Lower extremity reconstruction: utility of smartphone thermal imaging camera in planning perforator based pedicled flaps
AbstractBackground: Presence of good size perforators are mandatory to design perforator based pedicelled flaps specially in lower limb as flap failure rate is relatively high. We have explored the use of smartphone based dynamic thermal imaging and compared it with doppler to devise a protocol for planning and execution of pedicled perforator flaps and described its use in deciding delay of flap. We have also compared the time required for detecting dominant perforators. Methods: This prospective case series was done at Jinnah burn and reconstructive surgery center Lahore from July to September 2018 and included patients requiring pedicled fasciocutaneous or musculocutaneous flap for lower extremity reconstruction. Smartphone based dynamic thermal imaging and doppler were used to map out suitable perforators and confirmed intraoperatively. Comparison was made regarding their ability to locate dominant perforators and total time required. Utility of thermal imaging to ascertain flap perfusion postoperatively was also assessed. Flaps were designed according to thermal mapping. Clinical judgement supplemented with thermal imaging was used to ascertain flap survival. Results: The study included 15 patients in which 22 out 23 dominant perforators as located with thermal imaging were confirmed intra-operatively (positive predictive value = 95.7%) as compared to 22 out of 32 with doppler (positive predictive value=68.8%). Mean time required with doppler was 591.27±252.48, compared to 598.47±192.94 seconds with thermal imaging. In two cases flap was delayed. Partial flap necrosis occurred in one case. Conclusion: Dynamic thermal imaging can be reliably used in planning of pedicled perforator flaps for lower limb reconstruction. We have found it more reliable than handheld doppler in locating dominant perforators. ps, Lower Extremity Reconstruction.
Khan UD, Miller JG. Reliability of handheld Doppler in planning local perforator-based flaps for extremities. Aesthetic Plast Surg 2007; 31(5): 521-5.
Gunnarsson GL, Jackson IT, Westvik TS, Thomson JB. The freestyle pedicle perforator flap: a new favorite for the reconstruction of moderate-sized defects of the torso and extremities. Eur J Plast Surg 2015; 38: 31–6.
Bekara F, Herlin C, Somda S, De Runz A, Grolleau JL, Chaput B. Free versus perforator – pedicled propeller flaps in lower extremity reconstruction: what is the safest coverage? A meta – analysis. Microsurgery 2018; 38(1): 109-19
Suphachokauychai S, Kiranantawat K, Sananpanich K. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg Glob Open 2016; 4(5): e722.
Theuvenet WJ, Koeyers GF, Borghouts MH. Thermographic assessment of perforating arteries. A preoperative screening method for fasciocutaneous and musculocutaneous flaps.. Scand J Plast Reconstr Surg 1986; 20(1): 25-9.
Hardwicke JT, Osmani O, Skillman JM. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg 2016; 137(1): 39-41.
John HE, Niumsawatt V, Rozen WM, Whitaker IS. Clinical applications of dynamic infrared thermography in plastic surgery: a systematic review. Gland Surg 2016; 5(2): 122-32.
Konczalik W, Nikkhah D, Mosahebi A. Applications of Smartphone thermal camera imaging system in monitoring of the deep inferior epigastric perforator flap for breast reconstruction. Microsurgery 2017; 37(5): 457-8.
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(3): 787-92.
de Weerd L, Mercer JB, Weum S. Dynamic infrared thermography. Clin Plast Surg 2011; 38(2): 277-92.
Paul SP. Using a thermal imaging camera to locate perforators on the lower limb. Arch Plast Surg 2017; 44(3): 243–7.
Perng CK, Ma H, Chiu YJ, Lin PH, Tsai CH. Detection of free flap pedicle thrombosis by infrared surface temperature imaging. J Surg Res 2018; 229: 169-76.
Georgescu AV. Propeller perforator flaps in distal lower leg: Evolution and clinical applications. Arch Plast Surg 2012; 39(2): 94-105.
Stadler F, Brenner E, Todoroff B, Papp C. Anatomical study of the perforating vessels of the lower leg. Anat Rec 1999; 255(4): 374-9.
Panse NS, Bhatt YC, Tandale MS. What is safe limit of the perforator flap in lower extremity reconstruction? Do we have answers yet?. Plast Surg Int 2011; 2011: 349357.
Hamilton K, Wolfswinkel EW, Weathers WM, Xue AS, Hatef DA, Izaddoost S et al. The delay phenomenon: A compilation of knowledge across specialties. Craniomaxillofac Trauma Reconstr 2014; 7(2): 112-8.
Teo TC. Perforator local flaps in lower limb reconstruction. Cirugia Plastica Ibero-Latinoamericana 2006; 32: 15-6+287.
Gersch RP, Fourman MS, Dracea C, Bui DT, Dagum AB. The delay phenomenon: Is one surgical delay technique superior?. Plast Reconstr Surg Glob Open 2017; 5(10): e1519.
Meier JK, Prantl L, Müller S, Moralis A, Liebsch G, Gosau M.. Simple, fast and reliable perfusion monitoring of microvascular flaps. Clin Hemorheol Microcirc 2012; 50(1-2): 13-24.
Yamamoto T, Todokoro T, Koshima I. Handheld thermography for flap monitoring. J Plast Reconstr Aesthet Surg 2012; 65(12): 1747-8.
Perng CK. Recent advances in postoperative free microvascular flap monitoring. Formos J Surg 2013; 46(5): 145-8.
Busic V, Das-Gupta R. Temperature monitoring in free flap surgery. Br J Plast Surg 2004; 57(6): 588.