Indocyanine green angiography in acute nasal revascularization: Case report and implications for facial trauma surgery

Abstract

Microsurgical restoration of avulsed facial tissue is technically challenging because of the small vessel size and complex anatomy. In trauma cases, accurate identification of ischemic zones is essential for achieving successful outcomes. We report a successful case of microvascular restoration in degloving-type nasal trauma, assisted with indocyanine green angiography for ischemic zone identification. A 56-year-old man sustained a devascularized nasal avulsion following an escalator injury. Microsurgical exploration guided by indocyanine green angiography revealed compromised perfusion in the left lateral nasal region. Focused microvascular repair of the left lateral nasal artery led to immediate perfusion improvement and complete nasal tissue survival. Intraoperative indocyanine green angiography enabled precise identification of ischemia, minimized unnecessary dissection, and improved efficiency, thereby allowing greater emphasis on the aesthetic and functional restoration of the nose. Real-time indocyanine green angiography may enhance decision-making and improve outcomes in nasal avulsion injuries. Broader adoption of indocyanine green may enhance both efficiency and outcomes in facial trauma surgery.

Introduction

Avulsion injuries of the nasal soft tissues present a major challenge in facial trauma and require meticulous surgical intervention to restore both function and aesthetics. ¹ Given the central position of the nose on the face and its vital physiological role, successful management of nasal soft tissue injuries is imperative.

The multilayered, complex anatomy of the nose—comprising mucosa, soft tissue, cartilage, and skin—poses unique reconstructive challenges. This challenge is especially pronounced when avulsion injuries disrupt multiple types of tissue, including the vascular supply. Although secondary reconstructive options exist for various types of defects, salvaging the native tissue in the primary setting remains the most desirable and straightforward approach in complex nasal trauma, as it offers the best potential for restoring the original contour, skin quality, and structural anatomy. ² Therefore, microsurgical revascularization should be considered when primary nasal units remain anatomically viable. However, success in these cases requires both technical efficiency and surgical experience.

Recent advancements in addressing tissue perfusion, particularly indocyanine green (ICG) near-infrared fluorescence angiography, have established it as a reliable tool to assess tissue perfusion. ³ ICG use has been widely validated across reconstructive procedures, including breast reconstruction and microvascular reconstruction. ⁴ However, its application on the face, particularly in acute trauma settings, remains underreported. In particular, its application in acute nasal trauma for real-time microsurgical decision-making has not been previously reported. This case represents one of the earliest documented uses of ICG to guide targeted revascularization in nasal avulsion injuries. Here, we report the utility of combining microsurgical arterial repair with ICG guidance for the effective management of nasal avulsion trauma. The reporting of this study conforms to the Case Report (CARE) guidelines. ⁵

Case presentation

A man in his 50 s with a history of diabetes mellitus presented to the Catholic University of Korea, Seoul Saint Mary’s Hospital in July 2023, approximately 20 h after sustaining facial trauma from a fall into a moving escalator. He was found to have a near-total avulsive amputation involving the lower third of the nasal soft tissue (Figure 1). On examination, the nasal complex was almost completely separated from the face and appeared dusky with cyanotic discoloration, indicative of compromised perfusion. Three-dimensional computed tomography of the facial bone confirmed intact underlying bony structures despite severe soft tissue injury. To objectively assess the vascularity of the avulsed segment, we decided to perform intraoperative ICG angiography. Overall, 12.5 mg of ICG (Diagnogreen, Jeil Pharmaceuticals, Korea) diluted in 2.5 mL of normal saline was administered intravenously. Fluorescence monitoring was performed using an ICG detector (SPY Portable Handheld Imaging System, Stryker, Michigan, USA). Assessment was conducted through qualitative visual interpretation of fluorescence patterns, with wash-in times <30 s considered adequate perfusion and those >60 s indicating compromised circulation. Real-time imaging demonstrated negative fluorescence in the left lateral nasal region, whereas the contralateral side showed normal perfusion with a wash-in time of <15 s (Figure 2(a)). No quantitative analysis was performed in this emergency setting.

Figure 1.

Clinical and radiologic findings of the case. (a) Preoperative presentation showing dusky discoloration of the avulsed lower third of the nose, suggestive of vascular compromise (dotted circle). (b) Intraoperative findings demonstrating exposed nasal bone with comminuted fracture (single asterisk) and full-thickness penetrating injury of the nasal mucosa exposing the inferior turbinate (double asterisk). (c) Computed tomography revealing skin and soft tissue defect of the nasal area with comminuted nasal bone fracture (arrowhead).

Figure 2.

Intraoperative and postoperative findings of the case. (a) ICG angiography demonstrating a perfusion defect on the left lateral side of the nose (asterisk). (b) Intraoperative view after microsurgical anastomosis of the lateral nasal artery. (c) Immediate postoperative photograph showing improved circulation of the avulsed nasal tissue. (d) Long-term follow-up clinical photograph after healing and scar therapy.

Emergency microsurgical intervention was performed. Following debridement and anatomical reapproximation of nasal subunits, an end-to-end microvascular anastomosis of the left lateral nasal artery was performed using 10-0 nylon sutures (Figure 2(b)). Immediate improvement in perfusion was observed intraoperatively. The decision to perform artery-only anastomosis was based on ICG findings that demonstrated adequate venous drainage in unaffected regions and the absence of delayed fluorescence pooling or prolonged washout times indicative of venous congestion. Clinical examination revealed no signs of vascular congestion and demonstrated normal capillary refill after anastomosis. Postoperatively, robust perfusion was maintained, and the nasal tissue demonstrated complete survival without necrosis or infection (Figure 2(c)). Follow-up at 1 year showed excellent structural and functional outcomes without complications (Figure 2(d)). Contour irregularities, pigmentation changes, and partial atrophy were not evident. Nasal function remained normal, with patent airways bilaterally. Minor scarring at the repair site was present but did not require revision other than silicone gel sheeting. All patient information was deidentified, and informed consent was obtained for the publication of this report.

