Pre- and intraoperative identification of perforator vessels using MRA/MDCTA, doppler sonography, and ICG fluorescence angiography

Here, we introduce our method of combined use of magnetic resonance angiography/multidetector-row computed tomography (MRA/MDCTA), Doppler sonography, and indocyanine green (ICG) fluorescence angiography to identify the locations of the perforator vessels of the flaps. This method can be used to accurately confirm perforator vessel location on pre- or intraoperative images. If a detectable perforator is obtained using preoperative MRA/MDCTA and Doppler sonography, we use the term "freestyle perforator-based flap" for propeller or V-Y advancement flaps. In some cases, aggressive perforator dissection is necessary to free these flaps from adhesions and evenly distribute the torsion, and the intraoperative identification of perforator vessels detected by Doppler sonography and ICG fluorescence angiography makes it possible to select perforators of larger caliber and stronger pulsatility without fear of anatomic inconsistencies; furthermore, such identification facilitates the surgical mechanics and shortens the operation time.