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Localizing Perforators of the Anterolateral Thigh Flap: Color Doppler Ultrasonography Vs Indocyanine Green
Shuai Dong1,2, Xinwei Hou1,2, Yang Cao1,2
1From the Department of Hand Surgery, Suzhou Ruihua Orthopedic Hospital, Suzhou, Jiangsu, China.
Background:
The anterolateral thigh flap (ALTF) is widely used, but perforator variability and fat distribution affect outcomes. We compared indocyanine green angiography (ICGA) and color Doppler ultrasonography (CDU) for preoperative perforator localization and identified factors affecting accuracy.
Methods:
We retrospectively analyzed 56 ALTF reconstructions (January-July 2024). Perforator distribution in proximal, hot, and distal zones was analyzed. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Multivariate regression assessed 20 variables, including flap thickness and perforator diameter, for their impact on accuracy.
Results:
ICGA outperformed CDU: sensitivity 92.5% versus 84.9%, specificity 82.0% versus 80.0%, positive predictive value 93.9% versus 84.7%, negative predictive value 90.2% versus 79.2%, accuracy 92.2% versus 82.3%. Localization error did not differ significantly. Multivariate analysis identified flap thickness as independent predictor of ICGA accuracy (odds ratio 0.16; 95% confidence interval, 0.04-0.62; P = 0.008; cutoff 2.35 cm), whereas surgery timing affected CDU accuracy (odds ratio 0.88; 95% confidence interval, 0.78-0.99; P = 0.029). Septocutaneous perforators were most common in the proximal zone (61.2%), and the hot zone had higher density.
Conclusions:
ICGA offers better perforator detection for ALTF planning, though its accuracy declines when flap thickness exceeds 2.35 cm. Proximal zone perforators are more favorable, whereas the hot zone has higher concentration, guiding preoperative mapping.