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Near-Infrared Vein Visualization in Index Finger Pollicization
SURGICAL TECHNIQUE
Near-Infrared Vein Visualization in Index Finger Pollicization Brooks W. Ficke, MD,* Erin F. Ransom, MD,* Jean E. Oakes, MD*
Near-infrared vein visualization devices allow for noninvasive identification of superficial veins. During index finger pollicization, preservation of the dorsal veins is important for protecting blood outflow from the digit. Near-infrared vein visualization devices can be used to identify the location of the dorsal veins prior to skin incision, allowing increased confidence during dissection. We describe the use of this device to identify veins during index finger pollicization. (J Hand Surg Am. 2017;-(-):1.e1-e2. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Pollicization, surgical technique, near-infrared vein visualization.
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VEIN VISUALIZATION devices allow for noninvasive identification of veins for multiple uses. They function by illuminating the skin with near-infrared light (700e900 nm), which penetrates the skin and subcutaneous tissues to a depth of approximately 3 mm (Lingyu and Leedham, presented at the IEEE International Conference on Video and Signal Based Surveillance, 2006). The light is differentially absorbed by the underlying tissues, with increased absorption by deoxygenated hemoglobin. The difference in absorption is detected by the device camera, and a reproduction of this is projected onto the subject’s skin in real time. The technique is commonly used in pediatric hospitals for improving the ability to obtain intravenous access and may aid in obtaining venous access in difficult situations.1 It has also been used to identify potential donors for vein grafts, minimizing the incision size at the harvest site, and to aid in the planning and design of free flaps for breast reconstruction.2,3 During index finger pollicization, the dorsal veins must be preserved to allow blood outflow from the digit. The goal is to separate the veins from both the EAR-INFRARED
From the *Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL. Received for publication September 16, 2016; accepted in revised form March 21, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
skin and the extensor mechanism while not disturbing their associated fat envelope.4 Knowledge of the location and number of these veins prior to skin incision provides confidence during dissection of the dorsal tissues. INDICATIONS Near-infrared vein visualization is useful to identify the pattern and location of dorsal veins on the index finger during pollicization procedures. Identification of vein locations prior to surgical incision allows for gentle treatment of the veins, providing the best chance for preservation of blood outflow from the digit. CONTRAINDICATIONS Near-infrared vein visualization is a noninvasive tool, with no known harmful effects. It is not dependable for identifying deep arteries and veins, such as the digital artery. TECHNIQUE The veins may be identified either before or after skin preparation. Prior to tourniquet inflation, the
Corresponding author: Jean E. Oakes, MD, Division of Orthopaedic Surgery, University of Alabama at Birmingham, Orthopaedic Specialties Building, 1313 13th St. South, Birmingham, AL 35205; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.03.039
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
INDEX FINGER POLLICIZATION
FIGURE 1: The vein visualization device is used to illuminate the subject’s hand and demonstrate a superficial vein (black arrow).
FIGURE 3: The dorsal dissection has been performed, exposing and preserving the veins underneath the skin markings.
visualized as dark lines, are traced with a skin marker (Fig. 2). After this, the procedure can proceed in the usual fashion. Gentle exsanguination via elevation rather than elastic bandage helps with identification of blood vessels. During dorsal dissection, the areas identified by the device can be avoided, allowing the vein to be preserved in a healthy layer of fat (Fig. 3). DISCUSSION In summary, we present a technique for determining the location of the dorsal veins prior to skin incision. Many pediatric hospitals already use these devices for other purposes, so they are easily available and add no expense to the procedure. Near-infrared vein visualization is not necessary for successful index pollicization, but it is a convenient, low-cost adjuvant that may simplify the procedure and increase surgeon confidence during dissection. REFERENCES 1. Guillon P, Makhloufi M, Baillie S, Roucoulet C, Dolimier E, Masquelier AM. Prospective evaluation of venous access difficulty and a near-infrared vein visualizer at four French haemophilia treatment centres. Haemophilia. 2015;21(1):21e26. 2. Basat SO, Aksan T, Askeroglu U, Akan M. A practical guiding method for vein graft harvesting. J Hand Microsurg. 2013;5(2):86. 3. Chu MW, Sarik JR, Wu LC, Serletti JM, Bank J. Non-invasive imaging of preoperative mapping of superficial veins in free flap breast reconstruction. Arch Plast Surg. 2016;43(1):119e121. 4. Carter PR. Making a Thumb: The Story of Pollicization [DVD]. Dallas, TX: Texas Scottish Rite Hospital for Children; 2006.
