in a deep inferior epigastric perforator flap breast reconstruction prior to vessel dissection (first row, right abdomen; second row, left abdomen). Evaluation of perfusion after isolation of flap on selected perforating vessels of the left abdomen, but prior to transfer (third row). Evaluation of flap perfusion after successful transfer and microsurgical anastomosis (fourth row).