Abstract
Background:
This study evaluated the impact of computed tomography angiography (CTA) and 3-dimensional (3D) reconstruction on the outcomes of repairing cervicofacial burn scars using expanded extra-long fasciocutaneous flaps.
Methods:
In a prospective cohort study, 64 patients were randomly assigned to an intervention group (n = 32) receiving CTA and 3D reconstruction for preoperative planning, and a control group (n = 32) without these imaging modalities. Primary outcomes included flap survival rate, postoperative complications, aesthetic outcomes, and functional restoration. In this study, we assessed inflammatory variables to evaluate postoperative inflammatory responses and oxidative stress management. We measured serum levels of interleukin-1, tumor necrosis factor-alpha, and vascular endothelial growth factor using enzyme-linked immunosorbent assay. Additionally, we evaluated oxidative stress markers, malondialdehyde and superoxide dismutase.
Results:
The intervention group demonstrated a higher flap survival rate (93.75% versus 84.38%, P = 0.038), reduced postoperative complications, and improved aesthetic and functional outcomes compared with the control group. Inflammatory markers interleukin-1 and malondialdehyde were significantly lower in the intervention group (P = 0.04 and P = 0.02, respectively), suggesting better postoperative inflammatory response and oxidative stress management. The intervention group also showed a significantly lower visual analog scale score (P = 0.038), indicating better pain management.
Conclusions:
The integration of CTA and 3D reconstruction in the repair of cervicofacial burn scars offers significant advantages, including improved preoperative planning, increased flap survival rates, and superior aesthetic and functional outcomes.
Takeaways
Question: How can the integration of computed tomography angiography (CTA) and 3-dimensional (3D) reconstruction technologies improve surgical outcomes in cervicofacial burn scar reconstruction using expanded extra-long trapezius fasciocutaneous flaps?
Findings: A prospective study of 64 patients showed that using CTA and 3D reconstruction increased flap survival to 93.75%, improved aesthetics and function, and reduced complications.
Meaning: Incorporating advanced imaging with CTA and 3D reconstruction before flap surgery in burn scar patients leads to higher success rates and better functional and cosmetic results, underscoring the value of precise preoperative planning in complex reconstructive procedures.
INTRODUCTION
Burn injuries, especially those in the cervicofacial region, present a challenge to reconstructive surgery due to the complex form–function interplay.1 They often cause disfiguring scars and functional impairments, severely affecting patients’ quality of life.2 Historically, treatment focused on wound coverage and life-threatening complication mitigation. However, medical and surgical advancements have shifted the focus to restoring both form and function.3
Early large autologous skin grafts in functionally significant burn areas reduce deformities and improve patients’ quality of life.4 As wound and grafting techniques evolve, restoring both function and aesthetics of injured areas is increasingly emphasized.5 For severe burns requiring skin grafts, medium-thickness grafts are favored for their balance of take rates and cosmetic results. Split-thickness grafts are more likely to survive but are prone to contracture and pigmentation changes, whereas full-thickness grafts offer a better texture match and fewer pigmentary issues.6 Advanced devices such as drum or electric dermatomes produce uniformly thick, easily sutured skin grafts.7
In China, many hospitals use large full- or medium-thickness skin grafts for deep facial burns, accepting their risks for satisfactory outcomes.8 Selecting flaps for wound coverage requires balancing recipient-site needs against donor-site impact. Radiological tools are crucial for flap surgery as they provide vessel information. Handheld Doppler ultrasound has limitations in tissue imaging and vessel-depth determination.9 High-frequency color Doppler ultrasound can detect small vessels but is time-consuming. Digital subtraction angiography is invasive and costly, so it is not widely used. In contrast, computed tomography angiography (CTA) with its postprocessing can reconstruct bones, soft tissues, and vessels, showing vessel details and their relationships.10,11
CTA and 3-dimensional (3D) reconstruction enhance complex reconstructions, such as cervicofacial burn scar repair with expanded flaps.12 They assist in preoperative planning and surgery execution, improving success rates and aesthetics.13 Previous studies mainly used CTA for vascular mapping, not fully exploiting 3D reconstruction. This study explored how these technologies are applied and their impact on patients.
