Reverse-flow island flap: clinical report and venous drainage

Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery

Purpose

Internal thoracic veins are increasingly used as recipient’s vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins.

Methods

We evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made.

Results

Efficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez’s classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed.

Conclusion

Our study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.

Unique Characteristics and Applications of Reverse Superior Labial Artery Island Flaps: A Case Series

Background: The reverse superior labial artery (rSLA) island flap can be used to reconstruct the cheek, ala, columella and vestibule of the nose when other techniques appear insufficient or impractical. The aim of this case series was to present applications of rSLA pedicle flaps in the post-ablative oncologic reconstruction of the face. Patients and Methods: Using a retrospective case-series study design, the investigators enrolled a cohort of patients undergoing procedures involving rSLA flaps treated at a Polish Otolaryngology Department for facial reconstruction after tumour excision. The main outcomes were functional and aesthetic aspects. Descriptive statistics were computed as appropriate. Results and Conclusions: The use of rSLA flaps allows surgeons to obtain a large skin island with only minimal cosmetic and functional alterations. In all of the cases in this series, the use of this pedicle flap resulted in both optimal healing and satisfactory cosmetic and functional outcomes.

Reverse-Flow Intrinsic Fasciocutaneous Island Flaps in Foot Reconstruction

Reconstruction of soft tissue defects in the foot remains a challenge due to its specialized tissue for weightbearing and ambulation. Considering the principle of replacing "like with like," adjacent soft tissues would be a best option for a donor site. Although several kinds of reverse-flow island flaps for the lower leg have been well described, intrinsic foot reverse flow flaps have been rarely reported. We describe 3 kinds of reverse-flow intrinsic fasciocutaneous flaps (RIFFs) for foot reconstruction. From September 2012 to August 2015, a retrospective study was done on case notes of all patients who had a RIFF for coverage of soft tissue defects within the foot following trauma or tumor ablation. A total of 7 patients were included in this study, with an average of 5 × 3.5 cm sized defects in the forefoot, second and third web space, and sole, which were reconstructed with RIFF. All flaps were well perfused and recovered excellent function of the foot with satisfactory aesthetics and minimal limitations in range of motion. However, one case showed a complication of venous congestion, due to remnant scar tissues, which resolved after medical leech application. Donor defects healed completely with split thickness skin grafting in all cases. Soft tissue defects within the foot were repaired successfully by RIFF. In spite of its technical challenges, it is a reliable one-stage procedure requiring no microsurgical anastomosis. Precise vascular evaluation of the reverse inflow has to be preceded for satisfactory outcome of RIFF.

Reverse-Flow Lateral Tarsal Island Flap for Covering the Great Toe Donor Site of Wraparound Flap

BACKGROUND

Coverage of the great toe donor site of wraparound flap remains a challenge. This report presents the results of using an innervated pedicled reverse-flow lateral tarsal island flap for covering the great toe donor site of wraparound flap.

PATIENTS AND METHODS

Between 2005 and 2010, 11 reverse-flow lateral tarsal island flaps were used to cover the great toe donor site of wraparound flap in 11 patients. This pedicled flap designed on the lateral tarsal area of foot was based distally on the dorsalis pedis artery; the lateral dorsal pedal cutaneous nerve was incorporated into the reverse-flow lateral tarsal island flap and coapted with the first plantar digital nerve. The donor sites of reverse-flow lateral tarsal island flap were covered with inguinal full-thickness skin grafts.

RESULTS

All flaps achieved primary healing except for two that suffered from mild venous insufficiency which was managed by conservative intervention. All skin grafts covering the donor site of reverse-flow lateral tarsal island flap healed uneventfully. The mean follow-up was 24 months (range, 18-48 months). The mean hallux metatarsophalangeal-interphalangeal scale score was 92 points (range, 85-97 points) at 6 months postoperatively. The static 2-point discrimination of the reverse-flow lateral tarsal island flap ranged from 6 to 14 mm (mean 10 mm). None of the patients were restricted in standing or walking during follow-up.

