Application of indocyanine green angiography in repair of facial soft tissue defect using superficial temporal artery based forehead flap_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHOU Mengqi , LIU Yuanbo , RAN Xiaoye , ZHU Shan , LI Shanshan , CHEN Zixiang , HAN Tinglu , JIN Shengyang , WANG Miao ,  ZANG Mengqing

Scar & Wound Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P. R. China;

Corresponding author：

ZANG Mengqing, Email: zangmengqing@sina.com

Keywords：

Indocyanine green angiography; facial soft tissue defect; forehead flap; superficial temporal vein; vein mapping

DOI：

10.7507/1002-1892.202306095

Video：

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Objective To explore the feasibility of using indocyanine green angiography in mapping the superficial temporal vessels and assisting design and harvesting of the superficial temporal artery based forehead flap. Methods A clinical data of 14 patients with facial soft tissue defects repaired with superficial temporal artery based forehead flaps between October 2015 and November 2022 was retrospectively analyzed. There were 9 males and 5 females with a median age of 9.5 years (range, 3-38 years). The forehead flaps were used to reconstruct facial soft tissue defects following excision of facial scar (8 cases) or congenital melanocyte nevus (6 cases). The size of defects ranged from 3 cm×2 cm to 24 cm×9 cm. Before operation, the indocyanine green angiography was used to map the superficial temporal artery and vein, and to analyze the relationship of the arteries and veins. The forehead flaps with unilateral superficial temporal fascia as the pedicle was transferred to repair the small facial defect in 2 cases. The facial pedicle contained the frontal branch of the superficial temporal artery and 2 cm of the superficial temporal fascia around the vessel, and the tiny accompanying vein of the frontal branch of the superficial temporal artery was used as the outflow of the flap. The forehead flaps with the skin pedicle including bilateral or unilateral superficial temporal fascia and the overlying skin was pre-expanded and transferred to repair the large facial defect in 12 cases. The skin pedicle contained the frontal branch of superficial temporal artery and one of main branches of superficial temporal vein. Among the 12 cases, the frontal branch of superficial temporal vein was used as the outflow in 4 cases, and the parietal branch was used as the outflow in 8 cases. The size of the flaps ranged from 3 cm×2 cm to 30 cm×13 cm. The skin pedicles were divided at 3 weeks after the flap transfer. Results Indocyanine green angiography could clearly showed the course and branching of the superficial temporal artery and vein. Individual differences existed in the location where the frontal branch of the superficial temporal artery entered the forehead. The superficial temporal vein had great variability and did not follow the artery. One patient had expander-related complication, which resulted in 3-cm flap necrosis. The necrotic tissue was debrided and repaired with skin grafting. The other flaps totally survived and the incisions healed by first intention. All patients were followed up 2-24 months, with a median of 11.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. Hypertrophic scar was not observed in recipient or donor site. All patients were satisfied with the reconstructive outcomes. Conclusion Indocyanine green angiography can clearly visualize the course and the branches of the superficial temporal arteries and veins, which can help surgeons understand the position, distribution, and concomitant relationship of the superficial temporal vessels, and make a rational surgical plan of the forehead flap.

Citation： ZHOU Mengqi, LIU Yuanbo, RAN Xiaoye, ZHU Shan, LI Shanshan, CHEN Zixiang, HAN Tinglu, JIN Shengyang, WANG Miao, ZANG Mengqing. Application of indocyanine green angiography in repair of facial soft tissue defect using superficial temporal artery based forehead flap. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(10): 1259-1265. doi: 10.7507/1002-1892.202306095 Copy

