Background
Evaluate imaging photoplethysmography (iPPG) as a novel noninvasive technique to assess flap perfusion in head and neck free flap reconstructive (FFR) surgeries.

Methods
Intraoperative iPPG was performed in 17 patients undergoing FFR surgery. Imaging consisted of a 30-s video from which perfusion maps were extracted, providing detailed information about blood flow and pulsatility in the flap microvasculature. During each procedure, iPPG acquisitions were acquired representing distinct perfusion conditions of the flap (fully perfused/ischemic/reperfused). When possible, postoperative measurements were performed to assess flap recovery during the critical time period (3 days) and long-term follow-up (30 days).

Results
Perfusion maps, displaying iPPG amplitude and delay times, correlated strongly (p < 0.001) with the perfusion status of the tissue. One case of postoperative thrombosis, leading to flap failure, was identified with iPPG. After surgical revision in this case, flap perfusion was restored and confirmed by iPPG. Postoperative follow-up imaging allowed for objective visualization of flap recovery short term (3 days) and up to 30 days after the surgical procedure.

Conclusions
This study shows that iPPG is suitable for objective and noninvasive assessment of flap perfusion in head and neck FFR surgery. In addition, postoperative monitoring shows potential for assessing flap perfusion in patients with increased risk of postoperative complications.