Intraoperative Perfusion Assessment in Full-length Peritoneal Flap Vaginoplasty Using Indocyanine Green Angiography

Summary:

This article reports the real-time perfusion assessment of a full-length anterior peritoneal flap vaginoplasty, previously published in Plastic and Reconstructive Surgery, using intraoperative indocyanine green (ICG) fluorescence angiography. A 20-year-old transgender woman with dense pubic and scrotal hair underwent full-length anterior turnover peritoneal flap vaginoplasty to achieve a hairless neovaginal canal. Intraoperative ICG fluorescence angiography was used to assess perfusion of the laparoscopically harvested 20 × 20 cm flap both before and after tubularization. Real-time imaging confirmed rapid, uniform fluorescence throughout the flap, including the distal segment for introital inset, with no perfusion gaps or ischemic zones. The strongest uptake was seen along the midline, likely corresponding to urachal vascular branches, with robust lateral perfusion, particularly in areas including the posterior rectus sheath. Even fascial-free zones demonstrated detectable perfusion. The flap was inset, achieving 14.7 cm of immediate postoperative neovaginal depth. No intraoperative or postoperative complications occurred. This is the first case to confirm real-time perfusion of a peritoneal flap in gender-affirming surgery using ICG angiography, supporting the vascular reliability of the technique and its potential value in optimizing outcomes and guiding broader reconstructive applications.

Indocyanine green (ICG) fluorescence imaging, in combination with near-infrared systems, has become increasingly used in surgical fields to assess tissue perfusion, map lymphatics, and identify critical structures.¹ In flap-based surgery, ICG provides a dynamic and objective evaluation of vascular integrity. In gender-affirming surgery, ensuring adequate perfusion of vascularized flaps is crucial to avoid ischemic complications, particularly in the distal neovaginal canal.^2,3

We previously described a laparoscopically harvested anterior turnover peritoneal flap for full-length neovaginal reconstruction.⁴ In this study, we present a follow-up case using intraoperative ICG angiography to visualize perfusion patterns before and after tubularization, offering real-time confirmation of flap viability.

CASE REPORT

A 20-year-old transgender woman (body mass index 18.27 kg/m²) with extensive hair over the pubic and scrotal regions presented requesting vaginal reconstruction without hair in the neovaginal canal. Full-length peritoneal flap vaginoplasty was undertaken to avoid the use of hair-bearing genital skin for neovaginal lining.

The patient was positioned in a 30-degree Trendelenburg position. A 20 × 20 cm anterior peritoneal flap was harvested laparoscopically according to our previously published technique. ICG (2.5 mg/mL, 2.5 mg) was injected intravenously after flap harvest. Near-infrared imaging (Storz NIR/ICG system) confirmed immediate uptake, with perfusion visualized within seconds. (See Video 1 [online], which displays ICG perfusion assessment of a full-length anterior peritoneal flap before tubularization during vaginoplasty.)

Video 1. This video shows intraoperative ICG fluorescence angiography of a 20×20 cm anterior peritoneal flap before tubularization during full-length vaginoplasty. Near-infrared imaging confirms rapid, uniform perfusion throughout the flap, with strongest fluorescence along the midline and adequate lateral uptake. These findings validate vascular integrity prior to inset.

Download video file ^{(14MB, mp4)}

Following lateral-to-lateral tubularization, a second ICG dose was administered. Perfusion was again visualized throughout the flap, including the distal segment designated for introital inset. (See Video 2 [online], which displays ICG perfusion reassessment following tubularization and detachment of the flap during full-length peritoneal flap vaginoplasty.)

Video 2. This video demonstrates reassessment of flap perfusion using indocyanine green (ICG) fluorescence angiography following tubularization and detachment of a full-length anterior peritoneal flap during vaginoplasty. Near-infrared imaging confirms preserved perfusion along the entire length of the tubularized flap, including the distal segment for introital inset. No ischemic areas or perfusion deficits were observed, supporting the flap’s vascular integrity despite folding and manipulation.

Download video file ^{(15.8MB, mp4)}

Perfusion was most intense along the midline, likely corresponding to urachal vascular branches, with notable enhancement at lateral zones containing the posterior rectus sheath. Fluorescence remained visible, though attenuated, even in lateral areas lacking fascial support (Fig. 1). Capillary bleeding was observed at the distal edge. The flap was then successfully inset into the neovaginal space without intraoperative complication. The immediate postoperative vaginal depth achieved was 14.7 cm.

