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J Reconstr Microsurg 2023; 39(06): 413-418
DOI: 10.1055/s-0042-1758183
Original Article

Precision of Dynamic Infrared Thermography in Anterolateral Thigh Flap Planning: Identification of the Perforator Fascia Passage

Claudius Illg 
1   Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
,
Sabrina Krauss
1   Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
,
Henrik Lauer
1   Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
,
Adrien Daigeler
1   Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
,
Ruth Christine Schäfer
1   Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
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Abstract

Background The anterolateral thigh (ALT) flap is commonly utilized in reconstructive surgery. Preoperative perforator mapping facilitates dissection. Dynamic infrared thermography can be applied to identify ALT perforators. However, its accuracy has not been evaluated in detail before. Therefore, this study aimed to assess the precision of dynamic infrared thermography in ALT perforator localization.

Methods The survey site was defined as a 25 × 8 cm rectangle on the anterolateral thigh and a coordinate system was established. The area was examined consecutively by dynamic infrared thermography with a FLIR ONE camera after 2-minute fan precooling. Two surgeons then independently performed color duplex ultrasound on the basis of the identified hotpots.

Results Twenty-four healthy subjects were examined. About 74.8% of perforators were musculocutaneous or musculoseptocutaneous. The mean distance between study area center and perforator or hotspot center was 51.8 ± 27.3 and 46.5 ± 26.2 mm, respectively. The mean distance from hotspot center to sonographic perforator fascia passage was 15.9 ± 9.9 mm with a maximum of 48.4 mm. The positive predictive value of thermographic ALT perforator identification was 93%.

Conclusion Thermographic hotspot and perforator location diverge widely in ALT flaps. Dynamic infrared thermography can therefore not be used as standalone technique for preoperative ALT perforator identification. However, the application before color duplex ultrasound examination is a reasonable upgrade and can visualize angiosomes and facilitate the examination.