CONCLUSIONS

The reverse-flow lateral tarsal island flap based distally on the dorsalis pedis artery has a constant pedicle that is sufficiently long. This innervated pedicle flap is a reliable option to cover the great toe donor site of wraparound flap with satisfactory functional and cosmetic results and acceptable donor site morbidity.

The Number of Perforators Included in Reversed Flow Posterior Interosseous Artery Flap: Does It Affect the Incidence of Venous Congestion?

Background:

The purpose of this study is to decrease the incidence of venous congestion occurring in the reversed flow posterior interosseous artery flap used for coverage of hand defects.

Methods:

This may be achieved by studying the incidence of venous congestion in flaps including only 1 perforator and comparing the results with others including more than 1 perforator both in small and large sized flaps.

Results:

This study showed that inclusion of only 1 perforator in the flap decreased the incidence of venous congestion with complete flap loss in flaps to 5%. Also, it decreased the incidence of venous congestion with partial flap loss in flaps to 10%.

Conclusions:

The small sized reversed flow posterior interosseous artery flap should be less than 40 cm² and should include only 1 perforator to decrease the incidence of venous congestion with partial and complete loss of the flap. The level of evidence for this study is the type II prospective comparative study.

Experience with the Distally Based Sural Neurocutaneous Flap for Ankle and Heel Wounds

Background/Purpose

Soft tissue loss over the ankle and heel is a challenging issue for reconstructive surgeons. The aim of this study is to present the technique of using sural neurocutaneous flap and analyse the results.

Methods

From 2002 to 2014, 15 cases of sural flap were performed in the Department of Orthopaedics and Traumatology of United Christian Hospital, Hong Kong. All cases were handled by two hand surgeons. The outcomes and complications were reviewed retrospectively.

Results

The aetiology included trauma (6 cases), neoplasm (4 cases), Achilles tendon repair wound complication (3 cases) and ulcer (2 cases). The age of patients ranged from 21 years to 82 years (average, 61.9 years). The size ranged from 12 cm2 to 99 cm2. The mean follow-up period was 20 months. Eleven flaps healed successfully without significant complications.

Conclusion

Sural neurocutaneous flap is a reliable flap design with constant vascular anatomy. There is minimal donor site morbidity, and no major vessels are sacrificed. It provides a durable, pain-free, functionally and aesthetically satisfying coverage for ankle and heel wounds.

Distally based sural flap for ankle and foot coverage in children

BACKGROUND

Coverage of soft-tissue defects of the ankle and foot is often challenging. The distally based sural fascio-cutaneous flap is useful for reconstructing the lower leg, ankle, heel, and foot but has rarely been evaluated in paediatric patients. The objectives of this study were to assess the reliability of this flap in paediatric patients, to describe the complications associated with its use, and to define its indications in paediatric patients with soft-tissue defects of the ankle and foot.

HYPOTHESIS

We hypothesised that the sural flap was reliable for covering soft-tissue defects at the ankle and foot in paediatric patients.

MATERIAL AND METHODS

A distally based sural fascio-cutaneous flap was used to cover soft-tissue defects of the ankle and foot in 20 paediatric patients between 1997 and 2013. The evaluation at last follow-up included a physical examination and determination of the modified functional Kitaoka score. Mean follow-up was 50.6 months (range, 10-192 months) and mean patient age at surgery was 8.8 years (range, 1.5-17 years). Trauma was the most common cause of soft-tissue defect (n=12); other causes were surgical-site infections (n=2), tumours (n=3), chronic ulcer (n=1), burn injury (n=1), and infusion fluid extravasation (n=1).

RESULTS

Of the 20 flaps, 16 (80%) remained fully viable, whereas 4 developed partial necrosis requiring excision and skin grafting, which consistently ensured a good outcome. Other complications consisted of marginal necrosis (n=4), unsightly donor-site scars (n=5), and infection (n=2). Abnormal flap sensation was noted in 11 patients. The mean modified Kitaoka score was 65/80 (range, 0-80), and the score value indicated that function was excellent in 9 (45%) patients, good in 9 (45%) patients, and poor in 2 (10%) patients.

