Mapping Perfusion and Predicting Success: Infrared Thermography-Guided Perforator Flaps for Lower Limb Defects

<i>Background and Objectives</i>: Lower limb defects often present significant reconstructive challenges due to limited soft tissue availability and exposure of critical structures. Perforator-based flaps offer reliable solutions, with minimal donor site morbidity. This study aimed to evaluate the efficacy of infrared thermography (IRT) in preoperative planning and postoperative monitoring of perforator-based flaps, assessing its accuracy in identifying perforators, predicting complications, and optimizing outcomes. <i>Materials and Methods</i>: A prospective observational study was conducted on 76 patients undergoing lower limb reconstruction with fascio-cutaneous perforator flaps between 2022 and 2024. Perforator mapping was performed concurrently with IRT and Doppler ultrasonography (D-US), with intraoperative confirmation. Flap design variables and systemic parameters were recorded. Postoperative monitoring employed thermal imaging on days 1 and 7. Outcomes were correlated with thermal, anatomical, and systemic factors using statistical analyses, including <i>t</i>-tests and Pearson correlation. <i>Results</i>: IRT showed high sensitivity (97.4%) and positive predictive value (96.8%) for perforator detection. A total of nine minor complications occurred, predominantly in patients with diabetes mellitus and/or elevated glycemia (<i>p</i> = 0.05). Larger flap-to-defect ratios (A/C and B/C) correlated with increased complications in propeller flaps, while smaller ratios posed risks for V-Y and Keystone flaps. Thermal analysis indicated significantly lower flap temperatures and greater temperature gradients in flaps with complications by postoperative day 7 (<i>p</i> < 0.05). CRP levels correlated with glycemia and white blood cell counts, highlighting systemic inflammation's impact on outcomes. <i>Conclusions</i>: IRT proves to be a reliable, non-invasive method for perforator localization and flap monitoring, enhancing surgical planning and early complication detection. Combined with D-US, it improves perforator selection and perfusion assessment. Thermographic parameters, systemic factors, and flap design metrics collectively predict flap viability. Integration of IRT into surgical workflows offers a cost-effective tool for optimizing reconstructive outcomes in lower limb surgery.