Clinical effect of designing and harvesting expanded flaps assisted by indocyanine green angiography for repairing wounds after scar excision

Hu Yanan; Xie Tingjun; Liu Yuanbo; Zhu Shan; Yang Zengjie; Tian Jia; Gan Cheng; Jiao Hu; Li Shanshan; Chen Zixiang; Zhou Lu; Han Bing; Jin Shengyang; Zeng Yan; Wang Miao; Zang Mengqing

doi:10.3760/cma.j.cn501225-20250108-00013

Turn off MathJax

Article Contents

Abstract

References

Article Navigation > CHINESE JOURNAL OF BURNS AND WOUNDS > > Accepted Manuscript

Hu Yanan,Xie Tingjun,Liu Yuanbo,et al.Clinical effect of indocyanine green angiography in designing and harvesting expanded flaps for scar excision wound repair[J].Chin J Burns Wounds,2025,41(4):1-7.DOI: 10.3760/cma.j.cn501225-20250108-00013.

Citation:

PDF( 6922 KB)

Clinical effect of designing and harvesting expanded flaps assisted by indocyanine green angiography for repairing wounds after scar excision

doi: 10.3760/cma.j.cn501225-20250108-00013

Scar and wound Treatment Center, Plastic Surgery Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100144, China

Funds:

Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences 2023-I2M-C&T-B-104

More Information

Corresponding author: Zang Mengqing, Email: zangmengqing@sina.com
Received Date: 2025-01-08
Available Online: 2025-04-02

Abstract

Abstract

Objective To explore the clinical effect of designing and harvesting expanded flaps assisted by indocyanine green angiography, as a superficial blood flow visualization tool for repairing wounds after scar excision. Methods This study was a retrospective observational study. From April 2019 to August 2023, 19 patients (8 males, 11 females; aged 3-38 years) treated at the Plastic Surgery Hospital of Peking Union Medical College and Chinese Academy of Medical Sciences met the inclusion criteria. In stage Ⅰ surgery, tissue expanders were implanted in suitable areas around the scars for soft tissue expansion. In stage Ⅱ surgery, scar tissue was excised, resulting in wound areas ranging from 100 to 210 cm² and expanded flaps were designed. ICGA was used to identify target perforators and accompanying veins, and the flap design was adjusted to ensure the inclusion of complete arterial and venous axes. Expanded flaps with back-up design ranging from 120 to 240 cm² were harvested and transferred to the recipient site, with direct closure of the donor site. The durations of the arterial and venous phases of ICGA during flap design were recorded. The length-to-width ratios of the flaps were calculated for different anatomical regions. Postoperatively in stage Ⅱ surgery, flap perfusion, survival, donor site healing, and complications were assessed. During follow-up, the appearance, color, and texture of the patient's flap were observed. Results The arterial phase of ICGA lasted 10-27 (18±5) s, and the venous phase lasted 78-116 (100±10) s. The length-to-width ratios of the flaps were 1.22 ± 0.32, 1.63±0.12, and 1.15±0.21 for the head and neck, trunk, and limb regions, respectively. In one case during the postoperative phase Ⅱ, ICGA showed significant hypoperfusion of the transferred flap and this was improved after loosening the sutures at the oral commissure. All flaps survived completely, with well-healed donor sites and no complications. During 0.5-14 months of follow-up, all flaps demonstrated excellent appearance, color, and texture, matching the surrounding skin. Conclusions As a superficial blood flow visualization tool, ICGA can not only clearly show the microvascular distribution of the expanded flap before operation, assist in optimizing the design of the flap, but also evaluate the blood perfusion of the flap after operation, reduce the occurrence of complications, and provides comprehensive navigation for the harvesting of expanded flaps.
- Cicatrix,
- Angiography,
- Perforator flap,
- Indocyanine green angiography,
- Soft tissue expansion,
- Flap design,
- Wound repair

FullText(HTML)

References(35)

