title: The Role of Intraoperative Perfusion Assessment: What Is the Current State and How Can I Use It in My Practice?
abstract: Evolving intraoperative technology has an increased presence and usefulness in aiding surgeon clinical judgment. Many surgical devices are readily available as an adjunct to this gold standard assessment of adequate tissue perfusion. Intraoperative perfusion monitoring provides surgeons with the ability to interpret additional information that enhances surgical decision-making in real-time. Technologies include various dye-based and non-dye-based near-infrared angiography, tissue oximetry measurements, and ultrasound-based tools. This review summarizes the available intraoperative technologies for planning and assessment of tissue perfusion in plastic and reconstructive surgery. The authors discuss the available literature for the individual devices and supporting evidence for their use. The authors recommend the evidence-based use of these tools in indicated surgical cases to improve clinical outcomes.
authors.affiliation: Durham, N.C.; New York, N.Y.; and Burlington, Mass. From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center; the Division of Plastic Surgery, Columbia University College of Physicians and Surgeons; and the Department of Plastic Surgery, Lahey Hospital Medical Center.
authors.forename: Brett T
authors.initials: BT
authors.lastname: Phillips
authors.forename: Naikhoba C O
authors.initials: NCO
authors.lastname: Munabi
authors.forename: Rosiane A
authors.initials: RA
authors.lastname: Roeder
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Ascherman
authors.forename: Lifei
authors.initials: L
authors.lastname: Guo
authors.forename: Michael R
authors.initials: MR
authors.lastname: Zenn
mesh_terms: D000792:Angiography / Q000379:methods; D006801:Humans; D007208:Indocyanine Green; D016343:Monitoring, Intraoperative / Q000379:methods*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012039:Regional Blood Flow
chemical_list: D007208:Indocyanine Green
references.citation: Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: An introduction to the chimera flap principle. Ann Plast Surg. 1991;27:126–131
references.citation: Rozen WM, Rajkomar AK, Anavekar NS, Ashton MW. Post-mastectomy breast reconstruction: A history in evolution. Clin Breast Cancer. 2009;9:145–154
references.citation: Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: A further step forward for perforator flap surgery. Plast Reconstr Surg. 2009;124(Suppl):e419–e426
references.citation: Murphy BD, Zuker RM, Borschel GH. Vascularized composite allotransplantation: An update on medical and surgical progress and remaining challenges. J Plast Reconstr Aesthet Surg. 2013;66:1449–1455
references.citation: Pomahac B, Bueno EM, Sisk GC, Pribaz JJ. Current principles of facial allotransplantation: The Brigham and Women’s Hospital Experience. Plast Reconstr Surg. 2013;131:1069–1076
references.citation: Pratt GF, Rozen WM, Chubb D, et al. Modern adjuncts and technologies in microsurgery: An historical and evidence-based review. Microsurgery. 2010;30:657–666
references.citation: Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. Br J Plast Surg. 1987;40:113–141
references.citation: Sacks JM, Nguyen AT, Broyles JM, Yu P, Valerio IL, Baumann DP. Near-infrared laser-assisted indocyanine green imaging for optimizing the design of the anterolateral thigh flap. Eplasty. 2012;12:e30
references.citation: Losken A, Zenn MR, Hammel JA, Walsh MW, Carlson GW. Assessment of zonal perfusion using intraoperative angiography during abdominal flap breast reconstruction. Plast Reconstr Surg. 2012;129:618e–624e
references.citation: Phillips BT, Lanier ST, Conkling N, et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: Results of a prospective trial. Plast Reconstr Surg. 2012;129:778e–788e
