Intraoperative Indocyanine Green Angiography Facilitates Flap Fenestration and Facial Organ Fabrication in Total Facial Restoration.

Background: Because of a lack of effective measures to visualize flap vasculature and perfusion, flap fenestration and facial organ fabrication cannot be performed effectively, preventing the transition from two-dimensional coverage to restoration of the three-dimensional (3D) structure of facial organs. This study aimed to evaluate the efficacy of indocyanine green angiography (ICGA) in guiding flap fenestration and facial organ fabrication in total facial restoration.

Methods: Ten patients with total facial scarring after burn injury were enrolled in the study. They were treated with preexpanded, prefabricated monoblock flaps for total face restoration. The openings of nostrils and oral and palpebral orifices, together with organ fabrication, were conducted under the guidance of intraoperative ICGA by hemodynamic evaluation of flap perfusion. Postoperative follow-up measures include vascular crisis, infection, flap necrosis, and aesthetic and functional recovery.

Results: The opening of facial organ orifices was performed at the stage of flap transfer in nine patients. To avoid damaging the major nourishing vessels, the left palpebral orifice was opened 8 days after the flap transfer in one patient, as observed by ICGA. Based on ICGA evaluation, the decision to perform additional vascular anastomosis before flap fenestration was made in six patients. Hemodynamic analysis of flap perfusion after fenestration revealed no significant change. Follow-up showed satisfactory aesthetic recovery and well-restored 3D structures of facial organs.

Conclusion: This pilot study demonstrates how intraoperative ICGA can enhance the safety of flap fenestration, thereby transforming full facial restoration from the two-dimensional to the 3D realm by facilitating facial organ fabrication.

Clinical Question/level Of Evidence: Therapeutic, IV.