DISCUSSION

The distally based sural fascio-cutaneous flap is a method of choice for covering soft-tissue defects of the ankle and foot in paediatric patients. This reliable flap spares the major blood vessels and has a strong blood supply. Its best indication is coverage of an acute traumatic soft-tissue defect with exposure of a vital structure. In patients requiring late reconstruction, caution is in order when considering the use of a distally based sural fascio-cutaneous flap, which can induce delayed complications, most notably at the donor site.

LEVEL OF EVIDENCE

IV, retrospective case-series study.

[New cutaneous strategy in sural flap surgery and possibility to adapt this technique to other pedicled flaps]

INTRODUCTION

Therapeutic managements in losses of substance of the lower limb using sural flap give an important scar and, sometimes, an impossibility to close the flap donor site. That led us to think about an operative procedure that can reduce those scars without increasing the risk of necrosis of the cutaneous paddle.

PATIENTS AND METHOD

We present this operative procedure which underwent in the plastic and reconstructive surgery service in our hospital. Classical flap procedure with two cutaneous parts was used. The cutaneous laxity was evaluated so as to close with one cutaneous part; the other cutaneous part was taken and used like a skin graft after the suture of the calf and the formation of a bursa on the donor site. The leg was closed with only one cutaneous flap.

RESULTS

This technique is illustrated by a case report. Results at the 4th month are very interesting with an acceptable scar and a good result of the skin graft. However, with this technique, we don't decrease the venous risk of this flap. We used this technique for an antebrachial flap.

CONCLUSION

This technique is an easy and reliable technique based on cutaneous laxity and that decreases scarring of this very useful flap: the neurocutaneous sural flap. We can have a diminution of the number of surgery, a diminution of the scar and good aesthetics results.

Vascularized dorsal digital fascial flap improves flexor tendon repairs

We report a new method of flexor tendon repair in zone II using a standard modified Kessler technique combined with a vascularized dorsal fascial flap from the finger pedicled on a dorsal cutaneous branch of the proper digital artery, which is placed as a mechanical barrier between the flexor digitorum superficialis and profundus tendons. The functional outcomes of 14 patients (Group A) with flexor tendon repairs in zone II by this new technique were compared with those of 32 patients (Group B) with flexor tendon repairs in zone II using a standard modified Kessler technique only. Patients in Group A had a higher proportion of excellent results (on the modified Strickland system) and more movement in the distal interphalangeal joint than the patients in Group B.

Reconstruction of great toe soft-tissue defect with the retrograde-flow medial pedis island flap

BACKGROUND

Several investigators have reported their clinical experience with medial pedis flaps for reconstruction of soft-tissue defects of the distal forefoot. However, they had only a few reports where this flap was used to repair soft-tissue defects of the great toe. Thus, reconstruction of soft-tissue defects of the great toe remains a challenge in reconstructive surgery. The authors describe the use of the medial pedis island flap to cover this region.

METHODS

This study was divided into two parts: an anatomic study and clinical application. In the anatomic study, 48 cadaveric feet were injected with latex, and then the main vessels distributed at the medial aspect of the foot were observed. Clinically, retrograde-flow medial pedis island flaps were harvested to cover the soft-tissue defects of the great toe in eight cases.

RESULTS

An anatomic study revealed that the arterial circle under the first metatarsophalangeal joint and the arterial network on the surface of the abductor hallucis were responsible for the blood supply of the medial region of the foot. The diameter of the pedicle was great, and the pedicle was longer than previously reported. In terms of clinical application, all flaps were successful, without any significant complications.

