title: Use of laser-assisted indocyanine green angiography for early division of the forehead flap pedicle.
abstract: OBJECTIVE
  The paramedian forehead flap is used to reconstruct medium to large nasal defects. The staged nature, with its vascular pedicle bridging the medial eyebrow to the nose, results in significant facial deformity. Earlier division lessens this morbidity.
  
  
  OBJECTIVE
  To quantify flap neovascularization 2 weeks after the initial flap transfer and to describe an algorithm for earlier division of the flap pedicle in select patient populations.
  
  
  METHODS
  We performed a prospective and retrospective study at the Ambulatory Surgery Center, Stanford University, Palo Alto, California, from October 14, 2014, through January 21, 2015. Patients with defects appropriate for paramedian forehead flap reconstruction had partial-thickness defects, vascularized tissue in more than 50% of the recipient bed, and no nicotine use. The patients underwent reconstructive surgery by a single surgeon from August 24, 2012, through September 12, 2014. Laser-assisted indocyanine green angiography was used for imaging before and immediately after the initial flap transfer, before pedicle division with the pedicle atraumatically clamped, and immediately after pedicle division and flap inset. Analysis of data and calculation of relative perfusion were performed using a postprocessing analysis toolkit.
  
  
  METHODS
  Perfusion was calculated using the analysis toolkit as the percentage of the area of interest relative to a predetermined reference point in normal peripheral tissue.
  
  
  RESULTS
  We enrolled a total of 10 patients. The mean (SD) relative perfusion of the forehead donor site before flap transfer was 61.2% (3.4%); at initial flap transfer, 81.4% (50.2% [range, 31%-214%]) (P = .70 compared with measurement before flap transfer). The mean (SD) relative perfusion of the forehead donor site was 57.5% (21.2% [range, 32%-89%]) at the time of atraumatic pedicle clamping and 58.6% (32.4% [range, 16%-127%]) after pedicle division and flap inset (P = .85 compared with measurement before flap transfer). No flap failures or other complications were observed.
  
  
  CONCLUSIONS
  In select patients (those meeting the inclusion criteria), division of the pedicle at 2 weeks after the initial flap transfer is safe. Earlier pedicle division and flap transfer reduces the duration of facial deformity for the patient.
  
  
  METHODS
  3.
authors.affiliation: Currently in private practice, Cary, North Carolina.
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Surowitz
authors.affiliation: Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California.
authors.forename: Sam P
authors.initials: SP
authors.lastname: Most
mesh_terms: D000368:Aged; D000792:Angiography / Q000379:methods*; D003287:Contrast Media; D005260:Female; D005546:Forehead / Q000098:blood supply* / Q000601:surgery*; D006801:Humans; D007208:Indocyanine Green; D007834:Lasers; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D012225:Rhinoplasty / Q000379:methods*; D013524:Surgical Flaps / Q000098:blood supply*
chemical_list: D003287:Contrast Media; D007208:Indocyanine Green