references.citation: Losken A, Styblo TM, Schaefer TG, Carlson GW. The use of fluorescein dye as a predictor of mastectomy skin flap viability following autologous tissue reconstruction. Ann Plast Surg. 2008;61:24–29
references.citation: Munabi NC, Olorunnipa OB, Goltsman D, Rohde CH, Ascherman JA. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial. J Plast Reconstr Aesthet Surg. 2014;67:449–455
references.citation: Nahabedian MY. Overview of perforator imaging and flap perfusion technologies. Clin Plast Surg. 2011;38:165–174
references.citation: Zenn MR. Fluorescent angiography. Clin Plast Surg. 2011;38:293–300
references.citation: Lohman RF, Ozturk CN, Ozturk C, Jayaprakash V, Djohan R. An analysis of current techniques used for intraoperative flap evaluation. Ann Plast Surg. 2015;75:679–685
references.citation: Smit JM, Zeebregts CJ, Acosta R, Werker PM. Advancements in free flap monitoring in the last decade: A critical review. Plast Reconstr Surg. 2010;125:177–185
references.citation: Wood EH. Diagnostic applications of indicator-dilution technics in congenital heart disease. Circ Res. 1962;10:531–568
references.citation: Samet P, Bernstein WH, Jacobs W, Fomon J. Indicator-dilution curves in systemic arteriovenous fistulas. Am J Cardiol. 1964;13:176–187
references.citation: Flower RW, Hochheimer BF. A clinical technique and apparatus for simultaneous angiography of the separate retinal and choroidal circulations. Invest Ophthalmol. 1973;12:248–261
references.citation: Ott P. Hepatic elimination of indocyanine green with special reference to distribution kinetics and the influence of plasma protein binding. Pharmacol Toxicol. 1998;83(Suppl 2):1–48
references.citation: Desmettre T, Devoisselle JM, Mordon S. Fluorescence properties and metabolic features of indocyanine green (ICG) as related to angiography. Surv Ophthalmol. 2000;45:15–27
references.citation: O’goshi K, Serup J. Safety of sodium fluorescein for in vivo study of skin. Skin Res Technol. 2006;12:155–161
references.citation: Myers MB, Brock D, Cohn I Jr. Prevention of skin slough after radical mastectomy by the use of a vital dye to delineate devascularized skin. Ann Surg. 1971;173:920–924
references.citation: Singer R, Lewis CM, Franklin JD, Lynch JB. Fluorescein test for prediction of flap viability during breast reconstructions. Plast Reconstr Surg. 1978;61:371–375
references.citation: Benya R, Quintana J, Brundage B. Adverse reactions to indocyanine green: A case report and a review of the literature. Cathet Cardiovasc Diagn. 1989;17:231–233
references.citation: Azuma R, Morimoto Y, Masumoto K, et al. Detection of skin perforators by indocyanine green fluorescence nearly infrared angiography. Plast Reconstr Surg. 2008;122:1062–1067
references.citation: Still J, Law E, Dawson J, Bracci S, Island T, Holtz J. Evaluation of the circulation of reconstructive flaps using laser-induced fluorescence of indocyanine green. Ann Plast Surg. 1999;42:266–274
references.citation: Vogt PR, Bauer EP, Graves K. Novadaq Spy Intraoperative Imaging System: Current status. Thorac Cardiovasc Surg. 2003;51:49–51
references.citation: Reuthebuch O, Häussler A, Genoni M, et al. Novadaq SPY: Intraoperative quality assessment in off-pump coronary artery bypass grafting. Chest. 2004;125:418–424
references.citation: Desai ND, Miwa S, Kodama D, et al. A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts. J Thorac Cardiovasc Surg. 2006;132:585–594
references.citation: Sekijima M, Tojimbara T, Sato S, et al. An intraoperative fluorescent imaging system in organ transplantation. Transplant Proc. 2004;36:2188–2190
references.citation: Gurtner GC, Jones GE, Neligan PC, et al. Intraoperative laser angiography using the SPY system: Review of the literature and recommendations for use. Ann Surg Innov Res. 2013;7:1
