title: Submental perforator flap design with a near-infrared fluorescence imaging system: the relationship among number of perforators, flap perfusion, and venous drainage.
abstract: BACKGROUND
  The submental flap is a reliable alternative to microsurgical reconstruction of facial deformities, providing an excellent cosmetic match with the contour and color of the face. In this study, the authors evaluated submental flap design by using near-infrared fluorescence angiography to identify perforator arteries. The impact of the number of preserved perforator arteries on flap perfusion and venous drainage was quantified.
  
  
  METHODS
  Indocyanine green was injected intravenously into 18 pigs. Three groups of six animals each had one, two, or three perforator arteries preserved. The fluorescence-assisted resection and exploration near-infrared fluorescence imaging system was used for image acquisition. Images were recorded before and after flap creation, and every hour, for 6 hours. The time to maximum perfusion, the drainage ratio (an indicator of venous drainage), and the percentage of perfused flap area were analyzed statistically at each time point.
  
  
  RESULTS
  Flaps with a single dominant perforator artery had an initial mean perfused area of 80 percent, which improved to 97 percent at 6 hours. For flaps with two and three preserved perforator arteries, perfused area at 6 hours was 99.8 percent and 100 percent, respectively. A significant increase was observed in all three metrics as more vessels were preserved. Regardless of the number of perforator arteries preserved, though, all three metrics improved over 6 hours.
  
  
  CONCLUSIONS
  Near-infrared fluorescence angiography can reliably identify submental perforator arteries for flap design and can be used to assess flap perfusion and venous drainage in real time. Flap metrics at 6 hours were equivalent when either one or multiple perforator arteries were preserved.
authors.affiliation: Boston, Mass.; and Sapporo, Japan From the Division of Hematology/Oncology, Department of Medicine, the Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Radiology, Beth Israel Deaconess Medical Center, the Department of Surgery, Brigham & Women's Hospital; and the Division of Cancer Diagnostics and Therapeutics, Hokkaido University Graduate School of Medicine.
authors.forename: Aya
authors.initials: A
authors.lastname: Matsui
authors.forename: Bernard T
authors.initials: BT
authors.lastname: Lee
authors.forename: Joshua H
authors.initials: JH
authors.lastname: Winer
authors.forename: Rita G
authors.initials: RG
authors.lastname: Laurence
authors.forename: John V
authors.initials: JV
authors.lastname: Frangioni
mesh_terms: D000792:Angiography / Q000379:methods; D000818:Animals; D004396:Coloring Agents; D005453:Fluorescence; D007208:Indocyanine Green; D007259:Infrared Rays; D013524:Surgical Flaps / Q000098:blood supply*; D013552:Swine
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green