Viewpoint
Determining Transverse Rectus Abdominis Musculo-cutaneous Flap
Viability using Fingerstall-type Tissue Oximetry as an Alternative toIndocyanine Green Fluorescence Imaging: A Case of a Patient withIodine Hypersensitivity
Itaru Tsuge, MD Susumu Saito, MD, PhD

Downloaded from https://journals.lww.com/prsgo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3bhnalqTQiPvj6yq2XzzNYQgE3fIYfNoGU/CjDc0ph/q+vfOg8XGVRA== on 11/15/2018

The blood circulation regions of Zone IV and Zone
II in the transverse rectus abdominis musculo-cutaneous flap are known to depend on individual patients.1
Conducting the indocyanine green (ICG) test helps ensure the safety of flap surgery; however, there have beenreports of anaphylactic shock due to ICG intravenous injection.2,3 Even a single small-dose administration (5 mg)of intravenous ICG can cause anaphylactic shock,4 so its
administration to patients with iodine hypersensitivity iscontraindicated. We developed a noninvasive method
using the fingerstall-type tissue oximetry system Toccare(Astem, Japan) to determine the skin perfusion area.5
Accumulating results indicated the average tissue oxygen
saturation (StO2) matching the ICG border to be 41.4%.
We applied this result to a clinical patient with iodine
hypersensitivity for the first time.

lines (Fig. 1). Comprehensive StO2 measurement of theentire flap and determination of the boundary lines took
about 5 minutes. When the flap was cut with a 40% line,
dark-red continuous bleeding was observed. After transferring the flap to the right chest, the skin was furtherCASEThe medical ethics committee of our institution approved this study. A 47-year-old woman underwent rightbreast reconstruction by a pedicle transverse rectus abdominis musculo-cutaneous flap. She had asthma andatopic dermatitis in her medical history. An asthma attack
occurred during a previous session of iodinated contrast
computed tomography performed at another hospital.
She was therefore diagnosed with iodine hypersensitivity.
No subsequent imaging inspections using contrast media
had been performed. She also reported food allergies
for shrimp and crab. We judged the risk of an ICG test to
be very high and therefore contraindicated. As such, theToccare system was applied as an intraoperative noninvasive evaluation method. For intraoperative use, an echoprobe cover was used. Blue fabric was laid under theflap to avoid any influence of underlying structures. We
searched for points at which the StO2 was 45%, 40%, or30% after elevation of the flap to describe the boundary

Fig. 1. Measurement of the StO2 value. Lines for 45%, 40%, and 30%
were described.

From the Department of Plastic and Reconstructive Surgery, Graduate
School of Medicine, Kyoto University, Kyoto, Japan.
Received for publication June 16, 2018; accepted August 7, 2018.

Copyright © 2018 The Authors. Published by Wolters Kluwer Health,Inc. on behalf of The American Society of Plastic Surgeons. Thisis an open-access article distributed under the terms of the CreativeCommons Attribution-Non Commercial-No Derivatives License 4.0(CCBY-NC-ND), where it is permissible to download and share thework provided it is properly cited. The work cannot be changed inany way or used commercially without permission from the journal.
Plast Reconstr Surg Glob Open 2018;6:e1966; doi:10.1097/
GOX.0000000000001966; Published online 24 September 2018.

Fig. 2. Transfer of the flap to the right chest. The skin was trimmed
on a 45% line. The fat was trimmed along a 40% line.

www.PRSGlobalOpen.com

1

PRS Global Open • 2018
trimmed to a 45% line and showed red bleeding (Fig. 2).
The fat layer was excised along a 40% line, and dark-red,continuous bleeding was observed. The surgery resulted
in no flap failure.
Anaphylactic shock has been reported even in caseswith negative iodine test findings or no history of drug
allergies.4 The ICG test should be considered as an invasive method, even for patients with no history of allergy. Our novel method can be expected to be widely
applicable as a new alternative method for evaluating
flap viability.
Itaru Tsuge, MD
Department of Plastic and Reconstructive Surgery
Graduate School of Medicine
Kyoto University
54 Shogoin kawahara-cho, sakyou-ku
Kyoto 606–8507, Japan
E-mail: itsuge@kuhp.kyoto-u.ac.jp

2DISCLOSURE

The authors have no financial interest to declare in relation tothe content of this article. The Article Processing Charge was paid
for by the authors.
REFERENCES
1. Scheflan M, Dinner MI. The transverse abdominal island flap:
part I. Indications, contraindications, results, and complications.
Ann Plast Surg. 1983;10:24–35.
2. Hope-Ross M, Yannuzzi LA, Gragoudas ES, et al. Adverse reactions due to indocyanine green. Ophthalmology. 1994;101:529–533.
3. Timothy WO, Jennifer IL, Antonio CJ, et al. Anaphylactic shock
following indocyanine green angiography. Arch Ophthalmol. 1996;
114: 97.
4. Chu W, Chennamsetty A, Toroussian R, et al. Anaphylactic shock
after intravenous administration of indocyanine green during robotic partial nephrectomy. Urol Case Rep. 2017;12:37–38.
5. Tsuge I, Enoshiri T, Saito S, et al. A quick evaluation of TRAM flap
viability using fingerstall-type tissue oximetry. Plast Reconstr Surg
Glob Open. 2017;5:e1494.