1.	Wang Q, Song W, Hou D, et al. Expanded forehead flaps for reconstruction of different faciocervical units: selection of flap types based on 143 cases. Plast Reconstr Surg, 2015, 135(5): 1461-1471.
2.	Loh CYY, Shanmugakrishnan RR, Nizamoglu M, et al. Venous congestion in pedicled frontal branch superficial temporal artery flaps reconstructions for head and neck defects: a review. Ann Plast Surg, 2019, 82(3): 330-336.
3.	Imanishi N, Nakajima H, Minabe T, et al. Venous drainage architecture of the temporal and parietal regions: anatomy of the superficial temporal artery and vein. Plast Reconstr Surg, 2002, 109(7): 2197-2203.
4.	Pestana IA, Zenn MR. Correlation between abdominal perforator vessels identified with preoperative CT angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient. Ann Plast Surg, 2014, 72(6): S144-S149.
5.	Gurtner GC, Jones GE, Neligan PC, et al. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use. Ann Surg Innov Res, 2013, 7(1): 1.
6.	Li K, Zhang Z, Nicoli F, et al. Application of indocyanine green in flap surgery: a systematic review. J Reconstr Microsurg, 2018, 34(2): 77-86.
7.	Koziej M, Trybus M, Hołda M, et al. The superficial temporal artery: anatomical map for facial reconstruction and aesthetic procedures. Aesthet Surg J, 2019, 39(8): 815-823.
8.	Kleintjes WG. Forehead anatomy: arterial variations and venous link of the midline forehead flap. J Plast Reconstr Aesthet Surg, 2007, 60(6): 593-606.
9.	Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiol Anat, 2006, 28(3): 248-253.
10.	Fan J. A new technique of scarless expanded forehead flap for reconstructive surgery. Plast Reconstr Surg, 2000, 106(4): 777-785.
11.	Delgove L, Lebeau J, Raphaël B, et al. Drainage of the scalp by the superficial temporal vein: surgical implications. Surg Radiol Anat, 1991, 13(4): 277-282.
12.	Onishi S, Imanishi N, Yoshimura Y, et al. Venous drainage of the face. J Plast Reconstr Aesthet Surg, 2017, 70(4): 433-440.
13.	Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg, 1998, 101(1): 27-32.
14.	Onoda S, Azumi S, Hasegawa K, et al. Preoperative identification of perforator vessels by combining MDCT, doppler flowmetry, and ICG fluorescent angiography. Microsurgery, 2013, 33(4): 265-269.
15.	Kim YS, Lee KW, Kim JS, et al. Regional thickness of facial skin and superficial fat: Application to the minimally invasive procedures. Clin Anat, 2019, 32(8): 1008-1018.
16.	Leighton WD, Russell RC, Feller AM, et al. Experimental pretransfer expansion of free-flap donor sites: Ⅱ. Physiology, histology, and clinical correlation. Plast Reconstr Surg, 1988, 82(1): 76-87.
17.	Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg, 1986, 77(1): 17-28.

1. Wang Q, Song W, Hou D, et al. Expanded forehead flaps for reconstruction of different faciocervical units: selection of flap types based on 143 cases. Plast Reconstr Surg, 2015, 135(5): 1461-1471.
2. Loh CYY, Shanmugakrishnan RR, Nizamoglu M, et al. Venous congestion in pedicled frontal branch superficial temporal artery flaps reconstructions for head and neck defects: a review. Ann Plast Surg, 2019, 82(3): 330-336.
3. Imanishi N, Nakajima H, Minabe T, et al. Venous drainage architecture of the temporal and parietal regions: anatomy of the superficial temporal artery and vein. Plast Reconstr Surg, 2002, 109(7): 2197-2203.
4. Pestana IA, Zenn MR. Correlation between abdominal perforator vessels identified with preoperative CT angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient. Ann Plast Surg, 2014, 72(6): S144-S149.
5. Gurtner GC, Jones GE, Neligan PC, et al. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use. Ann Surg Innov Res, 2013, 7(1): 1.
6. Li K, Zhang Z, Nicoli F, et al. Application of indocyanine green in flap surgery: a systematic review. J Reconstr Microsurg, 2018, 34(2): 77-86.
7. Koziej M, Trybus M, Hołda M, et al. The superficial temporal artery: anatomical map for facial reconstruction and aesthetic procedures. Aesthet Surg J, 2019, 39(8): 815-823.
8. Kleintjes WG. Forehead anatomy: arterial variations and venous link of the midline forehead flap. J Plast Reconstr Aesthet Surg, 2007, 60(6): 593-606.
9. Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiol Anat, 2006, 28(3): 248-253.
10. Fan J. A new technique of scarless expanded forehead flap for reconstructive surgery. Plast Reconstr Surg, 2000, 106(4): 777-785.
11. Delgove L, Lebeau J, Raphaël B, et al. Drainage of the scalp by the superficial temporal vein: surgical implications. Surg Radiol Anat, 1991, 13(4): 277-282.
12. Onishi S, Imanishi N, Yoshimura Y, et al. Venous drainage of the face. J Plast Reconstr Aesthet Surg, 2017, 70(4): 433-440.
13. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg, 1998, 101(1): 27-32.
14. Onoda S, Azumi S, Hasegawa K, et al. Preoperative identification of perforator vessels by combining MDCT, doppler flowmetry, and ICG fluorescent angiography. Microsurgery, 2013, 33(4): 265-269.
15. Kim YS, Lee KW, Kim JS, et al. Regional thickness of facial skin and superficial fat: Application to the minimally invasive procedures. Clin Anat, 2019, 32(8): 1008-1018.
16. Leighton WD, Russell RC, Feller AM, et al. Experimental pretransfer expansion of free-flap donor sites: Ⅱ. Physiology, histology, and clinical correlation. Plast Reconstr Surg, 1988, 82(1): 76-87.
17. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg, 1986, 77(1): 17-28.

Chinese Journal of Reparative and Reconstructive Surgery

Application of indocyanine green angiography in repair of facial soft tissue defect using superficial temporal artery based forehead flap

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