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Exploring perfusion limits in pedicled perforator propeller flaps via intraoperative indocyanine green angiography
Adrian Sebald1, Ingo Ludolph1, Corinna Mundschau1
1Department of Plastic and Handsurgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuernberg FAU, Chair. Univ.-Prof. Dr. Prof.h.c. Dr.h.c. Raymund E Horch, Krankenhausstrasse 12, 91054 Erlangen, Germany.
Background:
Pedicled perforator propeller flaps are widely used for soft-tissue reconstruction because they preserve donor-site function while providing reliable defect coverage. However, intraoperative assessment of flap perfusion remains challenging, particularly in longer flaps or after axial rotation. Indocyanine green (ICG) fluorescence angiography allows real-time visualization of tissue perfusion and may improve intraoperative decision-making.
Methods:
A retrospective single-center study was performed including 30 patients who underwent reconstruction with pedicled perforator propeller flaps between 2014 and 2022. Intraoperative ICG angiography was performed using the SPY-Elite system after flap elevation and after inset. A total of 48 angiographic sequences were analyzed using ImageJ software. Fluorescence intensity, perfusion distribution, and contour levels (20% and 30%) were evaluated across standardized 3-cm flap segments from the perforator origin to the distal flap edge.
Results:
All flaps survived, resulting in a flap survival rate of 100%. Postoperative complications occurred in 6 patients (20%), including 3 cases of minor wound-healing disorders and 3 cases of venous congestion requiring revision. Mean flap length was 15.8 cm. The average perfused area at the 20% fluorescence contour level represented 97.2% of the total flap surface. Perfusion decreased progressively with increasing distance from the perforator and declined significantly in flaps exceeding 15 cm in length (p < 0.01). Flaps shorter than 10 cm demonstrated homogeneous perfusion across all segments. Lower extremity flaps showed more consistent perfusion patterns compared with truncal and gluteal flaps.
Conclusions:
Intraoperative ICG fluorescence angiography provides a reliable method for assessing perfusion in pedicled perforator propeller flaps. Perfusion mapping suggests that flap lengths under 10 cm and tissue areas within the 20%-30% fluorescence contour levels are associated with consistent viability. ICG angiography may therefore serve as a useful adjunct to optimize flap design and enhance surgical safety in reconstructive procedures.
