Indocyanine Green Fluorescence Angiography (ICG) Guided Perfusion Assessment Of Pectoralis Major Myocutaneous Flap (PMMC) During Oral Cancer Reconstruction

Abstract

The Pectoralis Major Myocutaneous (PMMC) flap is one of the most common reconstructive techniques in head and neck cancer surgery, providing good coverage of large defects. However, some of the complications include marginal necrosis and flap dehiscence which may result in longer hospital stays and other morbidities. This paper aims to establish the use of Indocyanine Green (ICG) fluorescence angiography in enhancing the results of PMMC flap reconstruction by offering real-time analysis of flap blood supply. A total of 18 patients who received PMMC flap reconstruction with the help of ICG perfusion mapping from January 2021 to July 2022 were included in this study. Patients with oral cancer aged 18 years and above with histologically confirmed disease, who had undergone PMMC flap reconstruction and had undergone both intraoperative and postoperative ICG imaging were included in the study. Patients with neck irradiation history or incomplete follow-up were excluded from the study. ICG fluorescence angiography was performed during the surgery and after the surgery to assess the perfusion of the flaps. The intraoperative parameters measured included intraoperative ICG transit time peak fluorescence intensity and the requirement for intraoperative flap modification. The assessment of flap viability, complications, and recovery metrics were also obtained postoperatively. The primary sites of occurrence of cancer were buccal mucosa (38. 9%), tongue (27. 8%), and floor of mouth (22. 2%). Intraoperative ICG fluorescence showed that 22 of the lesions had impaired blood perfusion. 2% of the patients and this led to flap adjustments on the same day. Postoperatively, 11. One percent of the patients had inconclusive clinical signs of flap compromise, but further ICG evaluation revealed satisfactory perfusion without any further management. There were no cases of flap necrosis noted in the study. Other complications that were observed in the study included postoperative morbidity; Grade 1 complications were observed in 11. Grade 1 in 1%, Grade 2 in 5%. 6% while 5% had a Grade 3a. 6%. The mean length of hospital stay was 9 ± 2 days, oral intake was started on postoperative day 5 ± 1, and decannulation was done on day 6 ± 1. ICG fluorescence angiography improves the management of PMMC flaps by offering real-time perfusion information that can be used to make immediate intraoperative corrections and minimize postoperative complications. The application of ICG angiography in intraoperative and postoperative periods enhances flap survival and reduces the recovery period and the rate of further surgeries. This technique should be incorporated into the routine practice of PMMC flap reconstruction to enhance the patients’ results and minimize the risk of complications.