10.14639/0392-100X-N1161
Objective. Laser-assisted angiography with indocyanine green (LAIG) allows objective intraoperative evaluation of tissue vascularity. We endeavored to describe our experience with this technique in the head and neck region. Methods. A retrospective review from February 2016 till October 2018 was conducted. We included patients who underwent head and neck procedures in which LAIG was employed. The main outcome was postoperative wound complications. We analysed the influence of LAIG results in intraoperative decision-making process. Results. Nineteen patients were included, and follow-up was for at least 6 months. LAIG was employed in 11 local flaps, 9 free flaps and 6 cases of pharyngeal closure during total laryngectomies. Wound complications occurred in two cases with distal tip flap necrosis. LAIG findings resulted in changes in decision making intraoperatively in 84% of procedures, which consisted in trimming poorly perfused tissues. There were no pharyngocutaneous fistulas. Conclusions. This represents a descriptive report on the use of LAIG on diverse head and neck reconstruction cases, with important impact on the decision-making process. A low number of postoperative wound complications were observed.
text/xml
1827-675X
1161
en
Kevin Higgins
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
SPY
Applications of intraoperative angiography in head and neck reconstruction
Text.Serial.Journal
https://www.actaitalica.it/
41
Head and neck
2021-07-07
2020-10-05
2021-07-08
2021-07-08
215-220
1
Kevin Higgins
2021/07/07
10.14639/0392-100X-N1161
215
Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
1827-675X
SPY
220
Applications of intraoperative angiography in head and neck reconstruction
https://www.actaitalica.it/article/download/1161/619
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:215-220; doi: 10.14639/0392-100X-N1161




Head and neck


Applications of intraoperative angiography in head
and neck reconstruction
Utilizzo dell’angiografia intraoperatoria nella ricostruzione del distretto testa-collo
Axel Sahovaler1,2, Tommaso Gualtieri2,3, John J.W. Lee1, Antoine Eskander1, Konrado Deutsch1, Sabrina Rashid1,
Mario Orsini1, Alberto Deganello3, Joel Davies1, Danny Enepekides1, Kevin Higgins1
1
 Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University
of Toronto, Toronto, Ontario, Canada; 2 Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto,
Ontario, Canada; 3 Unit of Otorhinolaryngology - Head and Neck Surgery, Department of Medical and Surgical Specialties,
Radiological Sciences and Public Health, University of Brescia, Brescia, Italy


SUMMARY
Objective. Laser-assisted angiography with indocyanine green (LAIG) allows objective in-
traoperative evaluation of tissue vascularity. We endeavored to describe our experience with
this technique in the head and neck region.
Methods. A retrospective review from February 2016 till October 2018 was conducted. We
included patients who underwent head and neck procedures in which LAIG was employed.
The main outcome was postoperative wound complications. We analysed the influence of
LAIG results in intraoperative decision-making process.
Results. Nineteen patients were included, and follow-up was for at least 6 months. LAIG
was employed in 11 local flaps, 9 free flaps and 6 cases of pharyngeal closure during total
                                                                                                Received: October 5, 2020
laryngectomies. Wound complications occurred in two cases with distal tip flap necrosis.
                                                                                                Accepted: November 20, 2020
LAIG findings resulted in changes in decision making intraoperatively in 84% of proce-
dures, which consisted in trimming poorly perfused tissues. There were no pharyngocuta-
                                                                                                Correspondence
neous fistulas.
                                                                                                Kevin Higgins
Conclusions. This represents a descriptive report on the use of LAIG on diverse head and        Department of Otolaryngology - Head & Neck
neck reconstruction cases, with important impact on the decision-making process. A low          Surgery, University of Toronto, Sunnybrook Health
number of postoperative wound complications were observed.                                      Sciences Centre
                                                                                                2075 Bayview Avenue, M-wing, 1st floor, room M1
KEY WORDS: laser-assisted angiography head and neck cancer, skin necrosis, indocyanine
                                                                                                102, Toronto, ON M4N 3M5, Canada
green, SPY                                                                                      E-mail: kevin.higgins@sunnybrook.ca