FIGURE 2: The dorsal veins are being traced on the skin.
near-infrared vein visualization device is brought up. Dimming the room lights may be useful for improving visualization. The device is activated and the projection is centered on the dorsum of the patient’s index finger (Fig. 1). The veins, which can be J Hand Surg Am.
r
Vol. -, - 2017
Near-Infrared Vein Visualization in Index Finger Pollicization Brooks W. Ficke, MD,* Erin F. Ransom, MD,* Jean E. Oakes, MD*
Near-infrared vein visualization devices allow for noninvasive identification of superficial veins. During index finger pollicization, preservation of the dorsal veins is important for protecting blood outflow from the digit. Near-infrared vein visualization devices can be used to identify the location of the dorsal veins prior to skin incision, allowing increased confidence during dissection. We describe the use of this device to identify veins during index finger pollicization. (J Hand Surg Am. 2017;-(-):1.e1-e2. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Pollicization, surgical technique, near-infrared vein visualization.
N
VEIN VISUALIZATION devices allow for noninvasive identification of veins for multiple uses. They function by illuminating the skin with near-infrared light (700e900 nm), which penetrates the skin and subcutaneous tissues to a depth of approximately 3 mm (Lingyu and Leedham, presented at the IEEE International Conference on Video and Signal Based Surveillance, 2006). The light is differentially absorbed by the underlying tissues, with increased absorption by deoxygenated hemoglobin. The difference in absorption is detected by the device camera, and a reproduction of this is projected onto the subject’s skin in real time. The technique is commonly used in pediatric hospitals for improving the ability to obtain intravenous access and may aid in obtaining venous access in difficult situations.1 It has also been used to identify potential donors for vein grafts, minimizing the incision size at the harvest site, and to aid in the planning and design of free flaps for breast reconstruction.2,3 During index finger pollicization, the dorsal veins must be preserved to allow blood outflow from the digit. The goal is to separate the veins from both the EAR-INFRARED
From the *Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL. Received for publication September 16, 2016; accepted in revised form March 21, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
skin and the extensor mechanism while not disturbing their associated fat envelope.4 Knowledge of the location and number of these veins prior to skin incision provides confidence during dissection of the dorsal tissues. INDICATIONS Near-infrared vein visualization is useful to identify the pattern and location of dorsal veins on the index finger during pollicization procedures. Identification of vein locations prior to surgical incision allows for gentle treatment of the veins, providing the best chance for preservation of blood outflow from the digit. CONTRAINDICATIONS Near-infrared vein visualization is a noninvasive tool, with no known harmful effects. It is not dependable for identifying deep arteries and veins, such as the digital artery. TECHNIQUE The veins may be identified either before or after skin preparation. Prior to tourniquet inflation, the
Corresponding author: Jean E. Oakes, MD, Division of Orthopaedic Surgery, University of Alabama at Birmingham, Orthopaedic Specialties Building, 1313 13th St. South, Birmingham, AL 35205; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.03.039
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
INDEX FINGER POLLICIZATION
FIGURE 1: The vein visualization device is used to illuminate the subject’s hand and demonstrate a superficial vein (black arrow).
FIGURE 3: The dorsal dissection has been performed, exposing and preserving the veins underneath the skin markings.
visualized as dark lines, are traced with a skin marker (Fig. 2). After this, the procedure can proceed in the usual fashion. Gentle exsanguination via elevation rather than elastic bandage helps with identification of blood vessels. During dorsal dissection, the areas identified by the device can be avoided, allowing the vein to be preserved in a healthy layer of fat (Fig. 3). DISCUSSION In summary, we present a technique for determining the location of the dorsal veins prior to skin incision. Many pediatric hospitals already use these devices for other purposes, so they are easily available and add no expense to the procedure. Near-infrared vein visualization is not necessary for successful index pollicization, but it is a convenient, low-cost adjuvant that may simplify the procedure and increase surgeon confidence during dissection. REFERENCES 1. Guillon P, Makhloufi M, Baillie S, Roucoulet C, Dolimier E, Masquelier AM. Prospective evaluation of venous access difficulty and a near-infrared vein visualizer at four French haemophilia treatment centres. Haemophilia. 2015;21(1):21e26. 2. Basat SO, Aksan T, Askeroglu U, Akan M. A practical guiding method for vein graft harvesting. J Hand Microsurg. 2013;5(2):86. 3. Chu MW, Sarik JR, Wu LC, Serletti JM, Bank J. Non-invasive imaging of preoperative mapping of superficial veins in free flap breast reconstruction. Arch Plast Surg. 2016;43(1):119e121. 4. Carter PR. Making a Thumb: The Story of Pollicization [DVD]. Dallas, TX: Texas Scottish Rite Hospital for Children; 2006.
FIGURE 2: The dorsal veins are being traced on the skin.
near-infrared vein visualization device is brought up. Dimming the room lights may be useful for improving visualization. The device is activated and the projection is centered on the dorsum of the patient’s index finger (Fig. 1). The veins, which can be J Hand Surg Am.
r
Vol. -, - 2017