references.citation: Newman MI, Samson MC. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg. 2009;25:21–26
references.citation: Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg. 2009;123:1239–1244
references.citation: Jones G. Fluorescent intraoperative tissue angiography for the evaluation of the viability of pedicled TRAM flaps. Plast Reconstr Surg. 2009;124(Suppl):53
references.citation: Murray JD, Jones GE, Elwood ET, Whitty LA, Garcia C. Fluorescent intraoperative tissue angiography with indocyanine green: Evaluation of nipple-areola vascularity during breast reduction surgery. Plast Reconstr Surg. 2010;126:33e–34e
references.citation: Jain V, Phillips BT, Conkling N, Pameijer C. Sentinel lymph node detection using laser-assisted indocyanine green dye lymphangiography in patients with melanoma. Int J Surg Oncol. 2013;2013:904214
references.citation: Liu DZ, Mathes DW, Zenn MR, Neligan PC. The application of indocyanine green fluorescence angiography in plastic surgery. J Reconstr Microsurg. 2011;27:355–364
references.citation: Newman MI, Jack MC, Samson MC. SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis. Ann Plast Surg. 2013;70:595–598
references.citation: 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;72:S144–S149
references.citation: Wu C, Kim S, Halvorson EG. Laser-assisted indocyanine green angiography: A critical appraisal. Ann Plast Surg. 2013;70:613–619
references.citation: Chatterjee A, Krishnan NM, Van Vliet MM, Powell SG, Rosen JM, Ridgway EB. A comparison of free autologous breast reconstruction with and without the use of laser-assisted indocyanine green angiography: A cost-effectiveness analysis. Plast Reconstr Surg. 2013;131:693e–701e
references.citation: Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J. 2014;34:61–65
references.citation: Sood M, Glat P. Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction. Ann Surg Innov Res. 2013;7:9
references.citation: Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg. 2014;133:448e–454e
references.citation: Spinoglio G, Priora F, Bianchi PP, et al. Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): A single-institutional prospective study. Surg Endosc. 2013;27:2156–2162
references.citation: Buretta KJ, Brat GA, Christensen JM, et al. Near-infrared lymphography as a minimally invasive modality for imaging lymphatic reconstitution in a rat orthotopic hind limb transplantation model. Transpl Int. 2013;26:928–937
references.citation: Holm C, Mayr M, Höfter E, Dornseifer U, Ninkovic M. Assessment of the patency of microvascular anastomoses using microscope-integrated near-infrared angiography: A preliminary study. Microsurgery. 2009;29:509–514
references.citation: Lee BT, Hutteman M, Gioux S, et al. The FLARE intraoperative near-infrared fluorescence imaging system: A first-in-human clinical trial in perforator flap breast reconstruction. Plast Reconstr Surg. 2010;126:1472–1481
references.citation: Ashitate Y, Lee BT, Laurence RG, et al. Intraoperative prediction of postoperative flap outcome using the near-infrared fluorophore methylene blue. Ann Plast Surg. 2013;70:360–365
references.citation: Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV. Quantitative assessment of perfusion and vascular compromise in perforator flaps using a near-infrared fluorescence-guided imaging system. Plast Reconstr Surg. 2009;124:451–460
references.citation: Nguyen JT, Ashitate Y, Buchanan IA, et al. Bone flap perfusion assessment using near-infrared fluorescence imaging. J Surg Res. 2012;178:e43–e50
references.citation: Nguyen JT, Ashitate Y, Buchanan IA, et al. Face transplant perfusion assessment using near-infrared fluorescence imaging. J Surg Res. 2012;177:e83–e88