References

[1]	GuoY, SongY, XiongS, et al. Mechanical stretch induced skin regeneration: molecular and cellular mechanism in skin soft tissue expansion[J]. Int J Mol Sci, 2022,23(17): 9622. DOI: 10.3390/ijms23179622.
[2]	RadwanAM, ZideMF. Tissue expansion in the head and neck[J]. Atlas Oral Maxillofac Surg Clin North Am, 2019,27(2):167-173. DOI: 10.1016/j.cxom.2019.05.010.
[3]	TongX, LuJ, ZhangW, et al. Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates[J/OL]. Burns Trauma, 2022,10:tkac045[2025-01-08]. https://pubmed.ncbi.nlm.nih.gov/36518877/. DOI: 10.1093/burnst/tkac045.
[4]	张伟, 张卫东, 陈斓, 等. 扩张皮瓣整复大面积烧伤后面颈部瘢痕挛缩畸形的临床效果[J]. 中华烧伤与创面修复杂志, 2023, 39(9):826-834. DOI: 10.3760/cma.j.cn501225-20230706-00248.
[5]	ZideBM, KarpNS. Maximizing gain from rectangular tissue expanders[J]. Plast Reconstr Surg, 1992,90(3):500-504; discussion 505-506.
[6]	CherryGW, AustadE, PasykK, et al. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin[J]. Plast Reconstr Surg, 1983,72(5):680-687. DOI: 10.1097/00006534-198311000-00018.
[7]	ZhuH, XieY, XieF, et al. Prevention of necrosis of adjacent expanded flaps by surgical delay[J]. Ann Plast Surg, 2014,73(5):525-530. DOI: 10.1097/SAP.0b013e31827fafce.
[8]	XieT, LiuY, ZhuS, et al. Finding perforator "freeway" for design optimization of expanded flaps by indocyanine green angiography[J]. Plast Reconstr Surg, 2025,155(2):414e-418e. DOI: 10.1097/PRS.0000000000011545.
[9]	TaylorGI, ChubbDP, AshtonMW. True and 'choke' anastomoses between perforator angiosomes: part Ⅰ. anatomical location[J]. Plast Reconstr Surg, 2013,132(6):1447-1456. DOI: 10.1097/PRS.0b013e3182a80638.
[10]	OgawaR, OkiK, HyakusokuH. Skin perforator freeways and pathways: understanding the role of true and choke anastomoses between perforator angiosomes and their impact on skin flap planning and outcomes[J]. Plast Reconstr Surg, 2014,133(5):719e-720e. DOI: 10.1097/PRS.0000000000000139.
[11]	AltafFM. The anatomical basis of the medial sural artery perforator flaps[J]. West Indian Med J, 2011,60(6):622-627.
[12]	GurtnerGC, JonesGE, NeliganPC, et al. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use[J]. Ann Surg Innov Res, 2013,7(1):1. DOI: 10.1186/1750-1164-7-1.
[13]	NarushimaM, YamasobaT, IidaT, et al. Pure skin perforator flaps: the anatomical vascularity of the superthin flap[J]. Plast Reconstr Surg, 2018,142(3):351e-360e. DOI: 10.1097/PRS.0000000000004698.
[14]	Saint-CyrM, WongC, SchaverienM, et al. The perforasome theory: vascular anatomy and clinical implications[J]. Plast Reconstr Surg, 2009,124(5):1529-1544. DOI: 10.1097/PRS.0b013e3181b98a6c.
[15]	HyakusokuH, GaoJH, PenningtonDG, et al. The microvascular augmented subdermal vascular network (ma-SVN) flap: its variations and recent development in using intercostal perforators[J]. Br J Plast Surg, 2002,55(5):402-411. DOI: 10.1054/bjps.2002.3865.
[16]	LiuY, ZangM, ZhuS, et al. Pre-expanded paraumbilical perforator flap[J]. Clin Plast Surg, 2017,44(1):99-108. DOI: 10.1016/j.cps.2016.08.003.
[17]	OnodaS, AzumiS, HasegawaK, et al. Preoperative identification of perforator vessels by combining MDCT, doppler flowmetry, and ICG fluorescent angiography[J]. Microsurgery, 2013,33(4):265-269. DOI: 10.1002/micr.22079.
[18]	Vander KolkCA, McCannJJ, KnightKR, et al. Some further characteristics of expanded tissue[J]. Clin Plast Surg, 1987,14(3):447-453.
[19]	ChanP, ColonAF, CluneJ, et al. External tissue expansion in complex extremity reconstruction[J]. J Hand Surg Am, 2021,46(12):1094-1103. DOI: 10.1016/j.jhsa.2021.07.039.
