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J Reconstr Microsurg
DOI: 10.1055/s-0043-1777325
Original Article

Perfusion Dynamics during Secondary Flap Debulking with Liposuction

Maxim Geeroms
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
,
Yun-Jui Lu
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
,
Chung-Chen Hsu
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
,
Ren-Wen Huang
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
,
Chih-Hung Lin
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
,
Cheng-Hung Lin
1   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
› Author Affiliations Funding None.
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Abstract

Background Lower extremity trauma often necessitates reconstruction with flap transfer. One of the reconstructive goals is a thin soft tissue coverage with appropriate contour. Therefore, a secondary debulking of the flap is usually performed.

Methods Debulking through conventional lipectomy is compared with liposuction followed by excision of the defatted flap excess. Demographic data, surgical details, and postoperative outcomes are compared and analyzed. The perfusion dynamics of the flaps undergoing liposuction debulking are studied by means of perioperative indocyanine green fluorescence angiography, as well as postoperative laser Doppler imaging.

Results Patients undergoing lipectomy (n = 69; 57.5%) or liposuction (n = 51; 42.5%) debulking had a similar rate of postoperative complications. Partial necrosis was observed in 7.2% (lipectomy) versus 7.8% (liposuction) of flaps. Fluorescence angiography showed a substantial decrease in flap perfusion following the infiltration with an epinephrine-containing tumescent solution (74.3% ± 8.2% prior to infiltration versus 16.8% ± 7.1% after infiltration; p < 0.001), resulting in a dark flap appearance. Laser Doppler imaging confirmed the hypoperfusion on postoperative day 1.

Conclusion Secondary debulking of a lower extremity flap can be safely and efficiently performed through liposuction combined with peripheral excision of the defatted flap in a single stage. Perfusion studies may show a misleading hypoperfusion of the defatted flap, which does not accurately predict subsequent necrosis or complications.

Keywords

indocyanine green - fluorescence angiography - perfusion dynamics - reconstructive microsurgery - debulking - liposuction