MATERIALS AND METHODS
Study Subjects
In this prospective cohort study, a randomized controlled design was used to evaluate the efficacy of CTA and 3D reconstruction in repairing cervicofacial burn scars with expanded extra-long flaps. From March 2020 to April 2024, 64 eligible patients at the General Hospital of Ningxia Medical University undergoing treatment with such flaps were recruited. The cohort consisted of 41 men and 23 women, 23–45 years of age (mean 28 y), all with varying severity of hypertrophic scars in the mouth, chin, and neck from deep cervicofacial burns.
Patients were randomly divided into 2 groups. The intervention group (n = 32) received CTA and 3D reconstruction for preoperative planning of flap repair, whereas the control group (n = 32) had the same repair without these imaging techniques. The study protocol followed the Declaration of Helsinki and was approved by the hospital’s ethics committee (2019-439). All participants gave informed consent, understanding the study’s aims, procedures, risks, and benefits.
Inclusion Criteria
The following were the inclusion criteria:
Age older than 18 years.
Facial and neck repair required due to flame or scald burns.
No surgical contraindications.
Scar surface without ulcers.
Scar area greater than 20 × 15 cm.
Signed informed consent form.
Exclusion Criteria
The following were the exclusion criteria:
Comorbidities such as diabetes or hypoproteinemia affecting wound healing.
Severe heart or lung diseases.
Inhalation injuries.
High risk of infection due to contamination or foreign-body inoculation.
Pregnant or lactating women.
Severely malnourished patients.
Surgical Methods
Insertion of Soft Tissue Expanders
Based on the scar’s excision area and location, 1 or more appropriately sized and shaped expanders were selected. An incision in the scar allowed for dissecting a cavity under the trapezius or deltoid muscle for expander implantation, with the reservoir under the scar. A drainage tube was placed, and dressings were changed every 2–3 days. The tube was removed 1–3 days postoperation based on drainage, and sutures were removed 10–12 days later. After suture removal, normal saline injection started (2 times/wk), with 10%–20% of the expander’s rated capacity injected each time, depending on expander size, skin tension, and patient tolerance. The flap size was designed according to the damaged area and tissue loss, using an expander with 4.5–5.0 mL capacity per 1.0 cm of facial and neck defect.
Preoperative Imaging
In the intervention group, after 2–5 months of expander saline injection and 1-month expansion maintenance, CTA was done for 3D images (Fig. 1A). A nonionic contrast agent (iodine iopamide injection, 370 mg/mL, Bayer Healthcare AG, Germany) was injected at 5.0–5.5 mL/s, followed by a 40-mL saline flush (1.2 mL/kg). Scanning with a Philips 256-slice computed tomography (Philips Healthcare, Netherlands) started 35 seconds after injection, with 120-kV tube voltage, spiral scanning, 0.9-mm slice thickness, 0.45-mm slice spacing, and 2:1 pitch. The blood vessel branches of the flap area were located, and the main vessels supplied or drained the flap. CTA simulated the defect range, and Mimics software reconstructed and simulated the flap for optimal imaging of trapezius/deltoid area vessels. A 3D neck extra-long flap model was designed in the coronal plane, with fascia and subcutaneous tissue removed in the horizontal plane. After locating the artery and adding the flap image, the model was completed (Fig. 1B). The model was observed from multiple angles, and flap images were magnified to study vessels and perforators (diameter > 0.5 mm). Two experienced radiologists handled the 3D image work, and all intervention group participants gave consent.
Fig. 1.
A 25-year-old female. A, CTA image. B, 3D reconstruction model.
In the control group, after the same injection and expansion period, Doppler blood flow detection was done. A portable Doppler ultrasound located and marked the trapezius/deltoid artery and perforators.
Flap Delay Surgery
One week before the second-stage postexpansion surgery, both groups had flap delay surgery. Secondary pedicles were ligated to boost the flap’s vascular network. The shoulder–neck wound-suturing incision, made in 1 stage along the flap’s distal third edges, reached the expander’s external fascia and was sutured for blood supply. Surgery was under general anesthesia with endotracheal intubation, in the lateral decubitus position. The flap, designed along the muscle artery to include many perforators, was 10% larger than the wound defect for easy donor-site suturing.
