title: Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction.
abstract: OBJECTIVE
  Composite tissue defects in the head and neck region present unique challenges. Definitive head and neck reconstruction of these cases is often complicated by complex 3-dimensional defects that may require multiple flap or chimeric flap procedures. These advanced techniques can have serious repercussions should poor perfusion of the flap cause flap failure, which can be devastating.
  
  
  METHODS
  A retrospective review was completed for those complex reconstructions using free tissue transfers and fluorescent indocyanine green angiography (Lifecell SPY Elite imaging, Lifecell Corporation, Bridgewater, NJ) at Walter Reed National Military Medical Center over a 24-month period. Data analyzed included flap type (myocutaneous, osteocutaneous, or fasciocutaneous), flap success and failure rates, and complications. These also were compared with data from the institution before the study period and the incorporation of SPY technology.
  
  
  RESULTS
  Sixty-one free flaps, including 11 head and neck flaps, were performed. The head and neck flaps included 1 latissimus, 3 gracilis, 1 vastus lateralis, 4 anterior lateral thigh, and 2 fibular flaps. The overall success rate was 98.4%; 1 flap was lost (1.6%) and 2 flaps developed partial flap necrosis (3.3%). Where SPY Elite was used, there was no unpredicted partial flap necrosis. The only total flap loss was related to a hypercoagulable condition.
  
  
  CONCLUSIONS
  Free tissue transfer can be technically challenging, especially in complex head and neck reconstruction. An algorithmic approach using SPY Elite imaging aids in pedicle location, angiosomal assessment, anastomotic flow visualization, and cutaneous and osteocutaneous flap perfusion assessment. This objective tool can assist the reconstructive surgeon in avoiding perfusion-related complications and total and partial flap losses, thus improving patient outcomes.
authors.affiliation: Oral and Maxillofacial Surgery Service, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA. Marshall.Green@med.navy.mil
authors.forename: J Marshall
authors.initials: JM
authors.lastname: Green
authors.forename: Shane
authors.initials: S
authors.lastname: Thomas
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sabino
authors.forename: Robert
authors.initials: R
authors.lastname: Howard
authors.forename: Patrick
authors.initials: P
authors.lastname: Basile
authors.forename: Steven
authors.initials: S
authors.lastname: Dryden
authors.forename: Chris
authors.initials: C
authors.lastname: Crecelius
authors.forename: Ian
authors.initials: I
authors.lastname: Valerio
mesh_terms: D004396:Coloring Agents; D005451:Fluorescein Angiography / Q000379:methods*; D058752:Free Tissue Flaps; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D007208:Indocyanine Green; D007430:Intraoperative Care / Q000379:methods*; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green