Publication History

Received: 12 May 2023

Accepted: 13 October 2023

Article published online:
13 December 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 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 (04) 1239-1244
    CrossrefPubMedGoogle Scholar
  • 2 Rübben A, Eren S, Krein R, Younossi H, Böhler U, Wienert V. Infrared videoangiofluorography of the skin with indocyanine green–rat random cutaneous flap model and results in man. Microvasc Res 1994; 47 (02) 240-251
    CrossrefPubMedGoogle Scholar
  • 3 Alstrup T, Christensen BO, Damsgaard TE. ICG angiography in immediate and delayed autologous breast reconstructions: peroperative evaluation and postoperative outcomes. J Plast Surg Hand Surg 2018; 52 (05) 307-311
    CrossrefPubMedGoogle Scholar
  • 4 Fuse Y, Yoshimatsu H, Karakawa R, Yano T. Pedicled anterolateral thigh flap transfer for the reconstruction of a large gluteal defect assisted by preoperative computed tomographic angiography and intraoperative indocyanine green angiography: a case report. Microsurgery 2021; 41 (08) 777-781
    CrossrefPubMedGoogle Scholar
  • 5 Ludolph I, Arkudas A, Schmitz M. et al. Cracking the perfusion code?: Laser-assisted Indocyanine Green angiography and combined laser Doppler spectrophotometry for intraoperative evaluation of tissue perfusion in autologous breast reconstruction with DIEP or ms-TRAM flaps. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1382-1388
    CrossrefPubMedGoogle Scholar
  • 6 Malagón-López P, Vilà J, Carrasco-López C. et al. Intraoperative indocyanine green angiography for fat necrosis reduction in the deep inferior epigastric perforator (DIEP) flap. Aesthet Surg J 2019; 39 (04) NP45-NP54
    CrossrefPubMedGoogle Scholar
  • 7 Montorfano L, Bordes SJ, Azarkhail R, Sarmiento Cobos M, Medina M. Use of indocyanine green fluorescent imaging in the assessment of a tongue flap after lateral hemiglossectomy. Cureus 2021; 13 (05) e15248
    PubMedGoogle Scholar
  • 8 Montorfano L, Bordes SJ, Sarmiento Cobos M, Garcia Lopez EA, Medina M. Use of indocyanine green angiography for real-time assessment of a sternocleidomastoid muscle flap during complex facial reconstruction. Cureus 2021; 13 (03) e13970
    PubMedGoogle Scholar
  • 9 Piwkowski C, Gabryel P, Gąsiorowskia Ł. et al. Indocyanine green fluorescence in the assessment of the quality of the pedicled intercostal muscle flap: a pilot study. Eur J Cardiothorac Surg 2013; 44 (01) e77-e81
    CrossrefPubMedGoogle Scholar
  • 10 Suzuki Y, Shimizu Y, Kasai S. et al. Indocyanine green fluorescence videoangiography for reliable variations of supraclavicular artery flaps. Arch Plast Surg 2019; 46 (04) 318-323
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Chattha A, Bucknor A, Chen AD, Lee BT, Lin SJ. Indocyanine green angiography use in breast reconstruction: a national analysis of outcomes and cost in 110,320 patients. Plast Reconstr Surg 2018; 141 (04) 825-832
    CrossrefPubMedGoogle Scholar
  • 12 Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J 2014; 34 (01) 61-65
    CrossrefPubMedGoogle Scholar
  • 13 Khavanin N, Qiu C, Darrach H. et al. Intraoperative perfusion assessment in mastectomy skin flaps: how close are we to preventing complications?. J Reconstr Microsurg 2019; 35 (07) 471-478
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 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 (05) 778e-788e
    CrossrefPubMedGoogle Scholar
  • 15 Rinker B. A comparison of methods to assess mastectomy flap viability in skin-sparing mastectomy and immediate reconstruction: a prospective cohort study. Plast Reconstr Surg 2016; 137 (02) 395-401
    CrossrefPubMedGoogle Scholar
  • 16 Vasella M, Guidi M, Waldner M, Calcagni M, Giovanoli P, Frueh FS. Fluorescence angiography-assisted debridement of critically perfused glabrous skin in degloving foot injuries: Two case reports. Medicine (Baltimore) 2021; 100 (22) e26235
    CrossrefPubMedGoogle Scholar
  • 17 Wilke BK, Schultz DS, Huayllani MT. et al. A prospective evaluation of intraoperative indocyanine green fluorescence angiography for soft tissue sarcomas. J Am Acad Orthop Surg Glob Res Rev 2021; 5 (08) 00187-6
    PubMedGoogle Scholar
