Table 1 Methods for evaluation of tissue perfusion, by setting

Intraoperative

ICG intraoperative laser angiography*

→Visualize perforator perfusion zone in real time

→Visualizes perforator perfusion zones

→Requires administration of contrast media

Phillips et al., 2012 [12]

→Confirm patency of arterial and venous anastomoses

→No exposure to ionizing radiation

→Does not identify precise vessel location or course through muscle and fascia when lipodystrophy exists

Francisco et al., 2010 [52]

→Confirm perfusion of tissue prior to incision, after elevation of flaps, and prior to final closure

→Strong safety profile and short half-life of ICG

Komorowska-Timek & Gurtner, 2010 [1]

→Permits re-evaluation during same surgery

Murray et al., 2010 [16]

Tamburrino et al., 2010 [17]

Newman et al., 2009 [11]

Jones et al., 2009 [14]

Azuma et al., 2008 [18]

Prantl et al., 2008 [19]

De Lorenzi et al., 2005 [20]

Mothes et al., 2004 [8]

Holm, Tegeler, et al., 2002 [21]

Holm, Mayr, et al., 2002 [22]

Still et al. 1999 [23]

Doppler – handheld

→Identification of perforator vessel location

→Easy to use

→Provides information on discrete area below probe

Yu & Youssef, 2006 [29]

→Widely available

→Requires direct skin contact

→Inexpensive

→Does not identify perforator perfusion zone

→Provides confirmatory information

→Provides limited data and accuracy for flap design,

→especially in heavier patients

→Difficult to quantify

→Does not stratify perforators

Fluorescein

→Visualization of perforator perfusion zone

→Visualization of perforator perfusion zone

→Single use only

Phillips et al., 2012 [12]

→Widely available

→No venous information

Losken et al., 2008 [51]

→Long delay time

→Toxicity concerns

→Use of ultraviolet Woods lamp

→High sensitivity, low specificity

Preoperative

Clinical judgment

→Estimation of tissue perfusion and flap viability

→Familiarity, ease of use

→Poor reliability when used alone

Phillips et al., 2012 [12]

→Dependent on surgeon experience

Mothes et al., 2004 [8]

→Inferior to imaging modalities for estimation of flap survival

Olivier et al., 2003 [9]

Holm, Tegeler et al., 2002 [21]

Doppler Ultrasound (duplex, color, power)

→Identification of perforator vessel location

→No exposure to ionizing radiation or contrast media

→Inferior to CT angiography for identification of vessel location

Rozen et al., 2008 [24]

→Estimate of vessel flow rate

→Provides estimation of perforator location, caliber, and flow

→Considered operator-dependent

Khalid et al., 2006 [25]

→Does not identify perforator perfusion zone

Giunta et al., 2000 [26]

→High rate of false-positive findings reported

Hallock, 2003 [27]

Blondeel et al., 1998 [28]

Laser Doppler flowmetry

→Identification of vessel location and tissue perfusion

→No exposure to ionizing radiation or contrast media

→May underestimate flap survival

Schlosser et al., 2010 [30]

→Identifies ischemia in flaps

→Poor ability to detect perforator vessels

Holzle et al., 2006 [31]

→Sensitive to small movements

Heller et al., 2001 [32]

Heden et al.1986 [33]

CT angiography

→Visualization of location and course of vessels through muscles and fascia

→Accurate detection of anatomic location and course of vessels

→Does not assess vascular flow

Ghattaura et al.,2010 [34]

→Greater accuracy than Doppler ultrasound

→Does not show perforator perfusion zones

Smit et al., 2009 [35]

→Potential for reduced surgical time

→May have poor resolution for vessel caliber;

Rozen et al., 2008 [24]

→Exposure to ionizing radiation

Cina et al., 2010 [36]

→Potential toxicity of contrast media

Scott et al., 2010 [37]

Phillips et al., 2008 [38]

Rosson et al., 2007 [39]

Masia et al., 2006 [40]

MR angiography

→Visualization of location and course of vessels through muscles and fascia

→Greater accuracy than Doppler ultrasound

→Does not assess vascular flow

Schaverien et al., 2011 [42]

→Detection of small caliber vessels

→Does not show perforator perfusion zones

Newman et al., 2010 [43]

→Potential for reduced surgical time

→Less spatial resolution compared to CT angiography

Greenspun et al., 2010 [45]

→No exposure to ionizing

→Potential toxicity of contrast

Chernyak et al., 2009 [41]

→radiation

→media

Neil-Dwyer et al., 2009 [44]

Rozen et al., 2009 [46]

Postoperative

Transcutaneous oxygen monitoring**

→Assessment of tissue oxygen saturation

→Useful for postoperative monitoring

→Limited to discrete 1 cm² area under probe

Steele, 2011 [47]

→Accurately detects vascular compromise

→Numeric output only

Lin et al., 2011 [48]

→Improves flap salvage rate in postoperative setting

→Used primarily for postoperative monitoring

Keller, 2009 [49]

→Time consuming, cumbersome for intraoperative mapping

Keller, 2007 [50]