CONCLUSIONS

Using the arterial circle under the first metatarsophalangeal joint, the medial pedis island flap has a reliable retrograde blood supply. This flap should be considered as a preferential way of reconstructing soft-tissue defects of the great toe.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Effects of verapamil, nifedipine, and daflon on the viability of reverse-flow island flaps in rats

Reverse-flow flaps are preferable in reconstructive surgery due to their several advantages. However, they may have venous insufficiency and poor blood flow. In this study, effects of various pharmacological agents on the viability of reverse-flow flaps were investigated. Forty Sprague-Dawley rats were used. Superficial epigastric artery- and superficial epigastric vein-based reverse-flow island flaps were preferred. The rats were divided into 4 groups. Group 1 was considered as the control group. Group 2 was given verapamil 0.3 mg/kg per day, group 3 nifedipine 0.5 mg/kg per day, and group 4 Daflon 80 mg/kg per day for 7 days. On day 7, viable flap areas were measured, angiography was performed, serum nitric oxide levels were evaluated, and histopathological examination was done.The mean flap viability rate was 67.59% (±13.12259) in group 1, 77.38% (±4.12506) in group 2, 74.57% (±3.44780) in group 3, and 85.39% (±4.36125) in group 4 (P = 0.001). The mean nitric oxide level was 31.66 μmol/dL (±2.42212) in group 1, 51.00 μmol/dL (±2.96648) in group 2, 34.00 μmol/dL (±2.96648) in group 3, and 47.66 μmol/dL (±2.80476) in group 4 (P = 0.001). On angiography, there were vessel dilations and convolutions in group 2; capillaries became noticeable, and anastomotic vessels extended toward the more distal part of the flaps in group 4. Histological examinations showed severe inflammation in group 3 and minimal inflammation and venous vasodilatation in group 2.Verapamil and Daflon in therapeutic doses significantly increased the viability of reverse-flow island flaps. However, nifedipine did not make a significant contribution to the flap viability. The results of this study will contribute to the literature about the hemodynamics of reverse-flow island flaps and guide further studies on the issue.

Descending branch of the perforating branch of the peroneal artery perforator-based island flap for reconstruction of the lateral malleolus with minimal invasion

BACKGROUND

Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described.

METHODS

The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases.

RESULTS

The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications.

CONCLUSIONS

A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Experience with the distally based sural flap: a review of 25 cases

The reconstruction of soft tissue defects in the distal areas of the lower extremity remains a challenge. The distally based sural neurocutaneous flap based on the sural nerve and the superficial sural artery has been used for skin defect reconstruction of the distal third of the leg, the hindfoot, ankle, and heel. We describe our experience and evaluate the reliability of this surgical technique. From 2004-2010, 25 patients with an average age of 32.5 (6 to 70) years were treated using the distally based sural flap for reconstruction of skin defects of the lower third of the leg, the heel, the ankle, and the hindfoot. The skin defect was secondary to trauma in 20 patients (80%) and compromised tendon or bone in all cases. One venous congestion and 2 partial flap necroses were observed. The mean follow-up was 25 (9 to 46) months. The plastic result was assessed as satisfactory in all patients. The donor site morbidity was minimal. The sural flap is a good way to reconstruct soft tissue defects of the lower extremity; this surgical technique provides an alternative to microsurgical reconstruction.

Increasing versatility of the distally based sural flap

Repairing distal lower limb soft tissue defects remains challenging for reconstructive surgeons. Relatively few procedures have real efficiency and low morbidity. Since its initial description, the distally based sural flap has been used increasingly for this indication. However, controversy exists about the upper limit of the skin paddle of the sural flap. In the present series, 11 patients underwent surgery with distally based sural flaps. In 6 patients, the flap skin paddle was partially or totally placed beyond this controversial limit on the proximal calf region. To increase the skin irrigation of this region, whole mesenteric tissue under the deep fascia of the leg was included in the flap. Venous congestion and distal tip necrosis can impair the success of flap surgery. To overcome these problems, the flap pedicle was not passed through the subcutaneous tunnel. All flaps survived completely, and no cases of venous congestion developed. Thus, extending the donor area to the upper part of the leg is a reliable maneuver to repair more distal defects of the leg and foot, and abstaining from passing the pedicle through a subcutaneous tunnel could contribute to a decreased risk of venous congestion.