Design and Harvesting of Expanded Extra-long Flaps
After flap delay, both groups had the second-stage surgery. Preoperative Doppler or CTA data determined flap dimensions (up to 20 cm long and 10 cm wide for cervicofacial defects). The skin was incised, the expander removed, and the flap lifted from the distal end along the deep layer of superficial fascia, with a pedicle width greater than 3 cm for vascular support.
The method allowed for harvesting large flaps with little donor-site tension, facilitating direct suturing. The harvested flap covered the scar excision defect in the mouth, chin, neck, and chest. The pedicle was made into a skin tube, and narrow areas near it were protected with scar skin. For oral commissure repair, a 6-cm transverse incision at the normal site (slightly longer than the existing one) ensured 1.5 cm–wide upper and lower flaps for tension-free donor-site closure. Two to 3 weeks after flap repair, the pedicle was divided, the flap was repositioned and trimmed, and the pedicle and remaining scar skin were removed to complete the reconstruction.
Correction of Microstomia
For microstomia patients, the expander was removed, and flap repair was combined with microstomia correction. Two vertical lines from the inner medial canthus defined new mouth-corner positions. Methylene blue marked the red-lip outlines, and a 0.5- to 1.0-cm pedicle skin flap was designed at the new corner. The scar was excised, the lip mucosae dissected, and the mouth-corner mucosa incised 1–2 cm, pulled out, and sutured to the skin for the red lip. The triangular flap was turned inward and sutured to the mucosa for the mouth corner (Fig. 2). Postoperatively, the lip was treated with antibiotic ointment.
Fig. 2.
Correction of microstomia.
Postoperative Management and Follow-up
Postoperatively, the tissue flap was warmed; treated with anti-infection, anticoagulation, and antispasm drugs; and dressed. Functional exercises started when the flap was viable. A 6-month follow-up was conducted.
Observational Indicators
Clinical data of both groups (sex, age, burn area, degree, cause, scar contracture grade, area, time to surgery, and comorbidities such as poststroke sequelae, heart disease, and hypertension) were systematically documented. Postoperative conditions (wound healing time, visual analog scale [VAS] score, dressing change frequency, and adverse events) were also recorded.
Over 6 months, recipient-site conditions were monitored monthly by phone. Parameters included flap survival (uneventful/eventful), color (rosy is normal; black implies issues), elasticity/plumpness, temperature, capillary refill, exudate, epidermal blisters, venous congestion, swelling, color match, orofacial/neck function (scored 0–6 with the appearance and function method), scar recurrence, and therapeutic effect (marked/effective/ineffective).
Donor-site scar and function were evaluated, and complications (secondary infection, ulceration, necrosis, and hematoma) were noted. The wound healing rate was calculated as (initial wound area − area at various time points)/initial wound area × 100%. Donor-site scar healing was assessed with the Vancouver Scar Scale (0–15; 0 is best) and the North Carolina Scar Scale (itching, pain, abnormal sensation, pliability, 0–3 points each, total 0–12, with higher indicating worse outcomes). Six months postsurgery, fasting blood samples were used to measure serum interleukin-1 (IL-1), tumor necrosis factor-alpha, and vascular endothelial growth factor via enzyme-linked immunosorbent assay for inflammatory response, and malondialdehyde (MDA) and superoxide dismutase levels for oxidative stress.
Statistical Methods
Data were analyzed with SPSS 27.0. Continuous quantitative data were presented as mean (SD). The Shapiro–Wilk test was used to access data normality, and the Levene test was used to check variance homogeneity. Independent sample t tests were used for normally distributed and homogeneous variance data; approximate t tests for normally distributed but heterogeneous variance data. The Kruskal–Wallis H rank sum test was for nonnormal data. Categorical variables are presented as n (%) and were analyzed with the Pearson chi-square test (theoretical frequency > 5 and sample size ≥ 40). A P value of less than 0.05 was considered statistically significant.
COMPARISON OF CLINICAL DATA
The comparison of clinical data between the 2 groups (Table 1) showed no significant differences in age, sex, burn area, burn degree, injury cause, scar contracture grade, scar area, or time from burn to surgery. The groups were also similar in comorbidities such as poststroke sequelae, coronary heart disease, and hypertension, indicating a well-matched study population. All P values for these parameters were greater than 0.05, meaning the observed differences were not statistically significant, which was crucial for valid subsequent treatment outcome comparisons.
