Indocyanine green angiography technique assisted brachial artery perforator propeller flap to repair soft tissue defects of trunk and upper limb_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XIE Tingjun ,  LIU Yuanbo , HAN Tinglu , ZHU Shan , ZANG Mengqing , CHEN Bo , LI Shanshan

Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China;

Corresponding author：

LIU Yuanbo, Email: ybpumc@sina.com

Keywords：

Brachial artery; septocutaneous perforator; propeller flap; indocyanine green; angiography technique

DOI：

10.7507/1002-1892.202008094

Video：

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Objective To explore the feasibility of using indocyanine green (ICG) angiography to detect brachial artery perforators, and the clinical application of brachial artery perforator propeller (BAPP) flaps to repair soft tissue defects of the trunk and upper limbs.Methods Between August 2016 and February 2019, ICG angiography was used to detect the perforating vessels of the brachial artery muscle septum, and the BAPP flaps were cut out with the detected perforating vessels as the pedicle to repair 19 cases of trunk and upper limb soft tissue defects. There were 12 males and 7 females, with an average age of 28.6 years (range, 5-66 years). Etiologies included the post-burn scar in 10 cases, soft-tissue sarcoma in 5 cases, congenital melanocytic nevi in 2 cases, chronic chest wall ulcer in 1 case, and malignant melanoma in 1 case. Defects located in axilla in 8 cases, chest wall in 4 cases, elbow in 5 cases, and shoulder in 2 cases. The area of the defect ranged from 15 cm×3 cm to 20 cm×8 cm. Pre-transfer tissue expansion was used in 11 patients. Thirteen flaps were pedicled with 1 perforator vessel, and 6 flaps were pedicled with 2 perforator vessels. The length of the vascular pedicle was 2.5-4.5 cm, with an average of 3.08 cm. The area of the skin flap ranged from 11 cm×5 cm to 22 cm×10 cm. The flap rotation angle was 110° in 1 case, 120° in 1 case, and 180° in 17 cases. Except for one donor site repaired by skin graft, the other donor sites were directly sutured.Results A total of 24 perforating vessels of the brachial artery muscle septum were detected by ICG angiography, 26 were identified during the operation, with an accuracy rate of 92.31%. Eighteen flaps survived without arteriovenous crisis. Venous congestion was observed in the distal 3-cm of one flap and the flap survived after conservative management. Intraoperative analysis showed that the blood perfusion of the distal 4-cm of one flap was poor, the relative value was less than 32%, the flap survived after removing the poor perfusion area. All the patients were followed up 3 to 23 months (mean, 8.6 months). The color and texture of the flap were similar to those of the recipient area. Flap debulking was not needed in all patients owing to the thinness of the flap. The contracture symptoms of patients with scar contracture on the medial of the elbow joint and axilla were significantly improved; a patient with malignant melanoma underwent tumor resection at 1 year and 5 months after operation due to tumor recurrence, and additional surgery was done to remove the recurrent tumor. No tumor recurrence was found in other patients.Conclusion The ICG angiography technique can be used to explore the perforating vessels of the brachial artery muscle septum. The BAPP flap pedicled with the perforating vessels can be used for the repair of skin and soft tissue defects in the chest wall, axilla, shoulder, and elbow joint.

Citation： XIE Tingjun, LIU Yuanbo, HAN Tinglu, ZHU Shan, ZANG Mengqing, CHEN Bo, LI Shanshan. Indocyanine green angiography technique assisted brachial artery perforator propeller flap to repair soft tissue defects of trunk and upper limb. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(2): 200-205. doi: 10.7507/1002-1892.202008094 Copy