references.citation: Vargas CR, Nguyen JT, Ashitate Y, et al. Near-infrared imaging for the assessment of anastomotic patency, thrombosis, and reperfusion in microsurgery: A pilot study in a porcine model. Microsurgery. 2015;35:309–314
references.citation: Troyan SL, Kianzad V, Gibbs-Strauss SL, et al. The FLARE intraoperative near-infrared fluorescence imaging system: A first-in-human clinical trial in breast cancer sentinel lymph node mapping. Ann Surg Oncol. 2009;16:2943–2952
references.citation: Rozen WM, Stella DL, Ashton MW, Phillips TJ, Taylor GI. Three-dimensional CT angiography: A new technique for imaging microvascular anatomy. Clin Anat. 2007;20:1001–1003
references.citation: Alonso-Burgos A, García-Tutor E, Bastarrika G, Cano D, Martínez-Cuesta A, Pina LJ. Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: Imaging findings and initial experience. J Plast Reconstr Aesthet Surg. 2006;59:585–593
references.citation: Ghattaura A, Henton J, Jallali N, et al. One hundred cases of abdominal-based free flaps in breast reconstruction: The impact of preoperative computed tomographic angiography. J Plast Reconstr Aesthet Surg. 2010;63:1597–1601
references.citation: Casey WJ III, Chew RT, Rebecca AM, Smith AA, Collins JM, Pockaj BA. Advantages of preoperative computed tomography in deep inferior epigastric artery perforator flap breast reconstruction. Plast Reconstr Surg. 2009;123:1148–1155
references.citation: Ohkuma R, Mohan R, Baltodano PA, et al. Abdominally based free flap planning in breast reconstruction with computed tomographic angiography: Systematic review and meta-analysis. Plast Reconstr Surg. 2014;133:483–494
references.citation: Offodile AC II, Chatterjee A, Vallejo S, Fisher CS, Tchou JC, Guo L. A cost-utility analysis of the use of preoperative computed tomographic-angiography in abdomen-based perforator flap breast reconstruction. Plast Reconstr Surg. 2015;135:662e–669e
references.citation: Swanson EW, Hsu YC, Cheng HT. CTA and contrast-enhanced MRA are equally accurate for localizing deep inferior epigastric perforator flap arteries: A systematic review. J Plast Reconstr Aesthet Surg. 2015;68:580–581
references.citation: de Weerd L, Mercer JB, Setså LB. Intraoperative dynamic infrared thermography and free-flap surgery. Ann Plast Surg. 2006;57:279–284
references.citation: de Weerd L, Mercer JB, Weum S. Dynamic infrared thermography. Clin Plast Surg. 2011;38:277–292
references.citation: Itoh Y, Arai K. Use of recovery-enhanced thermography to localize cutaneous perforators. Ann Plast Surg. 1995;34:507–511
references.citation: Whitaker IS, Pratt GF, Rozen WM, et al. Near infrared spectroscopy for monitoring flap viability following breast reconstruction. J Reconstr Microsurg. 2012;28:149–154
references.citation: de Weerd L, Miland AO, Mercer JB. Perfusion dynamics of free DIEP and SIEA flaps during the first postoperative week monitored with dynamic infrared thermography. Ann Plast Surg. 2009;62:42–47
references.citation: Chubb D, Rozen WM, Whitaker IS, Ashton MW. Images in plastic surgery: Digital thermographic photography (“thermal imaging”) for preoperative perforator mapping. Ann Plast Surg. 2011;66:324–325
references.citation: Colwell AS, Buntic RF, Brooks D, Wright L, Buncke GM, Buncke HJ. Detection of perfusion disturbances in digit replantation using near-infrared spectroscopy and serial quantitative fluoroscopy. J Hand Surg Am. 2006;31:456–462
references.citation: Lin SJ, Nguyen MD, Chen C, et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg. 2011;127:1080–1085
references.citation: Colwell AS, Craft RO. Near-infrared spectroscopy in autologous breast reconstruction. Clin Plast Surg. 2011;38:301–307
references.citation: Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg. 2009;62:538–543
references.citation: Repez A, Oroszy D, Arnez ZM. Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy. J Plast Reconstr Aesthet Surg. 2008;61:71–77
