Optimizing ALT Flap Harvest: The Role of Combined Preoperative Duplex Ultrasound and Intraoperative ICG Angiography for Perforator Selection

TL;DR

Combining preoperative ultrasound and intraoperative fluorescence imaging improves ALT flap surgery by reducing unnecessary dissection and operative time.

Contribution

The study demonstrates that combining CCDS and ICGFA optimizes perforator selection and reduces operative morbidity in ALT flap harvesting.

Findings

Using CCDS and ICGFA reduced operative time by 52 minutes compared to fully dissected perforators.

Unnecessary dissection of 21 additional perforators was avoided in 16 cases.

No flap loss was observed, confirming the safety of the combined technique.

Abstract

Planning and harvesting anterolateral thigh flaps (ALT) requires precise perforator selection and accurate tissue perfusion assessment. Unfortunately, variable perforator anatomy and perfusion patterns often result in extensive exploratory dissection. We aimed to assess the impact of preoperative color-coded duplex sonography (CCDS) and intraoperative indocyanine green fluorescence angiography (ICGFA) on perforator selection and operative morbidity. Fifty-three ALTs were performed with preoperative CCDS and intraoperative ICGFA. Flaps had one, two, or three suitable perforators. Additional perforators were either included, or ligated following temporary clamping with ICGFA-based perfusion assessment. If perfusion was sufficient, further dissecting of additional perforators of unfavorable course was abstained from. The impact on perforator selection and operative outcomes was studied. Seven flaps were raised on a single, 34 on 2, and 12 on 3 perforators. There was no flap loss. Comparing the subgroups of fully dissected versus partially clamped and subsequently ligated perforators revealed significantly shorter harvest times in the latter (268 ± 71 versus 216 ± 47 min, p = 0.006). The unnecessary dissection of 21 additional perforators in 16 cases was avoided. Combining preoperative CCDS and intraoperative ICGFA aids in designing ALTs and guarantees the intraoperative selection of suitable perforators. This allows for significant reductions in operative time and donor-site morbidity by limiting unnecessary dissection.

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