Application of Indocyanine Green Angiography for Perfusion Assessment of Buccal Myomucosal Flaps

The indications for buccal myomucosal flaps (BMMFs) include velopharyngeal insufficiency (VPI) and palatal fistula. A major complication related to BMMF is partial flap necrosis due to its random blood supply. Indocyanine green (ICG) angiography is a proven technology to assess tissue perfusion, but there is limited report of its application to intraoral flaps, especially in cleft surgery. Two patients underwent BMMF for repair of palatal fistula and treatment of VPI. ICG angiography was performed to assess flap perfusion after flap elevation and again after flap inset. Patients were followed up for flap healing and speech assessments. In the first patient, ICG angiography confirmed excellent perfusion to both flaps after elevation and inset. In contrast, after elevation of bilateral BMMF in the second patient, ICG angiography identified excellent perfusion of the left BMMF but poor perfusion of the right BMMF. Debridement of the right flap was performed, and palatal reconstruction was completed with unilateral BMMF. Both patients healed uneventfully and had improvement in their hypernasality. In summary, ICG angiography can be a useful adjunct to assess the perfusion of BMMF during palatal reconstruction for VPI and/or palatal fistula. This intraoperative assessment may help to guide surgical decision-making with the aim of potentially reducing rates of flap necrosis and palatal fistula.