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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 29  |  Issue : 3  |  Page : 183-185

A practical tip for intraoperative perforator vessel selection: Portable thermal imaging


1 Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Trakya University, Edirne, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Konur Hospital, Bursa, Turkey

Date of Submission27-Sep-2020
Date of Acceptance30-Nov-2020
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Daghan Dagdelen
Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Trakya University, Hospital Building 8th Floor, Balkan Campus, Edirne-22030
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_104_20

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  Abstract 


In planning of free-style free perforator flaps, relying on defined anatomical landmarks and preoperative imaging technologies is difficult to locate the perforating arteries. Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle. In these situations, the ideal perforator has to be selected mostly by clinical inspection. We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera, which may be a reliable intraoperative adjunct. An index digit soft-tissue reconstruction was planned with a free posterior interosseous artery flap. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber (<0.8 mm) and pulsation. A cold challenge test was applied to flap and a continuous video record with thermal camera was taken for 1 min. Video record shows that the dominant perforator is the distal one. Thus, the flap was raised based on distal perforator. Postoperative follow-up was uneventful. The portable thermal imaging is a low cost and readily accessible intraoperative adjunct for selecting the dominant perforator in free-style perforator free flaps.

Keywords: Free tissue flaps, microsurgery, perforator flaps, thermography


How to cite this article:
Dagdelen D, Aksoy A, Benlier E. A practical tip for intraoperative perforator vessel selection: Portable thermal imaging. Turk J Plast Surg 2021;29:183-5

How to cite this URL:
Dagdelen D, Aksoy A, Benlier E. A practical tip for intraoperative perforator vessel selection: Portable thermal imaging. Turk J Plast Surg [serial online] 2021 [cited 2021 Sep 17];29:183-5. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/3/183/322669




  Introduction Top


In planning of perforator-based workhorse free flaps, relying on defined anatomical landmarks and preoperative imaging technologies aids the reconstructive surgeon to locate the perforating arteries, for which almost al[ways an anatomical variation encountered. However, adopting a standardized approach in operative plan is difficult when it comes to raising a free-style free perforator flap. For these procedures, using conventional imaging technologies may aid to locate the perforating vessel but gives no additional data on real-time flap perfusion or function of the perforating vessel. Handheld Doppler devices are commonly used by reconstructive surgeons intraoperatively when raising free-style flaps. However, the reliability of this device is still a question of debate.[1]

Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle, but the operative plan was to raise a flap based on single perforating artery. In these situations, the ideal perforator has to be selected mostly by clinical inspection. Size and reliable pulsation of the artery are evaluated to decide the ideal perforator.[2] This clinical approach can readily be used for workhorse perforator flaps such Anterolateral Thigh Flap (ALT), but it becomes difficult in flaps that a supermicrosurgical anastomosis has to be the performed (i.e., pedicle size <0.8 mm) such as free hypothenar perforator flaps or free posterior interosseous (PIO) flaps. There are increasing number of articles reporting the success and reliability of indocyanine green for evaluating the perfusion of a raised flap; hence, the perforating arteries. However, this technology has a cost burden and is not readily accessible.

We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera.


  Case Report Top


A 45-year-old industrial worker was internalized after a high-pressure injection injury to left second digit. After serial debridement, soft-tissue reconstruction was planned with a free PIO flap [Figure 1]. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber and pulsation [Figure 2]. A cold challenge test (10°C cold serum saline kept in contact with the flap for 30 s) was applied to flap. After the saline filled, glove was taken away a continuous video record with thermal camera was taken for 1 min. Video record shows that there is a heat gradient starting from the distal hotspot and radiating to proximal end [Video 1]. This was interpreted as the dominant perforator is the distal one. Thus, the proximal perforator was ligated, and flap was raised based on distal perforator. Flap was adapted to defect, and perforating artery was anastomosed to ulnar digital artery in an end-to-end fashion with 10/0 sutures. Two superficial veins were anastomosed in a similar fashion [Figure 3]. Postoperative follow-up was uneventful.
Figure 1: Defect after debridement

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Figure 2: Elevated posterior interosseous flap based on two perforating vessels

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Figure 3: Adapted view of free posterior interosseuos flap based on distal perforator

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  Discussion Top


Emerging number of articles can be found regarding the thermal cameras and their use. Most of these articles mainly focus on defining the reliability of the TC for selection of the ideal perforator preoperatively and comparison of these technology to other conventional imaging technologies in the background of breast reconstruction and deep inferior epigastric artery perforator flaps.[3],[4],[5] In our opinion, the true potential of thermal imaging lies in intraoperative selection of the perforating vessels not preoperatively.

Applying cold challenge to skin Island makes a shrinkage in vessels, which is analogous to physically clamping of the perforating vessels. After removal of the cold source (releasing the clamps), the thermogram of the skin is visualized. Hot spots begin to appear after a brief time. These hot spots correspond to the entrance point of the vessels to skin island. According to Hagen's equation, inflow through a lumen is proportional to the 4th power of radius of that lumen. If this equation is to be projected to a flap model, a larger perforator nourishes the flap way much larger than the smaller counterpart. Even if the selection of the dominant perforator cannot be done by naked eye, as is in free-style free perforator flaps, the thermal gradient of perfusion clearly indicates the dominant perforator. Reliability of this technique surely aids the surgeon to reduce the time spent for determining the dominant perforator otherwise clinically.

We routinely use portable thermal imaging in free-style free perforator flaps, especially if more than one perforating arteries are to be encountered. We advocate that portable thermal imaging is a low cost and readily accessible intraoperative adjunct.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stekelenburg CM, Sonneveld PM, Bouman MB, van der Wal MB, Knol DL, de Vet HC, et al. The hand held Doppler device for the detection of perforators in reconstructive surgery: What you hear is not always what you get. Burns 2014;40:1702-6.  Back to cited text no. 1
    
2.
Suh HS, Oh TS, Lee HS, Lee SH, Cho YP, Park JR, et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg 2016;138:702e-9e.  Back to cited text no. 2
    
3.
Hardwicke JT, Osmani O, Skillman JM. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg 2016;137:39-41.  Back to cited text no. 3
    
4.
Tenorio X, Mahajan AL, Elias B, van Riempst JS, Wettstein R, Harder Y, et al. Locating perforator vessels by dynamic infrared imaging and flow Doppler with no thermal cold challenge. Ann Plast Surg 2011;67:143-6.  Back to cited text no. 4
    
5.
Mohan AT, Zhu L, Wang Z, Vijayasekaran A, Saint-Cyr M. Techniques and perforator selection in single, dominant DIEP flap breast reconstruction: Algorithmic approach to maximize efficiency and safety. Plast Reconstr Surg 2016;138:790e-803e.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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