[20]	ErogluS, BuyukdoganH, DuranA. Direct-to-implant retropectoral dual plane approach with autologous inferior-based dermal flap: does spy-elite laser angiographic system reduce complication rates?[J]. Aesthetic Plast Surg, 2024,48(21):4414-4420. DOI: 10.1007/s00266-024-04075-1.
[21]	TaghizadehF, TroobSH, WaxMK. The role of fluorescent angiography in free flap reconstruction of the head and neck[J]. Laryngoscope, 2023,133(6):1388-1393. DOI: 10.1002/lary.30450.
[22]	GoncalvesLN, van den HovenP, van SchaikJ, et al. Perfusion parameters in near-infrared fluorescence imaging with indocyanine green: a systematic review of the literature[J]. Life (Basel), 2021,11(5):433. DOI: 10.3390/life11050433.
[23]	YangCE, ChungSW, LeeDW, et al. Evaluation of the relationship between flap tension and tissue perfusion in implant-based breast reconstruction using laser-assisted indocyanine green angiography[J]. Ann Surg Oncol, 2018,25(8):2235-2240. DOI: 10.1245/s10434-018-6527-1.
[24]	王石, 董帅, 曹阳, 等. 高选择性动脉吲哚菁绿造影在游离股前外侧皮瓣设计中的应用[J]. 中华烧伤与创面修复杂志, 2024, 40(10): 948-954. DOI: 10.3760/cma.j.cn501225-20240513-00174.
[25]	WangC, ZhangJ, HyakusokuH, et al. An overview of pre-expanded perforator flaps: part 2, clinical applications[J]. Clin Plast Surg, 2017,44(1):13-20. DOI: 10.1016/j.cps.2016.09.007.
[26]	TanO, AtikB, BekereciogluM. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap[J]. Microsurgery, 2005,25(1):36-43. DOI: 10.1002/micr.20072.
[27]	KimuraN, SaitohM, OkamuraT, et al. Concept and anatomical basis of microdissected tailoring method for free flap transfer[J]. Plast Reconstr Surg, 2009,123(1):152-162. DOI: 10.1097/PRS.0b013e3181934756.
[28]	DriessenC, ArnardottirTH, LorenzoAR, et al. How should indocyanine green dye angiography be assessed to best predict mastectomy skin flap necrosis? A systematic review[J]. J Plast Reconstr Aesthet Surg, 2020,73(6):1031-1042. DOI: 10.1016/j.bjps.2020.02.025.
[29]	BigcasJM, DeBiaseCA, HoT. Indocyanine green angiography as the principal design and perfusion assessment tool for the supraclavicular artery island flap in head and neck reconstruction[J]. Cureus, 2022,14(9):e29007. DOI: 10.7759/cureus.29007.
[30]	GelişkenF. Indocyanine green angiography[J]. Turk J Ophthalmol, 2024,54(1):38-45. DOI: 10.4274/tjo.galenos.2023.89735.
[31]	PanettellaT, MeroniM, ScaglioniMF. How to increase the success rate in microsurgical free and pedicled flap reconstructions with intraoperative multistep ICG imaging: a case series with 400 consecutive cases[J]. J Plast Reconstr Aesthet Surg, 2024,97:147-155. DOI: 10.1016/j.bjps.2024.07.047.
[32]	WangM, ZangM, ZhuS, et al. Utility of indocyanine green angiography for preventing pre-expanded extended lower trapezius myocutaneous flap necrosis: how to make the correct decision for hypoperfused areas[J]. J Reconstr Microsurg, 2023,39(5):383-391. DOI: 10.1055/a-1939-5606.
[33]	MattisonGL, LewisPG, GuptaSC, et al. SPY imaging use in postmastectomy breast reconstruction patients: preventative or overly conservative?[J]. Plast Reconstr Surg, 2016,138(1):15e-21e. DOI: 10.1097/PRS.0000000000002266.
[34]	LiuEH, ZhuSL, HuJ, et al. Intraoperative SPY reduces post-mastectomy skin flap complications: a systematic review and meta-analysis[J]. Plast Reconstr Surg Glob Open, 2019,7(4):e2060. DOI: 10.1097/GOX.0000000000002060.
[35]	ZhangY, XiaoW, NgS, et al. Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction[J]. J Plast Reconstr Aesthet Surg, 2021,74(9):2068-2075. DOI: 10.1016/j.bjps.2020.12.102.