Distally based dorsal pedal neurocutaneous flap for forefoot coverage

The authors describe their experience with the use of the distally based dorsal pedal neurocutaneous flap for distal foot coverage. Ten patients underwent reconstruction with 13 flaps between 2004 and 2008. One patient suffered from a traffic accident and 9 from electrical injury. All of the soft tissue defects resulted in metatarsophalangeal joint and phalanx bone exposure. The size of the flaps ranged from 6 × 2 cm to 11 × 6 cm. The flaps were elevated based on intermediate or medial dorsal pedal nerves. Nine flaps were harvested in first stage to repair the distal foot. Among them, 3 showed partial necrosis in the distal region because of venous insufficiency. Four flaps underwent a surgical delay procedure in the first stage and were then transferred to reconstruct phalanx wounds in the second stage, surviving completely. All patients were satisfied with their reconstruction and donor site contour. The distally based dorsal pedal neurocutaneous flap can be used to repair the distal foot soft tissue defects, providing sufficient skin territory and excellent aesthetic and functional recovery. Surgical delay effectively enhances the distally based dorsal pedal neurocutaneous flap survival, particularly for the large size flaps.

Soft tissue reconstruction of the foot using the distally based island pedicle flap after resection of malignant melanoma

BACKGROUND

We report on our experience with using a distally based island flap for soft tissue reconstruction of the foot in limb salvage surgery for malignant melanoma patients.

METHODS

A distally based sural flap was used for 10 cases for the hindfoot reconstruction, and a lateral supramalleolar flap was used for 3 cases for the lateral arch reconstruction of the mid- and forefoot after wide excision of malignant melanomas.

RESULTS

The length of the flap varied from 7.5 cm to 12 cm (mean, 9.6 cm) and the width varied from 6.5 cm to 12 cm (mean, 8.8 cm). Superficial necrosis developed in four flaps, but this was successfully treated by debridement and suture or a skin graft. All thirteen flaps survived completely and they provided good contour, stable and durable coverage for normal weight bearing.

CONCLUSIONS

The distally based sural flap is considered to be useful for reconstructing the hindfoot, and the lateral supramalleolar flap is good for reconstructing the lateral archs of the mid- and forefoot after resection of malignant melanoma of the foot.

A new experimental reversed-flow flap model: tail artery based skin flap on the dorsum of the rat

Reversed-flow flaps are widely preferred particularly in reconstruction of the defects of distal part of the extremities. To overcome the drawbacks faced during clinical practice of this flap type, experimental models in economical species are required. This study provides a new reversed-flow flap model on the dorsum of the rat which is supplied by the ipsilateral lateral caudal artery. It is designed as a triangle with a 4-cm long base and 5 cm long height and it is well protected from autocannibalization and environmental conditions because of its dorsal location. When compared with the present models, we believe that this simple, reproducible, and practical flap model can be considered as advantageous, and will be preferred by the researchers for future experimental studies in hemodynamics and physiology of reversed-flow flaps.

Venous drainage in retrograde island flap: an experimental study using fluorescence tracing technique

The pathway of venous drainage in retrograde island flaps was investigated by fluorescence tracing technique using the saphenous fasciocutaneous flap in New Zealand White rabbits. Forty animals were allocated into four groups according to the different times at 30 minutes (I), 24 hours (II), 72 hours (III), and 7 days (IV) after the operation. According to the different routes to give tracer, each group was further allocated into two subgroups of the artery injection and vein injection. For each animal, one hindlimb was assigned as the experimental side, the contralateral side as control without giving tracer. The erythrocytes were separated, labeled with fluorescein isothiocyanate (FITC), detected, and injected into the artery or vein. Subsequently, the flaps were harvested 5 seconds after injection and immediately frozen, sectioned, and observed under microscope. In group I and II, the fluorescence was observed mainly around the vessel adventitia of the vein and artery and tunica intima of the artery. In group III, there was weak fluorescence observed in the lumen of vein. In group IV, fluorescence was distributed principally in the lumen of the vein. In addition, fluorescence was not observed in the saphenous nerve in group I and there was mild fluorescence in the saphenous nerve in groups II, III, and IV. These findings suggest that the venous return is through "bypass route" in earlier period. In later period, the venous retrograde return is through "bypass route" and "incompetent valves route;" however, "incompetent valves route" becomes the main route.