Keywords

ALT flap - perforator - thermography - color duplex ultrasound - DIRT


Publication History

Received: 17 March 2022

Accepted: 17 September 2022

Article published online:
14 November 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009; 124 (06) 1965-1973
    CrossrefPubMedGoogle Scholar
  • 2 Shauly O, Teles S, Stone G, Gould DJ, Patel KM. Lower extremity limb salvage and amputation: a systematic review and meta-analysis of reported outcomes and the role of microsurgery. Ann Plast Reconstr Surg 2020; 4 (02) 1056
    PubMedGoogle Scholar
  • 3 Hoftiezer YAJ, Lans J, van der Heijden BEPA, Chen NC, Eberlin KR, Lozano-Calderón SA. Long-term patient-reported outcome measures following limb salvage with complex reconstruction or amputation in the treatment of upper extremity sarcoma. J Surg Oncol 2021; 123 (05) 1328-1335
    CrossrefPubMedGoogle Scholar
  • 4 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
    CrossrefPubMedGoogle Scholar
  • 5 Seth R, Manz RM, Dahan IJ. et al. Comprehensive analysis of the anterolateral thigh flap vascular anatomy. Arch Facial Plast Surg 2011; 13 (05) 347-354
    CrossrefPubMedGoogle Scholar
  • 6 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
    CrossrefPubMedGoogle Scholar
  • 7 Weise H, Naros A, Blumenstock G. et al. Donor site morbidity of the anterolateral thigh flap. J Craniomaxillofac Surg 2017; 45 (12) 2105-2108
    CrossrefPubMedGoogle Scholar
  • 8 Xie RG. Medial versus lateral approach to harvesting of anterolateral thigh flap. J Int Med Res 2018; 46 (11) 4569-4577
    CrossrefPubMedGoogle Scholar
  • 9 Schneider CM, Palines PA, Womac DJ, Tuggle CT, St Hilaire H, Stalder MW. Preoperative computed tomography angiography for ALT flaps optimizes design and reduces operative time. J Reconstr Microsurg 2022; 38 (06) 491-498
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Nassar AH, Maselli AM, Manstein S. et al. Comparison of various modalities utilized for preoperative planning in microsurgical reconstructive surgery. J Reconstr Microsurg 2022; 38 (03) 170-180
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Kehrer A, Sachanadani NS, da Silva NPB. et al. Step-by-step guide to ultrasound-based design of ALT flaps by the microsurgeon - basic and advanced applications and device settings. J Plast Reconstr Aesthet Surg 2020; 73 (06) 1081-1090
    CrossrefPubMedGoogle Scholar
  • 12 Cheng HT, Lin FY, Chang SCN. Diagnostic efficacy of color Doppler ultrasonography in preoperative assessment of anterolateral thigh flap cutaneous perforators: an evidence-based review. Plast Reconstr Surg 2013; 131 (03) 471e-473e
    CrossrefPubMedGoogle Scholar
  • 13 Feng S, Min P, Grassetti L. et al. A prospective head-to-head comparison of color Doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg 2016; 137 (01) 335-347
    CrossrefPubMedGoogle Scholar
  • 14 de Weerd L, Weum S, Mercer JB. The value of dynamic infrared thermography (DIRT) in perforator selection and planning of free DIEP flaps. Ann Plast Surg 2009; 63 (03) 274-279
    CrossrefPubMedGoogle Scholar
  • 15 Illg C, Krauss S, Rothenberger J, Kolbenschlag J, Daigeler A, Schäfer RC. Air flow cooling improves anterolateral thigh perforator mapping using the FLIR ONE thermal camera. J Reconstr Microsurg 2022; 38 (02) 144-150
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Chubb DP, Taylor GI, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: part II. dynamic thermographic identification. Plast Reconstr Surg 2013; 132 (06) 1457-1464
    CrossrefPubMedGoogle Scholar
  • 17 Xiao W, Li K, Kiu-Huen Ng S. et al. A prospective comparative study of color doppler ultrasound and infrared thermography in the detection of perforators for anterolateral thigh flaps. Ann Plast Surg 2020; 84 (5S, Suppl 3): S190-S195
    CrossrefPubMedGoogle Scholar
  • 18 Berner JE, Pereira N, Troisi L, Will P, Nanchahal J, Jain A. Accuracy of infrared thermography for perforator mapping: a systematic review and meta-analysis of diagnostic studies. J Plast Reconstr Aesthet Surg 2021; 74 (06) 1173-1179
    CrossrefPubMedGoogle Scholar
  • 19 Wade RG, Watford J, Wormald JCR, Bramhall RJ, Figus A. Perforator mapping reduces the operative time of DIEP flap breast reconstruction: a systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography. J Plast Reconstr Aesthet Surg 2018; 71 (04) 468-477
    CrossrefPubMedGoogle Scholar
  • 20 Ritschl LM, Fichter AM, Bomhard AV. et al. Comparison between different perforator imaging modalities for the anterolateral thigh perforator flap transfer: a prospective study. J Reconstr Microsurg 2020; 36 (09) 686-693
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Khoong YM, Huang X, Gu S, Zan T. Imaging for thinned perforator flap harvest: current status and future perspectives. Burns Trauma 2021; 9: tkab042
    CrossrefPubMedGoogle Scholar
  • 22 Hasebroock KM, Serkova NJ. Toxicity of MRI and CT contrast agents. Expert Opin Drug Metab Toxicol 2009; 5 (04) 403-416
    CrossrefPubMedGoogle Scholar
  • 23 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg 2006; 118 (04) 928-933
    CrossrefPubMedGoogle Scholar
  • 24 Golusiński P, Luczewski Ł, Pazdrowski J. et al. The role of colour duplex sonography in preoperative perforator mapping of the anterolateral thigh flap. Eur Arch Otorhinolaryngol 2014; 271 (05) 1241-1247
    CrossrefPubMedGoogle Scholar
  • 25 Hardwicke JT, Osmani O, Skillman JM. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg 2016; 137 (01) 39-41
    CrossrefPubMedGoogle Scholar
  • 26 Cruz-Segura A, Cruz-Domínguez MP, Jara LJ. et al. Early detection of vascular obstruction in microvascular flaps using a thermographic camera. J Reconstr Microsurg 2019; 35 (07) 541-548
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Pereira N, Hallock GG. Smartphone thermography for lower extremity local flap perforator mapping. J Reconstr Microsurg 2021; 37 (01) 59-66
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Jaspers MEH, Carrière ME, Meij-de Vries A, Klaessens JHGM, van Zuijlen PPM. The FLIR ONE thermal imager for the assessment of burn wounds: reliability and validity study. Burns 2017; 43 (07) 1516-1523
    CrossrefPubMedGoogle Scholar
  • 29 Muntean MV, Strilciuc S, Ardelean F. et al. Using dynamic infrared thermography to optimize color Doppler ultrasound mapping of cutaneous perforators. Med Ultrason 2015; 17 (04) 503-508
    PubMedGoogle Scholar
  • 30 Zhou G, Qiao Q, Chen GY, Ling YC, Swift R. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 1991; 44 (02) 91-96
    CrossrefPubMedGoogle Scholar
  • 31 Rodriguez ED, Rosson GD, Bluebond-Langner R. et al. The utility of the anterolateral thigh donor site in reconstructing the United States trauma patient. J Trauma 2007; 62 (04) 892-897
    PubMedGoogle Scholar
  • 32 Malhotra K, Lian TS, Chakradeo V. Vascular anatomy of anterolateral thigh flap. Laryngoscope 2008; 118 (04) 589-592
    CrossrefPubMedGoogle Scholar
  • 33 Moore R, Mullner D, Nichols G, Scomacao I, Herrera F. Color Doppler ultrasound versus computed tomography angiography for preoperative anterolateral thigh flap perforator imaging: a systematic review and meta-analysis. J Reconstr Microsurg 2022; 38 (07) 563-570
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Pereira N, Valenzuela D, Mangelsdorff G, Kufeke M, Roa R. Detection of perforators for free flap planning using smartphone thermal imaging: a concordance study with computed tomographic angiography in 120 perforators. Plast Reconstr Surg 2018; 141 (03) 787-792
    CrossrefPubMedGoogle Scholar
  • 35 Sheena Y, Jennison T, Hardwicke JT, Titley OG. Detection of perforators using thermal imaging. Plast Reconstr Surg 2013; 132 (06) 1603-1610
    CrossrefPubMedGoogle Scholar
  • 36 Zachara M, Drozdowski P, Wysocki M, Siewiera I, Wójcicki P. Anatomical variability of the anterolateral thigh flap perforators between sexes: a cadaveric study. Eur J Plast Surg 2013; 36 (03) 179-184
    CrossrefPubMedGoogle Scholar
  • 37 Yin J, Wang L, Yang G, Qin X, Xiong P. Correlation between body mass index and anterolateral thigh flap thickness: a retrospective study from a single center in China. Front Surg 2021; 8: 748799
    CrossrefPubMedGoogle Scholar