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

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.