1.	Daniel RK, Terzis J, Schwarz G. Neurovascular free flaps. A preliminary report. Plast Reconstr Surg, 1975, 56(1): 13-20.
2.	Karamürsel S, Bağdatli D, Demir Z, et al. Use of medial arm skin as a free flap. Plast Reconstr Surg, 2005, 115(7): 2025-2031.
3.	Bin S, Yuanbo L, Ji J, et al. Preexpanded pedicle medial arm flap: an alternative method of massive facial defect reconstruction. Aesthetic Plast Surg, 2011, 35(6): 946-952.
4.	Liu Y, Zang M, Tang M, et al. Pre-expanded brachial artery perforator flap. Clin Plast Surg, 2017, 44(1): 117-128.
5.	Teo TC. The propeller flap concept. Clin Plast Surg, 2010, 37(4): 615-626.
6.	Bekara F, Herlin C, Somda S, et al. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis. Microsurgery, 2018, 38(1): 109-119.
7.	Sekiguchi H, Motomiya M, Sakurai K, et al. Brachial artery perforator-based propeller flap coverage for prevention of readhesion after ulnar nerve neurolysis. Microsurgery, 2015, 35(2): 158-162.
8.	Carriquiry CE. Versatile fasciocutaneous flaps based on the medial septocutaneous vessels of the arm. Plast Reconstr Surg, 1990, 86(1): 103-109.
9.	刘元波, 朱珊, 臧梦青, 等. 穿支皮瓣研究领域的新技术、新方法. 中华整形外科杂志, 2019, 35(9): 835-846.
10.	Newman MI, Samson MC. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg, 2009, 25(1): 21-26.
11.	Casey WJ, Connolly KA, Nanda A, et al. Indocyanine green laser angiography improves deep inferior epigastric perforator flap outcomes following abdominal suction lipectomy. Plast Reconstr Surg, 2015, 135(3): 491e-497e.
12.	Azuma R, Morimoto Y, Masumoto K, et al. Detection of skin perforators by indocyanine green fluorescence nearly infrared angiography. Plast Reconstr Surg, 2008, 122(4): 1062-1067.
13.	Sacks JM, Nguyen AT, Broyles JM, et al. Near-infrared laser-assisted indocyanine green imaging for optimizing the design of the anterolateral thigh flap. Eplasty, 2012, 12: e30.
14.	Hwang K, Lee WJ, Jung CY, et al. Cutaneous perforators of the upper arm and clinical applications. J Reconstr Microsurg, 2005, 21(7): 463-469.
15.	薛兵建, 臧梦青, 陈博, 等. 上臂内侧肌间隔穿支血管分布规律及其皮瓣的临床应用. 中华整形外科杂志, 2019, 35(9): 874-880.
16.	González Martínez J, Torres Pérez A, Gijón Vega M, et al. Preoperative vascular planning of free flaps: comparative study of computed tomographic angiography, color doppler ultrasonography, and hand-held doppler. Plast Reconstr Surg, 2020, 146(2): 227-237.
17.	Rozen WM, Ashton MW, Stella DL, et al. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg, 2008, 122(4): 1003-1009.
18.	Pestana IA, Zenn MR. Correlation between abdominal perforator vessels identified with preoperative CT angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient. Ann Plast Surg, 2014, 2(6): S144-S149.
19.	刘元波, 王欣, 张世民, 等. “带蒂穿支皮瓣常见并发症原因分析与防治”专家共识. 中华显微外科杂志, 2017, 40(2): 105-108.
20.	Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg, 2009, 124(5): 1529-1544.
21.	Dai J, Chai Y, Wang C, et al. Distally based saphenous neurocutaneous perforator flap for reconstructive surgery in the lower leg and the foot: a long-term follow-up study of 70 patients. J Reconstr Microsurg, 2013, 29(7): 481-485.
22.	Leighton WD, Russell RC, Feller AM, et al. Experimental pretransfer expansion of free-flap donor sites: Ⅱ. Physiology, histology, and clinical correlation. Plast Reconstr Surg, 1988, 82(1): 76-87.
23.	Newman MI, Jack MC, Samson MC. SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis. Ann Plast Surg, 2013, 70(5): 595-598.
24.	Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg, 2012, 129(5): 1043-1048.