  • 18 Wilke BK, Schultz DS, Huayllani MT. et al. Intraoperative indocyanine green fluorescence angiography is sensitive for predicting postoperative wound complications in soft-tissue sarcoma surgery. J Am Acad Orthop Surg 2021; 29 (10) 433-438
    CrossrefPubMedGoogle Scholar
  • 19 Giunta RE, Holzbach T, Taskov C. et al. Prediction of flap necrosis with laser induced indocyanine green fluorescence in a rat model. Br J Plast Surg 2005; 58 (05) 695-701
    CrossrefPubMedGoogle Scholar
  • 20 Ludolph I, Bettray D, Beier JP, Horch RE, Arkudas A. Leaving the perfusion zones? Individualized flap design in 100 free DIEP and ms-TRAM flaps for autologous breast reconstruction using indocyanine green angiography. J Plast Reconstr Aesthet Surg 2022; 75 (01) 52-60
    CrossrefPubMedGoogle Scholar
  • 21 Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg 2012; 129 (05) 1043-1048
    CrossrefPubMedGoogle Scholar
  • 22 Valerio I, Green III JM, Sacks JM, Thomas S, Sabino J, Acarturk TO. Vascularized osseous flaps and assessing their bipartate perfusion pattern via intraoperative fluorescence angiography. J Reconstr Microsurg 2015; 31 (01) 45-53
    PubMedGoogle Scholar
  • 23 Nagata T, Masumoto K, Uchiyama Y. et al. Improved technique for evaluating oral free flaps by pinprick testing assisted by indocyanine green near-infrared fluorescence angiography. J Craniomaxillofac Surg 2014; 42 (07) 1112-1116
    CrossrefPubMedGoogle Scholar
  • 24 Varela R, Casado-Sanchez C, Zarbakhsh S, Diez J, Hernandez-Godoy J, Landin L. Outcomes of DIEP flap and fluorescent angiography: a randomized controlled clinical trial. Plast Reconstr Surg 2020; 145 (01) 1-10
    CrossrefPubMedGoogle Scholar
  • 25 Nelson JA, Fischer JP, Haddock NT. et al. Striving for normalcy after lower extremity reconstruction with free tissue: the role of secondary esthetic refinements. J Reconstr Microsurg 2016; 32 (02) 101-108
    PubMedGoogle Scholar
  • 26 Teimourian B, Kroll SS. Subcutaneous endoscopy in suction lipectomy. Plast Reconstr Surg 1984; 74 (05) 708-711
    CrossrefPubMedGoogle Scholar
  • 27 De Frene B, Van Landuyt K, Hamdi M. et al. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006; 59 (10) 1031-1036
    CrossrefPubMedGoogle Scholar
  • 28 Farid M, Nicholson S, Kotwal A, Akali A. DIEP breast reconstruction following multiple abdominal liposuction procedures. Eplasty 2014; 14: e47
    PubMedGoogle Scholar
  • 29 Fan S, Zhang HQ, Li QX. et al. The use of a honeycomb technique combined with ultrasonic aspirators and indocyanine green fluorescence angiography for a superthin anterolateral thigh flap: a pilot study. Plast Reconstr Surg 2018; 141 (06) 902e-910e
    CrossrefPubMedGoogle Scholar
  • 30 Schwabegger A, Ninković M, Wechselberger G, Anderl H. The bipedicled flap on the lower leg, a valuable old method? Its indications and limitations in 12 cases. Scand J Plast Reconstr Surg Hand Surg 1996; 30 (03) 187-193
    CrossrefPubMedGoogle Scholar
  • 31 Huang SH, Wu SH, Chang KP. et al. Contour refinements of free flaps for optimal outcome in oral reconstruction: combination of modified liposuction technique and w-plasty in one-stage procedure. J Craniomaxillofac Surg 2009; 37 (04) 201-205
    CrossrefPubMedGoogle Scholar
  • 32 Burk III RW, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg 1996; 97 (07) 1379-1384
    CrossrefPubMedGoogle Scholar
  • 33 Ozcan G, Shenaq S, Baldwin B, Spira M. The trauma of suction-assisted lipectomy cannula on flap circulation in rats. Plast Reconstr Surg 1991; 88 (02) 250-258
    CrossrefPubMedGoogle Scholar
  • 34 Lee ZH, Abdou SA, Daar DA. et al. Comparing outcomes for fasciocutaneous versus muscle flaps in foot and ankle free flap reconstruction. J Reconstr Microsurg 2019; 35 (09) 646-651
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Mégevand V, Suva D, Mohamad M, Hannouche D, Kalbermatten DF, Oranges CM. Muscle vs. fasciocutaneous microvascular free flaps for lower limb reconstruction: a meta-analysis of comparative studies. J Clin Med 2022; 11 (06) 1557
    CrossrefPubMedGoogle Scholar
  • 36 Nagel SS, Rauh A, Siegwart LC. et al. From esthetic medicine to optimizing reconstructive outcome: a feasibility trial on secondary refinement of fasciocutaneous anterolateral thigh flaps with cryolipolysis. J Reconstr Microsurg 2023; 39 (02) 156-164
    Article in Thieme ConnectPubMedGoogle Scholar