HYPOTHESIS AND THEORY article
Front. Surg.
Sec. Reconstructive and Plastic Surgery
This article is part of the Research TopicAdvancements and Applications of Indocyanine Green (ICG) in Plastic and Reconstructive SurgeryView all articles
Potential of Methylene Blue Fluorescence Angiography for Multiple Intraoperative Tissue Perfusion Assessments in Plastic and Reconstructive Surgery: Current Knowledge and Prospects
Provisionally accepted
- 1Maastricht University, Maastricht, Netherlands
- 2Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
- 3Zuyderland Medisch Centrum, Sittard-Geleen, Netherlands
- 4Universiteit Maastricht, Maastricht, Netherlands
- 5Universitair Ziekenhuis Brussel, Brussels, Belgium
Select one of your emails
You have multiple emails registered with Frontiers:
Notify me on publication
Please enter your email address:
If you already have an account, please login
You don't have a Frontiers account ? You can register here
The expansion of (minimally invasive) surgical techniques has led to the development of advanced tools, including high-definition visual systems and fluorescence-guided surgery (FGS), enhancing surgeons' performance and patient safety. FGS employs near-infrared light and fluorophores like indocyanine green (ICG) for intraoperative imaging to improve anatomical navigation and decision-making. Recently, an increasing number of fluorescence imaging systems have shown capability in visualizing methylene blue (MB), which has an excitation peak at 700 nm, and its potential role in perfusion assessment. A recent study has highlighted MB's advantage over ICG due to its shorter washout time, enabling repeated intraoperative perfusion assessments using a dose of 0.5mg/kg in a porcine model. This characteristic may be particularly beneficial in plastic and reconstructive surgery involving free (chimeric) flaps, pedicled skin flaps, pedicled intestinal transplants, and mastectomy skin flaps, where perfusion assessment can be critical at multiple stages. Therefore, we highlight some examples of flap reconstructions in this technical note. Important to know, MB is considered safe within the therapeutic doses (<2 mg/kg). However, it is contraindicated in certain patients, including those who are pregnant, have renal insufficiency, are on specific serotonin medications and some rare deficiencies. As dual-wavelength fluorescence imaging systems compatible with both ICG and MB advance, there is growing interest in the potential of MB for (multiple) flap perfusion assessment(s) in plastic and reconstructive surgery, building on promising research in bowel perfusion.
Keywords: Fluorescence Imaging, Reconstructive flap surgery, Methylene Blue, Indocyanine Green, Fluorescence angiography
Received: 07 Aug 2025; Accepted: 07 Nov 2025.
Copyright: © 2025 Heuvelings, Hillege, Al-Taher and Schols. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Rutger Schols, rutger.schols@mumc.nl
Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.