Table 1.
Comparative Clinical Data of Patients in Both Groups
| Indicator | Control Group (n = 32) | Intervention Group (n = 32) | t/χ² | P |
|---|---|---|---|---|
| Age, y | 28 ± (5.2) | 29 ± (5.4) | 0.71 | 0.481 |
| Sex, n (%) | 0.24 | 0.626 | ||
| Male | 18 (56.25) | 16 (50) | ||
| Female | 14 (43.75) | 16 (50) | ||
| Burn area, % | 15 (10–20) | 16 (10–20) | 0.48 | 0.632 |
| Degree of burn, n (%) | 0.48 | 0.489 | ||
| Superficial second-degree | 8 (25) | 10 (31.25) | ||
| Deep second-degree | 12 (37.5) | 14 (43.75) | ||
| Third-degree | 12 (37.5) | 8 (25) | ||
| Cause of injury, n (%) | 0.56 | 0.455 | ||
| Flame burn | 20 (62.5) | 22 (68.75) | ||
| Scald burn | 12 (37.5) | 10 (31.25) | ||
| Scar contracture grading, n (%) | 0.79 | 0.375 | ||
| Grade II | 10 (31.25) | 8 (25) | ||
| Grade III | 14 (43.75) | 18 (56.25) | ||
| Grade IV | 8 (25) | 6 (18.75) | ||
| Scar area, cm² | 250 (200–300) | 240 (210–290) | 0.59 | 0.554 |
| Time from burn to surgery, mo | 6 (3–12) | 7 (4–12) | 0.85 | 0.397 |
| Comorbidities, n (%) | 0.17 | 0.682 | ||
| Poststroke sequelae | 2 (6.25) | 3 (9.38) | ||
| Coronary heart disease | 4 (12.5) | 3 (9.38) | ||
| Hypertension | 6 (18.75) | 5 (15.63) |
COMPARISON OF POSTOPERATIVE CONDITIONS AFTER BURN SURGERY
A comparison of the 7-day postoperative situation (Table 2) revealed that the wound healing time and dressing change frequency were similar between the 2 groups, with no statistical difference. However, the intervention group had a significantly lower VAS score (P = 0.038), indicating better postoperative pain management. Adverse events such as hypoglycemia, allergic reactions to dressing, and wound infections were noted, but no significant differences were observed between the groups.
Table 2.
Comparative Postoperative Burn Conditions of Patients in Both Groups
| Indicator | Control Group (n = 32) | Intervention Group (n = 32) | t/χ² | P |
|---|---|---|---|---|
| Wound healing time, d | 14 (12–18) | 13 (11–17) | 0.79 | 0.431 |
| Dressing change frequency, times | 5 (4–7) | 4 (3–6) | 1.42 | 0.158 |
| VAS score | 3.5 (2.8–4.2) | 3.0 (2.5–3.8) | 2.11 | 0.038* |
| Adverse event occurrences | ||||
| Hypoglycemia | 2 (6.25%) | 1 (3.13%) | 0.31 | 0.579 |
| Allergic reaction to dressing | 3 (9.38%) | 2 (6.25%) | 0.18 | 0.669 |
| Wound infection | 5 (15.63%) | 4 (12.5%) | 0.11 | 0.742 |
Statistically significant difference.
SIX-MONTH POSTOPERATIVE MONITORING OF DONOR AND RECIPIENT SITES
Over the 6-month postoperative period, the intervention group, which used CTA and 3D reconstruction, had a higher rate of uneventful flap survival and more significant functional improvements in orofacial, chin, and neck movements than the control group (P < 0.05, Table 3). The efficacy assessment also showed a greater proportion of marked and effective results in the intervention group, suggesting that advanced imaging technologies improved the functionality and appearance of reconstructed areas. Monitoring of the donor site revealed a lower incidence of obvious scarring and no functional abnormalities in the intervention group (P < 0.05).
Table 3.
