Imaging Photoplethysmography (iPPG) in Head and Neck Reconstructive Surgery: A Novel Technique for Noninvasive Flap Perfusion Monitoring

Overview

Journal Lasers Surg Med

Specialties General Surgery
Pharmacology

Date 2024 Nov 14

PMID 39540240

Authors

S D van der Stel

M Lai

H C Groen

R Dirven

M B Karakullukcu

L H E Karssemakers

M van Gastel

B H W Hendriks

T J M Ruers

W H Schreuder

Affiliations

Soon will be listed here.

Abstract

Background: Evaluate imaging photoplethysmography (iPPG) as a novel noninvasive technique to assess flap perfusion in head and neck free flap reconstructive (FFR) surgeries.

Methods: Intraoperative iPPG was performed in 17 patients undergoing FFR surgery. Imaging consisted of a 30-s video from which perfusion maps were extracted, providing detailed information about blood flow and pulsatility in the flap microvasculature. During each procedure, iPPG acquisitions were acquired representing distinct perfusion conditions of the flap (fully perfused/ischemic/reperfused). When possible, postoperative measurements were performed to assess flap recovery during the critical time period (3 days) and long-term follow-up (30 days).

Results: Perfusion maps, displaying iPPG amplitude and delay times, correlated strongly (p < 0.001) with the perfusion status of the tissue. One case of postoperative thrombosis, leading to flap failure, was identified with iPPG. After surgical revision in this case, flap perfusion was restored and confirmed by iPPG. Postoperative follow-up imaging allowed for objective visualization of flap recovery short term (3 days) and up to 30 days after the surgical procedure.

Conclusions: This study shows that iPPG is suitable for objective and noninvasive assessment of flap perfusion in head and neck FFR surgery. In addition, postoperative monitoring shows potential for assessing flap perfusion in patients with increased risk of postoperative complications.

References

Kwasnicki R, Noakes A, Banhidy N, Hettiaratchy S . Quantifying the Limitations of Clinical and Technology-based Flap Monitoring Strategies using a Systematic Thematic Analysis. Plast Reconstr Surg Glob Open. 2021; 9(7):e3663. PMC: 8274739. DOI: 10.1097/GOX.0000000000003663. View

Chen K, Kuo S, Chien P, Hsieh H, Hsieh C . Comparison of the surgical outcomes of free flap reconstruction for primary and recurrent head and neck cancers: a case-controlled propensity score-matched study of 1,791 free flap reconstructions. Sci Rep. 2021; 11(1):2350. PMC: 7840944. DOI: 10.1038/s41598-021-82034-5. View

Salgado C, Chim H, Schoenoff S, Mardini S . Postoperative care and monitoring of the reconstructed head and neck patient. Semin Plast Surg. 2012; 24(3):281-7. PMC: 3324228. DOI: 10.1055/s-0030-1263069. View

Patel U, Hernandez D, Shnayder Y, Wax M, Hanasono M, Hornig J . Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours. JAMA Otolaryngol Head Neck Surg. 2017; 143(8):803-809. PMC: 5710561. DOI: 10.1001/jamaoto.2017.0304. View

Wang W . Investigation of reperfusion injury and ischemic preconditioning in microsurgery. Microsurgery. 2008; 29(1):72-9. PMC: 2662723. DOI: 10.1002/micr.20587. View

Kapoor A, Karmakar M, Roy C, Anand K . Assessment of perfusion of free flaps used in head and neck reconstruction using pulsatility index. Indian J Plast Surg. 2018; 50(2):173-179. PMC: 5770931. DOI: 10.4103/ijps.IJPS_23_17. View

Kohler L, Kohler H, Kohler S, Langer S, Nuwayhid R, Gockel I . Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study. BMC Surg. 2021; 21(1):222. PMC: 8086299. DOI: 10.1186/s12893-021-01232-0. View

Wang W, Ong A, Vincent A, Shokri T, Scott B, Ducic Y . Flap Failure and Salvage in Head and Neck Reconstruction. Semin Plast Surg. 2020; 34(4):314-320. PMC: 7759432. DOI: 10.1055/s-0040-1721766. View

Wolff K . New aspects in free flap surgery: Mini-perforator flaps and extracorporeal flap perfusion. J Stomatol Oral Maxillofac Surg. 2017; 118(4):238-241. DOI: 10.1016/j.jormas.2017.06.004. View

10.

Xiao T, Yan Z, Xiao S, Xia Y . Proinflammatory cytokines regulate epidermal stem cells in wound epithelialization. Stem Cell Res Ther. 2020; 11(1):232. PMC: 7291661. DOI: 10.1186/s13287-020-01755-y. View

11.

Smit J, Zeebregts C, Acosta R, Werker P . Advancements in free flap monitoring in the last decade: a critical review. Plast Reconstr Surg. 2010; 125(1):177-185. DOI: 10.1097/PRS.0b013e3181c49580. View

12.

Lindelauf A, Saelmans A, van Kuijk S, van der Hulst R, Schols R . Near-Infrared Spectroscopy (NIRS) versus Hyperspectral Imaging (HSI) to Detect Flap Failure in Reconstructive Surgery: A Systematic Review. Life (Basel). 2022; 12(1). PMC: 8778121. DOI: 10.3390/life12010065. View

13.

Cornejo A, Rodriguez T, Steigelman M, Stephenson S, Sahar D, Cohn S . The use of visible light spectroscopy to measure tissue oxygenation in free flap reconstruction. J Reconstr Microsurg. 2011; 27(7):397-402. DOI: 10.1055/s-0031-1281521. View

14.

Lai M, van der Stel S, Groen H, van Gastel M, Kuhlmann K, Ruers T . Imaging PPG for In Vivo Human Tissue Perfusion Assessment during Surgery. J Imaging. 2022; 8(4). PMC: 9031653. DOI: 10.3390/jimaging8040094. View

15.

Zaman T, Kyriacou P, Pal S . Free flap pulse oximetry utilizing reflectance photoplethysmography. Annu Int Conf IEEE Eng Med Biol Soc. 2013; 2013:4046-9. DOI: 10.1109/EMBC.2013.6610433. View

16.

Wolff K, Ritschl L, Bomhard A, Braun C, Wolff C, Fichter A . In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation. J Craniomaxillofac Surg. 2019; 48(1):90-97. DOI: 10.1016/j.jcms.2019.12.005. View

17.

Vieira L, Isacson D, Dimovska E, Rodriguez-Lorenzo A . Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies. Plast Reconstr Surg Glob Open. 2021; 9(1):e3329. PMC: 7858199. DOI: 10.1097/GOX.0000000000003329. View

18.

Chubb D, Rozen W, Ashton M . Early survival of a compromised fasciocutaneous flap without pedicle revision: monitoring with photoplethysmography. Microsurgery. 2010; 30(6):462-5. DOI: 10.1002/micr.20781. View

19.

Dindo D, Demartines N, Clavien P . Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2):205-13. PMC: 1360123. DOI: 10.1097/01.sla.0000133083.54934.ae. View

20.

Chae M, Rozen W, Whitaker I, Chubb D, Grinsell D, Ashton M . Current evidence for postoperative monitoring of microvascular free flaps: a systematic review. Ann Plast Surg. 2012; 74(5):621-32. DOI: 10.1097/SAP.0b013e3181f8cb32. View