RIASSUNTO                                                                                       Funding
Obiettivi. La tecnica LAIG (Laser-assisted angiography with indocyanine green) permette         None.
una valutazione intraoperatoria della vascolarizzazione tissutale. Con questo studio vo-
gliamo condividere la nostra esperienza con tale tecnica nel distretto testa collo.             Conflict of interest
Metodi. È stata condotta un’analisi retrospettiva che include pazienti sottoposti a chirurgia   The Authors declare no conflict of interest.
del distretto testa-collo con utilizzo di LAIG intraoperatorio. È stata valutata l’incidenza
di complicanze postoperatorie della ferita chirurgica e l’influenza dell’utilizzo di LAIG         How to cite this article: Sahovaler A, Gualtieri
intraoperatorio nel processo decisionale del chirurgo.                                            T, Lee JJW, et al. Applications of intraoperative
Risultati. Diciannove pazienti sono stati inclusi con follow-up minimo di 6 mesi. LAIG è          angiography in head and neck reconstruction.
stata applicata su 11 lembi locali, 9 lembi liberi ed in 6 casi di chiusura del faringe post      Acta Otorhinolaryngol Ital 2021;41:215-220. htt-
laringectomia totale. In due casi la necrosi distale del lembo ha portato a complicanze           ps://doi.org/10.14639/0392-100X-N1161
correlate alla ferita chirurgica. LAIG ha portato a modificazione del processo decisionale
intraoperatorio nell’84% dei casi.                                                              © Società Italiana di Otorinolaringoiatria
Conclusioni. Questo studio descrittivo dimostra la applicabilità di LAIG in diverse proce-      e Chirurgia Cervico-Facciale
dure ricostruttive nel distretto testa-collo, con un impatto importante sul processo decisio-
nale intraoperatorio ed una bassa incidenza di complicanze della ferita chirurgica.                            OPEN ACCESS

                                                                                                This is an open access article distributed in accordance with
PAROLE CHIAVE: angiografia laser-assistita, cancro del distretto testa-collo, necrosi           the CC-BY-NC-ND (Creative Commons Attribution-Non-
cutanea, verde indocianina, SPY                                                                 Commercial-NoDerivatives 4.0 International) license. The
                                                                                                article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
                                                                                                only in the original version. For further information: https://
                                                                                                creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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A. Sahovaler et al.




