The role of near-infrared angiography in the assessment of post-operative venous congestion in random pattern, pedicled island and free flaps  Kartik G. Krishnan, Gabriele Schackert, Ralf Steinmeier  British Journal of Plastic Surgery  Volume 58, Issue 3, Pages 330-338 (April 2005) DOI: 10.1016/j.bjps.2004.10.003 Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions

Figure 1 Large random pattern flaps were raised on the basis of the underlying muscles to cover this post-resection and post-radiation defect of the sacral region (left above and below). ICG-NIR-VA immediately after surgery (one session) showed delayed dye-intake at the tip regions of the flap (upper row). No clinically noticeable vascular complications were encountered. The graph shows the fluorescence saturation curves of the different areas of interest. British Journal of Plastic Surgery 2005 58, 330-338DOI: (10.1016/j.bjps.2004.10.003) Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions

Figure 2 An extended pedicled fasciocutaneous flap based on the artery supplying the tensor fasciae latae muscle was rotated to cover a nonhealing sacral pressure ulcer (left above and below). The vascularity of the cutaneous island completely depended on the subdermal microvascular plexus. Notice the delay in ICG-filling of the flap (delayed uptake) as compared to the surrounding skin in the ICG-NIR-VA performed immediately after transfer (upper row). There was no clinical correlate for this video-angiographic finding. Clinical healing was uneventful. The graph denotes the fluorescence saturation curves for the different areas of interest during this session of recording (the spikes are caused due to movement of the patient during recording). British Journal of Plastic Surgery 2005 58, 330-338DOI: (10.1016/j.bjps.2004.10.003) Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions

Figure 3 (illustrative case): This small flap from the volar forearm was raised as a distally based perforator flap as described by Jeng et al.21 for wound coverage in the palmar region (upper left and middle). After raising and rotation ICG-NIR-VA was performed (upper right): this showed good perfusion in the proximal region of the flap (+), where the vascular pedicle enters it (arrow); the distal region of the flap was not perfused (*), although clinically the flap showed ‘healthy’ color. Upon this result, a venoarterial microanastomosis was performed between a subcutaneous vein entering the distal pole of the flap and the palmar arch. Now the ICG-NIR-VA was repeated (middle row); this showed good filling in all areas of the flap (also see the fluorescence curve—lower left; the waves represent movement artifacts). Healing and functional results were uneventful; flap debulking is necessary to attain the desirable contour (lower right). British Journal of Plastic Surgery 2005 58, 330-338DOI: (10.1016/j.bjps.2004.10.003) Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions

Figure 4 A free lateral arm flap for coverage of a soft tissue defect of the dorsum of the foot. We did not observe any clinical complications what-so-ever during the entire healing process. ICG-NIR-VA, however, showed a significant delay of dye uptake and clearance from the flap (upper row) during the early post-operative course. Notice the ‘dark’ nonfluorescent flap, whereas the skin surrounding it is fluorescent. As the clearance stage approaches, the flap is fully fluorescent, whereas the surrounding skin is already drained of the dye. We performed the ICG-NIR-VA after healing had occurred (with the patient's informed consent) for purposes of comparison (middle row). This showed normal results as seen in the isointense fluorescence of both the flap and the surrounding area. The graphs show the fluorescence intensity curves of the respective areas of interest. British Journal of Plastic Surgery 2005 58, 330-338DOI: (10.1016/j.bjps.2004.10.003) Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions

Figure 5 Reconstruction of a through-and-through defect reaching the Achilles tendon complicated with wound healing problems and a painful nerve lesion using a lateral thigh perforator flap (left above and below). During the early post-operative phase, the NIR-VA showed a significant delay in the ICG assimilation and clearance from the flap, especially in its distal part as seen in the difference in fluorescence intensity (upper row and lower middle). There were no clinical correlates for this observation. Healing occurred primarily and without any further manipulations. The graph shows the fluorescence saturation curves at the various chosen areas of interest during one session of recording. British Journal of Plastic Surgery 2005 58, 330-338DOI: (10.1016/j.bjps.2004.10.003) Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions

Figure 6 The ICG-NIR-VA-graphic appearance of a free lateral arm flap Table 1, case 7 that showed clinical venous congestion soon after leeching (performed on day 3 after transfer). Notice the dye filling in the flap that completely corresponds to the surrounding healthy skin (upper row). The graph denotes the fluorescence saturation curves of the chosen areas of interest during this session of recording. Healing was uneventful after applying leeches (lower left). British Journal of Plastic Surgery 2005 58, 330-338DOI: (10.1016/j.bjps.2004.10.003) Copyright © 2004 The British Association of Plastic Surgeons Terms and Conditions