references.citation: Pelletier A, Tseng C, Agarwal S, Park J, Song D. Cost analysis of near-infrared spectroscopy tissue oximetry for monitoring autologous free tissue breast reconstruction. J Reconstr Microsurg. 2011;27:487–494
references.citation: Gioux S, Mazhar A, Lee BT, et al. First-in-human pilot study of a spatial frequency domain oxygenation imaging system. J Biomed Opt. 2011;16:086015
references.citation: Pharaon MR, Scholz T, Bogdanoff S, et al. Early detection of complete vascular occlusion in a pedicle flap model using quantitative [corrected] spectral imaging. Plast Reconstr Surg. 2010;126:1924–1935
references.citation: Yafi A, Vetter TS, Scholz T, et al. Postoperative quantitative assessment of reconstructive tissue status in a cutaneous flap model using spatial frequency domain imaging. Plast Reconstr Surg. 2011;127:117–130
references.citation: Nguyen JT, Lin SJ, Tobias AM, et al. A novel pilot study using spatial frequency domain imaging to assess oxygenation of perforator flaps during reconstructive breast surgery. Ann Plast Surg. 2013;71:308–315
references.citation: Swiontkowski MF. Laser Doppler flowmetry: Development and clinical application. Iowa Orthop J. 1991;11:119–26
references.citation: Boas DA, Dunn AK. Laser speckle contrast imaging in biomedical optics. J Biomed Opt. 2010;15:011109
references.citation: Dunn AK, Bolay H, Moskowitz MA, Boas DA. Dynamic imaging of cerebral blood flow using laser speckle. J Cereb Blood Flow Metab. 2001;21:195–201
references.citation: Hölzle F, Loeffelbein DJ, Nolte D, Wolff KD. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg. 2006;34:25–33
references.citation: Beier JP, Horch RE, Arkudas A, Dragu A, Schmitz M, Kneser U. Decision-making in DIEP and ms-TRAM flaps: The potential role for a combined laser Doppler spectrophotometry system. J Plast Reconstr Aesthet Surg. 2013;66:73–79
references.citation: Rothenberger J, Amr A, Schaller HE, Rahmanian-Schwarz A. Evaluation of a non-invasive monitoring method for free flap breast reconstruction using laser Doppler flowmetry and tissue spectrophotometry. Microsurgery. 2013;33:350–357
references.citation: Lee JW, Lee YC, Chang TW. Microvascularly augmented transverse rectus abdominis myocutaneous flap for breast reconstruction: Reappraisal of its value through clinical outcome assessment and intraoperative blood gas analysis. Microsurgery. 2008;28:656–662
references.citation: Vakharia KT, Henstrom D, Lindsay R, Cunnane MB, Cheney M, Hadlock T. Color Doppler ultrasound: Effective monitoring of the buried free flap in facial reanimation. Otolaryngol Head Neck Surg. 2012;146:372–376
references.citation: Groom R, Tryzelaar J, Forest R, et al. Intra-operative quality assessment of coronary artery bypass grafts. Perfusion. 2001;16:511–518
references.citation: D’Ancona G, Karamanoukian HL, Ricci M, Schmid S, Bergsland J, Salerno TA. Graft revision after transit time flow measurement in off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg. 2000;17:287–293
references.citation: Selber JC, Garvey PB, Clemens MW, Chang EI, Zhang H, Hanasono MM. A prospective study of transit-time flow volume measurement for intraoperative evaluation and optimization of free flaps. Plast Reconstr Surg. 2013;131:270–281
references.citation: Visscher K, Boyd K, Ross DC, Amann J, Temple C. Refining perforator selection for DIEP breast reconstruction using transit time flow volume measurements. J Reconstr Microsurg. 2010;26:285–290
references.citation: Sboros V, Tang MX. The assessment of microvascular flow and tissue perfusion using ultrasound imaging. Proc Inst Mech Eng H. 2010;224:273–290
references.citation: Chung YE, Kim KW. Contrast-enhanced ultrasonography: Advance and current status in abdominal imaging. Ultrasonography. 2015;34:3–18