1. Daniel RK, Terzis J, Schwarz G. Neurovascular free flaps. A preliminary report. Plast Reconstr Surg, 1975, 56(1): 13-20.
2. Karamürsel S, Bağdatli D, Demir Z, et al. Use of medial arm skin as a free flap. Plast Reconstr Surg, 2005, 115(7): 2025-2031.
3. Bin S, Yuanbo L, Ji J, et al. Preexpanded pedicle medial arm flap: an alternative method of massive facial defect reconstruction. Aesthetic Plast Surg, 2011, 35(6): 946-952.
4. Liu Y, Zang M, Tang M, et al. Pre-expanded brachial artery perforator flap. Clin Plast Surg, 2017, 44(1): 117-128.
5. Teo TC. The propeller flap concept. Clin Plast Surg, 2010, 37(4): 615-626.
6. Bekara F, Herlin C, Somda S, et al. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis. Microsurgery, 2018, 38(1): 109-119.
7. Sekiguchi H, Motomiya M, Sakurai K, et al. Brachial artery perforator-based propeller flap coverage for prevention of readhesion after ulnar nerve neurolysis. Microsurgery, 2015, 35(2): 158-162.
8. Carriquiry CE. Versatile fasciocutaneous flaps based on the medial septocutaneous vessels of the arm. Plast Reconstr Surg, 1990, 86(1): 103-109.
9. 刘元波, 朱珊, 臧梦青, 等. 穿支皮瓣研究领域的新技术、新方法. 中华整形外科杂志, 2019, 35(9): 835-846.
10. Newman MI, Samson MC. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg, 2009, 25(1): 21-26.
11. Casey WJ, Connolly KA, Nanda A, et al. Indocyanine green laser angiography improves deep inferior epigastric perforator flap outcomes following abdominal suction lipectomy. Plast Reconstr Surg, 2015, 135(3): 491e-497e.
12. Azuma R, Morimoto Y, Masumoto K, et al. Detection of skin perforators by indocyanine green fluorescence nearly infrared angiography. Plast Reconstr Surg, 2008, 122(4): 1062-1067.
13. Sacks JM, Nguyen AT, Broyles JM, et al. Near-infrared laser-assisted indocyanine green imaging for optimizing the design of the anterolateral thigh flap. Eplasty, 2012, 12: e30.
14. Hwang K, Lee WJ, Jung CY, et al. Cutaneous perforators of the upper arm and clinical applications. J Reconstr Microsurg, 2005, 21(7): 463-469.
15. 薛兵建, 臧梦青, 陈博, 等. 上臂内侧肌间隔穿支血管分布规律及其皮瓣的临床应用. 中华整形外科杂志, 2019, 35(9): 874-880.
16. González Martínez J, Torres Pérez A, Gijón Vega M, et al. Preoperative vascular planning of free flaps: comparative study of computed tomographic angiography, color doppler ultrasonography, and hand-held doppler. Plast Reconstr Surg, 2020, 146(2): 227-237.
17. Rozen WM, Ashton MW, Stella DL, et al. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg, 2008, 122(4): 1003-1009.
18. Pestana IA, Zenn MR. Correlation between abdominal perforator vessels identified with preoperative CT angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient. Ann Plast Surg, 2014, 2(6): S144-S149.
19. 刘元波, 王欣, 张世民, 等. “带蒂穿支皮瓣常见并发症原因分析与防治”专家共识. 中华显微外科杂志, 2017, 40(2): 105-108.
20. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg, 2009, 124(5): 1529-1544.
21. Dai J, Chai Y, Wang C, et al. Distally based saphenous neurocutaneous perforator flap for reconstructive surgery in the lower leg and the foot: a long-term follow-up study of 70 patients. J Reconstr Microsurg, 2013, 29(7): 481-485.
22. Leighton WD, Russell RC, Feller AM, et al. Experimental pretransfer expansion of free-flap donor sites: Ⅱ. Physiology, histology, and clinical correlation. Plast Reconstr Surg, 1988, 82(1): 76-87.
23. Newman MI, Jack MC, Samson MC. SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis. Ann Plast Surg, 2013, 70(5): 595-598.
24. Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg, 2012, 129(5): 1043-1048.

Chinese Journal of Reparative and Reconstructive Surgery

Indocyanine green angiography technique assisted brachial artery perforator propeller flap to repair soft tissue defects of trunk and upper limb

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