Postoperative 6-month Donor- and Recipient-site Conditions of Patients in Both Groups
| Indicator | Control Group (n = 32) | Intervention Group (n = 32) | t/χ² | P |
|---|---|---|---|---|
| Flap survival status in the recipient area | ||||
| Uneventful | 27 (84.38%) | 30 (93.75%) | 2.16 | 0.036* |
| Eventful | 5 (15.63%) | 2 (6.25%) | ||
| Epidermal blister status in the recipient area | ||||
| Present | 3 (9.38%) | 1 (3.13%) | 1.00 | 0.317 |
| Absent | 29 (90.63%) | 31 (96.88%) | ||
| Flap edema | ||||
| Present | 4 (12.5%) | 2 (6.25%) | 1.00 | 0.317 |
| Absent | 28 (87.5%) | 30 (93.75%) | ||
| Orofacial, chin, and neck function | ||||
| Significantly improved | 10 (31.25%) | 16 (50%) | 2.63 | 0.010* |
| Partially improved | 18 (56.25%) | 14 (43.75%) | ||
| Not improved | 4 (12.5%) | 2 (6.25%) | ||
| Scar recurrence | ||||
| Present | 2 (6.25%) | 1 (3.13%) | 0.31 | 0.579 |
| Absent | 30 (93.75%) | 31 (96.88%) | ||
| Efficacy assessment | ||||
| Marked effect | 12 (37.5%) | 18 (56.25%) | 2.56 | 0.013* |
| Effective | 16 (50%) | 13 (40.63%) | ||
| Ineffective | 4 (12.5%) | 1 (3.13%) | ||
| Donor-site scar condition | ||||
| Obvious | 3 (9.38%) | 1 (3.13%) | 1.00 | 0.317 |
| Not obvious | 29 (90.63%) | 31 (96.88%) | ||
| Donor-site function | ||||
| Normal | 31 (96.88%) | 32 (100%) | 1.00 | 0.317 |
| Abnormal | 1 (3.13%) | 0 (0%) | ||
| Secondary infection | ||||
| Present | 2 (6.25%) | 1 (3.13%) | 0.31 | 0.579 |
| Absent | 30 (93.75%) | 31 (96.88%) | ||
| Chronic ulcer | ||||
| Present | 1 (3.13%) | 2 (6.25%) | 0.31 | 0.579 |
| Absent | 31 (96.88%) | 30 (93.75%) | ||
| Partial skin necrosis | ||||
| Present | 0 (0%) | 1 (3.13%) | 0.00 | 0.317 |
| Absent | 32 (100%) | 31 (96.88%) | ||
| Hematoma | ||||
| Present | 1 (3.13%) | 0 (0%) | 1.00 | 0.317 |
| Absent | 31 (96.88%) | 32 (100%) | ||
| University of North Carolina Scar Scale | ||||
| VSS score | 4.5 (3.8–5.2) | 3.5 (2.9–4.1) | 2.89 | 0.005* |
Statistically significant difference.
VSS, Vancouver Scar Scale.
COMPARISON OF INFLAMMATORY INDICATORS
Table 4 compares inflammatory indicators (IL-1, tumor necrosis factor-alpha, vascular endothelial growth factor, MDA, and superoxide dismutase) between the control and intervention groups 6 months after surgery. The intervention group trended toward lower levels, indicating better postoperative inflammatory response and oxidative stress management. Statistical significance was reached for IL-1 (P = 0.04) and MDA (P = 0.02).
Table 4.
Comparative Inflammatory Indicators of Patients 6 Months Postoperatively in Both Groups
| Indicator | Control Group (n = 32) | Intervention Group (n = 32) | t | P |
|---|---|---|---|---|
| IL-1, pg/mL | 50.5 (45.1–56.3) | 47.2 (42.5–51.5) | 2.11 | 0.04* |
| TNF-α, pg/mL | 125.6 (115.5–140.8) | 121.0 (105.5–130.4) | 1.86 | 0.07 |
| VEGF, pg/mL | 450.8 (405.0–504.1) | 430.7 (380.8–476.3) | 1.53 | 0.13 |
| MDA, μmol/L | 3.5 (3.2–3.8) | 3.3 (3.0–3.6) | 2.45 | 0.02* |
| SOD, mU/mL | 120.5 (110.6–130.4) | 125.4 (115.2–135.3) | −1.62 | 0.11 |
Statistically significant difference.