Introduction                                                     were accounted for. In addition, we also calculated the ex-
                                                                 tra-costs and added time to the procedures. Costs were cal-
Without appropriate tissue perfusion even the most elegant
                                                                 culated based on total coded and non-coded billing infor-
reconstruction can be doomed for failure. In head and neck
                                                                 mation and contacting the pharmacy department, and time
surgery, employing vitally compromised tissues for recon-
                                                                 was calculated using a timer feature of the software after
struction can have substantial consequences both function-
                                                                 the ICG injection. Main outcome was postoperative wound
ally and aesthetically. Traditionally, tissue viability has
                                                                 complications (defined as any wound healing complication
been assessed using a combination of clinical observation
                                                                 within 30 days after the surgery). We also analysed if LAIG
and surgical expertise. This method lacks inherent objectiv-
                                                                 results affected the intraoperative decision-making process.
ity, reliability and reproducibility 1.
                                                                 Research ethics board approval was obtained from Sunny-
Laser-assisted angiography with indocyanine green (ICG)
                                                                 brook Health Sciences Centre (REB# 21-709.12).
dye utilises a near-infrared (NIR) imaging system that pro-
vides an intraoperative visual assessment of blood flow
                                                                 LAICG Dye Angiography Protocol
within tissues. The ICG molecule possess high affinity to
                                                                 Before using ICG, all patients were evaluated for an iodine or
plasma proteins, remaining entirely bound within the intra-
                                                                 shellfish allergy. The SPY Elite machine (Novadaq Technolo-
vascular space, which makes it suitable to evaluate perfu-
sion. It is metabolised by the liver and excreted in the kid-    gies, Mississauga, Ontario, Canada) is sterilely draped and
neys, without any hepatic or renal toxic effects, with a short   the area of interest if visualised. Three ml of the reconstituted
half-life of 3 to 5 minutes. The risk of anaphylactic reaction   ICG is injected peripherally and followed by a 10 ml saline
is low and is associated with iodine allergy. When the ICG       flush. Recording of the tissue of interest then commences. In
molecules are exposed to light and excited in the NIR spec-      the case of pedicled flaps, recording is done after flap eleva-
trum, tissue perfusion can be evaluated by identification        tion, to confirm adequate vascularisation of the tissue espe-
and quantification of the fluorescence intensity of the parti-   cially at the distal edges. In the case of free flaps, LAIG was
cles: well-perfused tissue appear fluorescent and ischemic       used in addition to the hand held doppler to select the most
tissue appears dark. Post-imaging annotation software pre-       suitable perforator (in Anterolateral Thigh -ALT- flaps), and
sent in the NIR devices can analyse results qualitatively        before completing the flap elevation, to ensure that the se-
and quantitively, decreasing subjectivity and increasing         lected perforator/s provided adequate vascularisation. It
interobserver reliability. This technology has been widely       was also used in cases where free flaps were trimmed after
implemented in breast surgery, where authors highlighted         their elevation (ALT, Temporoparietal fascia free flap and
the decrease in the occurrence of post-mastectomy necrosis       latissimus dorsi). In post-pharyngectomy cases, the edges
and subsequent implant loss 2-6, as it allowed to identify and   of native pharyngeal mucosa, which are high risk areas for
remove poorly vascularised tissue.                               fistula formation are evaluated. Areas of concern were con-
Nowadays, this technique is not as widely used in head and       sidered poorly perfused if, at 45-60 seconds after injection
neck reconstructive surgery, even though there have been         and flush of the IG, the intensity of the site by LAIG was
prior publications highlighting its benefits 7-10. The objec-    33% or less of a well perfused area set as a control on the
tive of this study was to communicate our initial experience     SPY software. This threshold value was determined fol-
using laser-assisted angiography with ICG (LAIG) in ma-          lowing previous reports of the literature 11,12. The poorly
jor head and neck reconstructive procedures, describing the      perfused area was marked and trimmed back to confirmed
range of applications and report our rates of postoperative      well perfused tissue.
wound complications.
                                                                 Results
Materials and methods                                            Intraoperative angiography was employed in 19 patients
A retrospective review from February 2016 till October           (Tab. I). The average patient age was 65 years (range 35 to
2018 at Sunnybrook Health Science Center was conducted.          84) and 14 were male. All but two cases were operated on
We only included patients who underwent a major head             for malignant disease; one trauma and one osteoradione-
and neck procedure in which LAIG was employed. The               crosis case. LAIG was employed in eleven cases of local
decision to employ this technology in certain cases was          flaps, nine cases of free flaps and six cases of pharyngeal
purely made based on the availability of the equipment as        closure (three of these were salvage laryngectomies). Of
it is mainly used by plastic surgery at our centre. Patient      note, LAIG was utilised for assessment in more than one
demographics, along with tumour histology, location, type        type of reconstruction. The added cost to the procedure by
of defect, previous treatment and reconstruction modality        the use of this technology was 30 USD as the ICG is non-



216
                                                                                                           An underrated and versatile technique in head and neck reconstruction




