RECONSTRUCTIVE Early Experience with Fluorescent Angiography in Free-Tissue Transfer Reconstruction Ivo A. Pestana, M.D. Brian Coan, M.D. Detlev Erdmann, M.D., Ph.D. Jeffrey Marcus, M.D. L. Scott Levin, M.D. Michael R. Zenn, M.D. Durham, N.C. Background: Soft-tissue and bony reconstruction with free-tissue transfer is one of the most versatile tools available to the reconstructive surgeon. Determination of flap perfusion and early detection of vascular compromise with prompt correction remain critical in free-tissue transfer success. The aim of this report is to describe the utility of laser-assisted indocyanine green fluorescent dye angiography in free-tissue transfer reconstruction. Methods: From October of 2007 to March of 2008, 27 nonrandomized, non- consecutive patients underwent surgical free flaps in conjunction with intraop- erative Novadaq SPY fluorescent angiography. Results: Twenty-seven patients underwent 29 free-tissue transfers. There was one partial flap loss in this group requiring operative revision. No complications attrib- utable to indocyanine green fluorescent dye administration were noted. Imaging procedures (including dye administration) added minimal additional time to the operative time and anesthesia, and assisted in intraoperative decision-making. Conclusions: Novadaq’s SPY fluorescent angiography system provides simple and efficient intraoperative real-time surface angiographic imaging. This tech- nology places control of vascular anastomosis evaluation and flap perfusion in the hands of the surgeon intraoperatively in a visual manner that is easy to use and is helpful in surgical decision-making. (Plast. Reconstr. Surg. 123: 1239, 2009.) S oft-tissue and bony reconstruction with free- tissue transfer is one of the most versatile tools available to the reconstructive surgeon. These methods are routinely used in the recon- struction of soft-tissue deficits of the head and neck, breast, trunk, and lower extremities. Early detection of vascular compromise and its prompt correction remain critical in the success of free- tissue transfer. 1 Many intraoperative and postop- erative monitoring devices and techniques have been developed, with varying success and clinical relevance. In conjunction with clinical evaluation (e.g., color, turgor, bleeding), monitoring includes both invasive and noninvasive techniques. Nonin- vasive studies include hand-held Doppler ultra- sound, infrared thermography, 2 polarized spectral imaging, 3 and laser Doppler perfusion imaging. 4 Invasive evaluations include implantable Doppler probes, 5 microdialysis, 6 and venous pressure mea- surements with indwelling venous catheters. 7 De- spite the various options, only few have gained universal acceptance. 8 The SPY system (Novadaq Technologies, Inc., Concord, Ontario, Canada) is an intraoperative fluorescent angiographic imaging system that pro- duces a real-time image of large- and small-caliber blood vessels. It is based on lyophilized indocya- From Duke University Medical Center. Received for publication September 1, 2008; accepted No- vember 7, 2008. Copyright ©2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31819e67c1 Disclosure: Novadaq supplied the SPY fluorescent angiography system at no charge to Duke University Medical Center for the study. No other financial sup- port was obtained. Since the acceptance of this article, Dr. Zenn has become a paid consultant for Novadaq Corporation. This change of disclosure does not affect this publication and has been so noted in the Plastic and Reconstructive Surgery and American Society of Plastic Surgeons disclosures submitted since. Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any web browser to access this content. Click- able links to the material are provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com). www.PRSJournal.com 1239