Office-based indocyanine green fluorescent angiography for surgical planning of pedicled flap division

Delayed pedicled flaps are a reliable reconstructive tool for limb salvage. Determining the optimal timing for pedicle division is critical for surgical success and minimizing complications. Assessment of optimal timing has traditionally relied on arbitrary timing or subjective measures. This study explores the use of indocyanine green (ICG) angiography in the office setting as an objective guide for timing the delayed pedicled flap pedicle division, aiming to improve surgical outcomes and resource efficiency. In the outpatient setting, ICG is administered intravenously while the flap pedicle is under tourniquet control. If the distal flap opacifies with the tourniquet still applied, appropriate revascularization has occurred, and the pedicle may be safely divided. We present the example of a 47-year-old male with multiple previous flap reconstructions who eventually required a reverse sural artery flap. Initial intraoperative ICG imaging on postoperative day (POD) 23 revealed insufficient perfusion, prompting the postponement of pedicle division. Subsequent office-based imaging on POD 47 revealed a persistent lack of neovascularization. Adequate vascularization was demonstrated on POD 81, enabling successful pedicle division in the operating room on POD 121 without complications. ICG fluorescent angiography can guide the timing of division for delayed pedicled flaps. We recommend its use in the outpatient setting to decrease unnecessary operating room usage and anesthetic events and reduce the risk of wound healing complications from early pedicle division.