Table I. Patients in which LAIG was employed.
 Pt      Age       Gender           Pathology                           Defect Location           Previous       Reconstructive strategy               LAIG                 Wound
                                                                                                 treatment                                           modified            complications
                                                                                                                                                     approach
 1          69            M              Cutaneous SCC                       Scalp                                           Lat                           +                     -
 2          64            F           Metastatic SCC parotid           Preauricular skin                                   SCAIF                           +                     -
 3          75            M                    BCC                       Cervical skin                                       ALT                           +                     -
 4          35            M                  Trauma                        T-E fistula                                      TPFF                           +                     -
 5          69            M             Supraglottic SCC                     Partial                                ALT/ 1ary pharyngeal                   +           Distal tip necrosis
                                            (T4aN2c)                    Pharyngectomy                                     closure                                      of ALT skin paddle
 6          60            F             Supraglottic SCC                     Partial                   +          1ary Pharyngeal closure                  +                     -
                                             (T3N1)                     Pharyngectomy
 7          80            M                Melanoma                    Preauricular skin                                    SCAIF                          +                      -
 8          60            M             Supraglottic SCC                     Partial                                 TPFF/1ary pharyngeal                  +                      -
                                            (T4aN2a)                    Pharyngectomy                                      closure
 9          58            M                    BCC                     Preauricular skin                                Fascial RFFF                       -                      -
 10         51            M              Cutaneous SCC                   Cervical skin                                      SCAIF                          +                      -
 11         52            M              Oral cavity SCC               Through-through                                ALT/Cervicofacial                    +            Distal tip necrosis
                                                                        buccal mucosa                                                                                    of cervicofacial
 12         84            F                    BCC                         Forehead                                     Pericranium                        -                      -
 13         52            F              Cutaneous SCC                 Preauricular skin                                Cervicofacial                      +                      -
 14         67            M            Osteoradionecrosis             Scalp/Calvarial bone                            Lat/Cervicofacial                    +                      -
 15         53            M           Hypopharyngeal SCC                     Partial                   +             ALT/1ary pharyngeal                   +                      -
                                            (T3N2b)                     Pharyngectomy                                      closure
 16         92            M          Mucoepidermoid parotid            Preauricular skin                                    SCAIF                          +                      -
 17         71            M           Hypopharyngeal SCC                     Partial                                 Pharyngeal closure                    +                      -
                                             (T4N1)                     Pharyngectomy
 18         79            F          Supraglottic SCC (T3N1)                 Partial                   +            SCAIF/1ary pharyngeal                  +                      -
                                                                        Pharyngectomy                                     closure
 19         61            M               Cutaneous SCC                Preauricular skin                             SCAIF/Cervicofacial                   -                      -
T-E: tracheoesophageal fistula; Lat: latissimus dorsi free flap; ALT: anterolateral thigh free flap; SCAIF: supraclavicular artery island flap; TPFF: temporalis fascia free flap; SCC: squamous
cells carcinoma; BCC: basal cells carcinoma.



proprietary and the pharmacy department facilitated it for                                         island flap (SCAIF) and a cervicofacial advancement flap
us. Regarding the extra time consumed, the total operation                                         to replace the skin defect were employed. Both flaps were
was prolonged by an average of 13 minutes.                                                         evaluated using the SPY system confirming good vascu-
LAIG findings resulted in changes in decision-making in-                                           larisation. No wound complications were noted at follow
traoperatively in 84% of the cases: tissues were trimmed                                           up. In this case the distal tip of the cervicofacial advance-
when poor distal perfusion was observed in cases of local,                                         ment flap appeared dusky and had venous flow from the
free tissue transfer and native pharyngeal mucosa. Minor                                           subdermal plexus, but had robust amplified ICG perfusion
wound complications occurred in two cases: distal tip flap                                         with values over the threshold so it was left intact.
necrosis in an anterolateral thigh free flap and in a cervi-
cofacial advancement flap. These were managed conserva-                                            Example 2
tively. There were no pharyngocutaneous fistulas or total                                          35-year-old quadriplegic male initially injured in a snow-
free flap loss.                                                                                    boarding accident in 2009. Shortly after injury he required
                                                                                                   anterior and posterior fusion to stabilise his c-spine. Un-
Example 1                                                                                          fortunately, the anterior plate eroded through his oespha-
61-year-old male with a neglected preauricular cutaneous                                           gus creating a trachea-oesophageal fistula which healed
squamous cell carcinoma. The patient underwent wide ex-                                            as a large laryngeal cleft preventing oral intake. A TPFF
cision of the skin, superficial parotidectomy and neck dis-                                        was utilised to reconstruct the defect. The flap was divided
section. To reconstruct the defect a supraclavicular artery                                        into leaflets and LAIG confirmed adequate blood supply.