Fig. 1.

Schematic representation of perfusion distribution in the anterior peritoneal flap. A, Before tubularization. B, After tubularization. Copyright 2025, Pea Pobpan. All rights reserved.

DISCUSSION

This case presented the first intraoperative demonstration of real-time perfusion in a vascularized peritoneal flap for primary gender-affirming vaginoplasty using ICG angiography. Consistent fluorescence before and after tubularization confirms robust axial perfusion, providing direct validation beyond prior indirect signs such as distal capillary bleeding.

Although ICG angiography did not alter intraoperative decisions, it offered valuable confirmation that the flap was vascularized along its entire length. In our previously published series, questions were raised as to whether the anterior peritoneal flap, given its narrow attachment at the bladder dome, should be classified as a vascularized flap or a free graft. The ICG findings presented here confirm continuous perfusion before and after tubularization, supporting its classification as a true vascularized flap likely supplied by urachal branches.

In our experience with free peritoneal grafts, we observed higher rates of neovaginal stenosis and loss of depth. In contrast, the vascularized flap described here maintained full depth at 3 months in more than 80% of cases.⁴ Although encouraging, we acknowledge that 3 months is a limited timeframe, and long-term follow-up is needed to assess durability.

Mobilization of the bladder and dissection of the anterior peritoneum expose the bladder wall and iliac vessels, creating raw surfaces that could promote adhesions involving the adjacent bowel. To mitigate this, an anti-adhesion barrier was routinely placed over the bladder dome, iliac vessels, and surrounding bowel before abdominal closure. This barrier helps separate vulnerable surfaces during early healing and reduces the likelihood of postoperative intra-abdominal adhesions. In 1 patient who later underwent unrelated abdominal surgery, the donor site showed minimal adhesions and near-complete peritoneal reepithelialization (Fig. 2), suggesting a favorable tissue response. As this is a single observation, further reports are needed to confirm generalizability.

Fig. 2.

Intraoperative view 1 year after full-length peritoneal flap vaginoplasty during unrelated abdominal surgery. Minimal adhesions were present and easily lysed. The donor site showed near-complete peritoneal regeneration, suggesting favorable long-term healing. Copyright 2025, Worapon Ratanalert. All rights reserved.

Other groups have proposed alternative vascularized peritoneal techniques, such as urachus-hinge or robotic mesenteric flaps, particularly in revision cases or when genital skin is insufficient. Although these reflect growing interest in vascularized peritoneal tissue for neovaginal lining, none have included intraoperative perfusion confirmation. Our use of ICG angiography offers real-time, objective evidence of vascular integrity throughout the flap, offering a distinct advantage over prior methods. Visualizing perfusion before and after tubularization may help reduce subclinical ischemia, especially at the distal end, and enhance surgical confidence in both primary and secondary applications.^5–8

The full-length peritoneal flap approach was developed to provide a hairless, smooth neovaginal lining with sufficient surface area for complete canal coverage, while avoiding visible donor site scarring and minimizing long-term morbidity. Second, despite preoperative electrolysis, patients with dense genital hair often retained visible follicles, which may not fully eliminate the risk of a hair-bearing neovaginal lining.

Confirmation of a robust vascular supply supports the flap’s potential utility beyond primary gender-affirming vaginoplasty. This approach may be useful in revision cases, such as neovaginal stenosis or failed skin-based reconstruction, as well as in gynecologic reconstruction for cisgender women requiring a long, vascularized neovaginal lining. Laparoscopic harvest including the posterior rectus sheath provides added vascular support while avoiding bowel mobilization, potentially reducing morbidity associated with intestinal-based vaginal reconstructions.

CONCLUSIONS

Intraoperative ICG angiography confirms robust perfusion of the anterior turnover peritoneal flap, supporting its use as a reliable full-length neovaginal lining in transgender women. The flap seems suitable not only for primary vaginoplasty but also for revision procedures and selected gynecologic reconstructions. Future studies incorporating long-term follow-up are needed to validate these findings and to further define the role of this technique relative to other neovaginal reconstructive options.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient has provided informed consent for publication.