Discussion

Surgical restoration of nasal soft tissue avulsion injuries is challenging because of their anatomical complexity, vascular intricacy, and significant aesthetic and functional implications. In particular, revascularization of the detached nasal tissue has low success rates and decreased patient satisfaction because of the limited number of cases and technical difficulties. ⁶

In this case, real-time perfusion assessment using ICG was pivotal in identifying ischemic nasal tissues and guiding targeted microvascular interventions. Identification of compromised perfusion facilitated microsurgical arterial anastomosis of the left lateral nasal artery, ultimately achieving complete survival of the nasal soft tissue despite a delayed presentation of 20 h after injury. Based on the ICG findings, we were confident that the contralateral lateral nasal region had adequate perfusion despite the global ischemic appearance of the avulsed segment. Therefore, we not only achieved complete survival of the nasal tissue but also observed improved efficiency by omitting exploration on the contralateral side of the nose, allowing greater focus on restoring the aesthetic and functional aspects of the nose.

Without ICG-guided trauma restoration, the nasal tissue may have been compromised and eventually required secondary reconstruction. The most common alternative would be skin grafting with or without composite tissue, which is generally reserved for small defects and has variable success rates. ⁷ Furthermore, multistage reconstruction might have been required, which would lead to increased cost and prolonged stay. In this context, ICG-guided trauma restoration may prove cost-effective than unguided repair, as has been reported in other reconstructive procedures. ⁸

ICG angiography has emerged as a valuable real-time imaging modality for evaluating tissue perfusion. ⁹ Its utility was first recognized in hepatobiliary surgery, colorectal surgery, and ophthalmology. The indications for ICG angiography are expanding to include mapping of lymphatic surgery and assessment of soft tissue viability in reconstructive surgery. ¹⁰ As demonstrated in our case, this imaging technique allows precise identification of areas at risk for ischemic necrosis, thereby guiding surgical decision-making more effectively than visual skin color assessment alone.^3,11 Didzun et al. ¹² and Patel et al. ¹³ suggested that ICG angiography significantly decreases the incidence of postoperative complications, such as partial flap necrosis and anastomotic failures, in trauma and reconstructive scenarios. Our case further expands its utility in acute trauma settings, where its application remains uncommon. This aligns with recent literature reporting its use in burn necrosis and lower extremity trauma.

ICG interpretation in acute trauma settings presents unique challenges, including signal interference from tissue edema, hematoma formation, and altered tissue thickness. These factors may affect fluorescence intensity and timing, requiring experienced interpretation to distinguish true perfusion deficits from technical artifacts.

ICG guidance eliminated the need for contralateral exploration, thus significantly reducing operative time. Without ICG angiography, standard practice would have required bilateral vessel exploration and potential additional anastomosis attempts, increasing operative duration and iatrogenic tissue trauma. However, direct comparative data remain limited, given the rarity of these cases. Unnecessary microsurgical exploration carries several risks, including additional tissue trauma, increased ischemia time, and potential damage to viable vascular structures. ICG angiography enabled a confident assessment revealing that contralateral perfusion was adequate, thereby avoiding potentially harmful exploration. This targeted approach using ICG angiography minimized surgical trauma while focusing resources on the compromised vascular territory identified by fluorescence imaging.

Based on the ICG findings, we strategically performed a unilateral, artery-only anastomosis. A systematic review by Secanho et al. ¹⁴ reported acceptable survival rates in cases of artery-only anastomosis. However, they noted a higher rate of postoperative heparin or leech therapy due to venous insufficiency. Based on our ICG findings, we concluded that artery-only anastomosis was sufficient for complete survival. The postoperative course was uneventful, and venous salvage was not required. The perfusion assessment in this case was conducted in a qualitative manner, a common practice for real-time surgical decision-making. Identifying differences in bright and dark fluorescence was sufficient to delineate perfused from ischemic tissue zones, providing the key information needed to guide targeted revascularization. Despite its utility in qualitative comparison, there is no absolute numerical threshold of perfusion that guarantees tissue survival. ¹⁵ Therefore, although valuable for research, quantitative data were not used to make the definitive clinical decision to proceed with the focused arterial repair. Postoperative ICG–fluorescent angiography (FA) was not performed because the immediate, robust perfusion observed intraoperatively and the patient’s uneventful clinical course provided sufficient evidence of a successful outcome.

Contraindications for the emergency administration of ICG are extremely rare.^16,17 The consensus position by Simone et al. ¹⁷ suggests that hypersensitivity to ICG is exceedingly uncommon and can be managed safely. ICG is exclusively metabolized in the liver, but its use is not contraindicated in patients with liver disorders. In our case, we did not experience any adverse drug reactions related to ICG. Because ICG angiography has high sensitivity, a minimal learning curve or experience is needed to use this technology in acute devascularizing trauma. Larger studies are warranted to establish the broader role and cost-effectiveness of ICG in facial trauma reconstruction.

In summary, although nasal avulsion injuries pose considerable reconstructive challenges, strategic decision-making and repair supported by advanced imaging can significantly improve outcomes. As this report was a single case study, future studies should continue to explore the potential of ICG angiography in facial trauma reconstructive procedures.

Conclusion

This case illustrates that ICG angiography can guide effective microsurgical repair in complex nasal avulsion injuries, even with delayed presentation. ICG enabled targeted revascularization, contributing to complete tissue survival and favorable outcomes. However, as this is a single case report, these results may not be generalizable. Larger studies are warranted to confirm these findings and clarify the broader role of ICG in facial trauma reconstruction.