                                                                                                                                                                                         217
A. Sahovaler et al.




This allowed reliable customisation of TPFF in order to re-                         assessment of areas of tissue perfusion that are not identi-
establish the tridimensional pharyngeal framework, with a                           fied by the surgeon, serving as a superior clinical indicator
fascial flap typical difficult to assess vascularisation. After                     compared with clinical intraoperative judgement alone 15.
the microvascular anastomosis, the flap had continued per-                          There is extensive breast reconstructive literature reporting
fusion and the patient had an uncomplicated postoperative                           the advantages of this technology 3,5, where a reduction in
course (Fig. 1).                                                                    post-mastectomy necrosis rates was found and therefore in
                                                                                    implant loss 3,6. In addition, it has been reported that the use
Example 3                                                                           of LAIG had an impact in decision-making intraoperatively
60-year-old female diagnosed with a T3N1 supraglottic                               in reconstructive surgery 10. However, in head and neck sur-
squamous cell carcinoma who previously received chemo-                              gery this technique is not routinely used. We endeavored to
radiation as part of an organ preservation strategy. Unfor-                         report the use of LAIG in a variety of clinical scenarios in
tunately, the tumour recurred mandating a salvage surgi-                            head and neck reconstruction.
cal approach. LAIG was used to evaluate the pharyngeal                              Necrosis of the distal tip of the flap is the most common
strip after tumour extirpation. The SPY system suggested                            complication when using large locoregional fasciocutane-
an area of poor perfusion and the mucosa was trimmed to                             ous flaps that extend beyond their vascular pedicle primary
healthy tissue (Fig. 2). The patient had an uneventful post-                        and adjacent angiosomes 16. Cervicofacial flaps and SCAIF
operative course.
                                                                                    have a 9% 17 and 18% 18 risk of partial necrosis respective-
                                                                                    ly. A recent survey capturing 221 head and neck surgeons
Discussion                                                                          revealed that the rate of complications with SCAIF was
In the head and neck surgical oncology setting, wound                               29.8% 19. In our series when using SCAIF we experienced
complications after reconstructive procedures may lead to                           only one distal tip necrosis (16,6%), and no complications
catastrophic consequences. Even minor cases of flap ne-                             were reported when using cervicofacial flaps.
crosis that can be managed conservatively may lead to sub-                          In free-flaps with high perforator variability such as the
optimal aesthetic results and affect quality of life. In cases                      anterolateral thigh (ALT) free flap 20, intraoperative angi-
of pharyngeal and oral cavity reconstructions, salivary                             ography was described as an adjunct to select the most reli-
fistulas cause delayed oral intake, and can result in life-                         able skin perforator, as well as allowing reliable trimming
threatening conditions such as carotid blow-out syndrome.                           prior to harvesting with good results 21. Although we did
Reconstruction failures can also indirectly impact on pa-                           not utilise LAIG for any fibula flap, Beckler et al. 13 also
tient prognosis as they may delay the initiation of adjuvant                        had very promising results with the intraoperative angiog-
treatment 13,14. Advocators for the use of LAIG highlight                           raphy approach observing a reduction in partial skin flap
its ability to provide real-time intraoperative and objective                       necrosis of fibula flaps in a cohort of 73 patients that un-



 A                                                    B                                                        C




Figure 1. (A) Temporoparietal fascial free flap harvested to reconstruct the defect; (B) TPFFF divided into leaflets for reconstructive purposes; (C) LAIG analysis
on TPFFF confirming adequate blood supply in all its regions.



218
                                                                                        An underrated and versatile technique in head and neck reconstruction




   A                                                                                        B




Figure 2. (A) Intraoperative picture showing a poorly perfused left pharyngeal area after tumour resection; (B) LAIG analysis showed an area of poor perfusion
(black dotted line). P: pharyngeal remnant; SMG: submandibular gland; CA: carotid artery; IJV: internal jugular vein; SCMM: sternocleidomastoid muscle.


derwent oromandibular reconstructions with through and                           Conclusions
through defects.
The reported post-laryngectomy pharyngocutaneous fistula                         We employed LAIG in a diverse range of head and neck
rates range between 16% to 65% 22. Two prospective stud-                         oncologic and reconstruction applications with encourag-
ies including 37 and 41 patients respectively, compared                          ing results. Postoperative wound complications were lim-
mucosal perfusion detected by this technology in salvage                         ited (10%) and were all managed successfully with con-
laryngectomies and found that patients who developed                             servative strategies. This technology determined a change
postoperative fistulas had lower mucosal perfusion values                        in decision making of the surgeon in a high percentage of
when compared with patients who did not develop fistu-                           the procedures. Subsequent studies evaluating its applica-
las 12,23, suggesting that there might be a role for LAIG in                     tion in head and neck surgery are required to validate our
assessing vascularisation of the pharyngeal mucosa rem-                          findings.
nant. In the same line as these two last reports, we did not
experience any pharyngocutaneous fistulas after pharyn-                          References
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