SOD, superoxide dismutase; TNF-α, tumor necrosis factor-alpha; VEGF, vascular endothelial growth factor.
CASE PRESENTATIONS
A 25-year-old woman had functional limitations due to head, face, and neck burn scar contractures from a hot water accident at age 18. The scars affected her eye and mouth closure, caused drooling, and restricted neck movements. In January 2023, 1200 mL expanders were placed in her neck for flap reconstruction. Starting in June, she underwent a series of operations including flap delay, scar release, and flap transfer. In mid-July, pedicle division and skin grafting restored form and function. Postsurgery, her quality of life improved significantly, with restored eye and mouth closure and better neck mobility. The integrated surgical approach successfully reconstructed the scarred areas, achieving aesthetic and functional effectiveness, as shown in Figure 3.
Fig. 3.
A and B, Before surgery, the trapezius or deltoid skin was expanded. C, During surgery. D and E, After surgery, at 6 months.
DISCUSSION
The complex anatomy of the facial region and the high demands for aesthetic and functional restoration pose unique challenges in burn reconstruction.2 Deep burn injuries frequently cause scarring and contractures, which can severely distort facial features and hinder vital functions such as vision, speech, and expression.14 A successful outcome requires a careful balance between form and function restoration.
Our study shows that integrating CTA and 3D reconstruction significantly improves the repair of cervicofacial burn scars. The intervention group, using these technologies, had a higher flap survival rate (93.75% versus 84.38%, P = 0.038). This was due to precise preoperative planning and detailed vascular mapping, enabling the design of well-matched flaps. Postoperatively, the intervention group had better pain management (lower VAS score, P = 0.038), and more patients achieved marked or effective results, indicating functional and aesthetic improvements. Inflammatory markers IL-1 and MDA were significantly lower in this group (P = 0.04 and P = 0.02), suggesting better postoperative inflammatory and oxidative stress management.
Preoperative vascular localization is crucial for flap surgery. Handheld Doppler ultrasound, though widely used, has limitations in detecting small vessels and lacks 3D imaging.14 Digital medical technology, converting 2D to 3D models, allows for precise flap design. This advanced visualization reduces surgical risks, shortens operating time, and boosts flap survival.15 When choosing a donor site for flap harvesting, factors such as blood supply, tissue match, and donor-site closure without deformities must be considered.16 Local flaps are favored for facial scar repair due to tissue-matching benefits, but the facial anatomy may limit suitable local tissue for large-scale expansions.17 Distant or free flaps, sometimes necessary, have issues such as color and texture mismatch and bulkiness, and require multiple revisions for aesthetics.18 Flap thickness and pedicle length affect survival and influence flap selection. The scapular region is often the top choice for head and neck free-flap transfers because of its reliable vasculature and large area.19 CTA and similar advanced imaging techniques revolutionize preoperative planning by providing detailed 3D vascular roadmaps.20 They help visualize vessel details, facilitating accurate preoperative planning. However, CTA has drawbacks, such as less clear venous imaging and a risk of allergic reactions to contrast agents.21–25
Integrating CTA and 3D reconstruction in facial burn scar reconstruction offers significant benefits, such as detailed vascular mapping, better flap design, and higher flap-transfer success rates.26,27 Future technological advancements may further improve facial reconstruction. A multidisciplinary approach, involving surgeons, radiologists, and other specialists, is essential for comprehensive patient care during recovery.
DISCLOSURES
The authors have no financial interest to declare in relation to the content of this article. This study was supported by the Ningxia Natural Science Foundation (Grant No. 2020AAC03410).
PATIENT CONSENT
The patient provided written consent for the use of her image.
ETHICAL APPROVAL
The project titled “Three-dimensional modeling of dilated ultra-long flaps by CT angiography and digital reconstruction techniques and its clinical applications” was approved by the institutional ethics committee under the ethics number 2019-439.
Footnotes
Published online 18 July 2025.
Disclosure statements are at the end of this article, following the correspondence information.
Drs Ma and Yang have contributed equally to this work and share first authorship.
All data generated or analyzed during this study are included in this published article. Additional data related to this research are available from the corresponding author upon reasonable request.
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