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BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery.METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement.RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments.CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Supplemental digital content is available in the text., BACKGROUND Clinical assessment of indeterminate burn wounds has been reported to yield poor accuracy, even when performed by burn experts. Indocyanine green (ICG) dye angiography has been found to be highly accurate in assessing burn depth, but there is still limited evidence of its use in indeterminate burn wounds. This study aims to compare the accuracy of ICG angiography to that of clinical assessment in assessing indeterminate burn wounds. METHODS This is a prospective, multicentered, triple-blinded, experimental study. Participants were stable patients, admitted to the hospital with burn wounds of indeterminate depth. The burn wounds were clinically assessed by an attending plastic surgeon. ICG angiography was performed and evaluated by another surgeon. Tissue biopsies were obtained and sent for histological study to be assessed as the gold standard. RESULTS In the 30 burn sites that were assessed, the accuracy of ICG angiography was 100.0%, compared with 50.0% for clinical assessment (p < 0.001). Clinical assessment yielded a sensitivity of 33.3% and specificity of 66.7%, while ICG angiography yielded both a sensitivity and specificity of 100.0%. Therefore, the number needed to treat for using ICG angiography in indeterminate burn wounds was two. CONCLUSION Indocyanine green angiography yields a significantly higher accuracy than clinical assessment in indeterminate burn wounds. This intervention can, thus, be a useful tool to aid clinical judgment. TRIAL REGISTRATION Thai Clinical Trials Registry, number TCTR20170821001. LEVEL OF EVIDENCE Diagnostic test, level I.

Background:. The clinical assessment of indeterminate burn wounds has relatively poor accuracy. Indocyanine green angiography (ICGA) has high accuracy and can be used to mark wounds precisely so as to guide burn excision. This study aimed to assess the differences between ICGA and clinical assessment marking and compare the marking result with the long-term wound outcome. Methods:. This was a prospective, multicentered, triple-blinded, experimental study. Indeterminate burn wounds were clinically assessed, and the area to be excised was firstly marked by the attending surgeon. ICGA marking was then performed by a second surgeon. Measurement of the marked area was conducted by a third surgeon. Three surgeons were each blinded to the others' processes. The wounds were followed up to assess complete wound closures on day 21. Results:. There were 20 burn sites included in the study. There was a significant difference in the marked areas between clinical assessment and ICGA (mean, 57.3 ± 44.1%; P = 0.001). The maximum difference found was as high as 160.9%. The correction rate of ICGA marking to complete wound closure on day 21 was 95.0%. Over 90% of the decreased areas of excision—which were assessed by ICGA to be superficial burns but evaluated by clinical assessment to be deep burns—were completely healed on day 21. Conclusions:. ICGA contributes to a significant difference versus clinical assessment in the marking for excision of indeterminate burns and strongly associates with long-term wound outcomes. The burn wounds can be assessed precisely to reduce unnecessary excision and prevent inadequate excision.

Performing interrupted intradermal suture during bi-layered skin closure is time consuming. The oblique intradermal suture is hypothesized to be a faster choice for intradermal closure while yielding similar wound cosmetic outcomes. This study aims to demonstrate the equivalence of wound outcomes between the interrupted oblique intradermal suture (OIS) and conventional interrupted intradermal suture (IS) methods. This prospective, multicenter, double-blind randomized equivalence trial included patients scheduled to undergo elective surgery with a linear incision wound. A split-wound model was used. One half of the wound was sutured using IS method and the other using OIS method. Wounds were evaluated at 1 week and 2 months after surgery. Of the 120 patients, OIS was found to be equivalent to IS for all clinical outcome parameters. OIS was associated with 50% reduction in suture time and the number of stitches required, and a 40% reduction in suture material used (p .001). Rates of wound dehiscence and infection were not different between methods. Wound outcomes using OIS were equivalent to those observed when using IS, except that OIS yielded reductions in suturing time, number of stitches and suturing material used. OIS is a cost and clinically effective wound closure method. Trial registration: ClinicalTrials.gov registration number NCT03001856 Meeting presentation: 7th Bozner Symposium of Plastic Surgery, Bozen, Italy, January 2017.

In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle.In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers.The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers.Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months' recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids.This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote.

Too much or too little information during patient education can increase patient anxiety. Needs-based patient education helps to determine the appropriate amount of information required to provide education based on patient needs. This study aimed to compare needs-based patient education with traditional patient education in reducing preoperative anxiety. This was a prospective, multicenter, single-blind, randomized controlled trial with a 1:1 allocation ratio. Patients undergoing day surgery were randomized into a study group (needs-based education) or a control group (traditional education). The primary outcome was patient anxiety. Secondary outcomes were patient satisfaction and time spent in patient education. Patients completed questionnaires to evaluate their anxiety and satisfaction before patient education, after patient education, and after surgery. In total, 450 patients were randomized and analyzed (study group n = 225, control group n = 225). Comparisons before education, after education, and after surgery showed that there was a significant decrease in patient anxiety and an increase in satisfaction in both groups (p