The effect of epidural anaesthesia on the reverse-flow fasciocutaneous flap: an experimental study in rabbits

BACKGROUND

The reverse-flow fasciocutaneous flap has been popularised as a feasible alternative to reconstruction of the post-burn contractures around lower-extremity joints. The effect of epidural anaesthesia (EA) on the haemodynamics of reverse-flow fasciocutaneous flap (RFFF) has not yet been investigated. Therefore, it was our primary objective to determine how EA impacts on vascular haemodynamics and tissue perfusion.

MATERIALS AND METHODS

This study included 30 New Zealand white rabbits. The reverse-flow saphenous fasciocutaneous island flap in rabbit model was used. In group I (n=10), epidural catheterisation of the rabbits were performed and they received an epidural infusion of 0.1 ml kg(-1) 0.125% bupivacaine 12-h periods until the 10th day. In group II (n=10), epidural catheterisation of the rabbits was performed and they received an epidural infusion of 0.1 ml kg(-1) isotonic sodium chloride solution. In group III (n=10), epidural catheterisation of the rabbits was not performed. Intra-arterial blood pressure (IABP) and intravenous blood pressure (IVBP) was recorded at time intervals of 5, 15, 30 and 60 min, respectively, after tourniquet release on the first and 10th day. Microcirculatory flow was measured by laser Doppler flowmetry at 2, 4, 6, 8 and 10 days in all the groups.

RESULTS

Throughout the experiment, the flaps showed complete survival. A significant difference was noted in the microcirculatory flow measurements in the flap surfaces between group I and groups II-III throughout the experiment (p<0.05). A significant difference was noted in IVBP and IABP between group I and groups II-III (p<0.05). On the first and the 10th day, however, there were no significant differences between groups II and III (p>0.05).

CONCLUSION

EA improves blood flow to RFFF and prevents the progression of venous congestion.

[Combined latissimus dorsi and serratus anterior reverse flow pedicle flap. Report of two clinical cases]

The use of combined flap involving the distally based latissimus dorsi muscle pedicled on the lumber perforating arteries and prolonged by the last digitations of the serratus anterior flap muscle supplied by the thoracic branch of thoracodorsal vessels is uncommon but has ever been described. We describe the use of this flap in two original cases. The first case is for coverage of a controlateral dorsal radionecrosis. The second case describes its use in emergency following ballistic chest trauma.

Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap

OBJECTIVE

Complex wounds of the lower extremity with concomitant Achilles tendon injury can be difficult to reconstruct. We favour the reverse sural artery fasciocutaneous flap because in a single step, flap elevation affords Achilles tendon exposure and adequate soft tissue for reconstruction. It also provides significant time and resource savings for both plastic and orthopaedic surgical teams.

MATERIALS AND METHODS

Our case series involved four consecutive patients who presented with Achilles tendon injuries and concomitant complex soft tissue defects. The reverse sural artery flap was planned in conjunction with the orthopaedic service to facilitate their approach for Achilles tendon repair. Outcome was measured as flap survival, time for flap elevation and total operative time.

RESULTS

Partial flap loss occurred in one patient. The Achilles repair was performed successfully in all cases. The mean time for flap elevation and Achilles exposure was 43 min (range, 37-52 min). Total operative time was 287 min (range, 211-347 min).

CONCLUSION

The reverse sural artery fasciocutaneous flap is a durable, efficient option for simultaneous Achilles tendon reconstruction and wound coverage. Simple flap elevation provides necessary exposure of the Achilles tendon for repair while the flap itself provides ample soft tissue with a reliable blood supply. In our experience, the reverse sural artery fasciocutaneous flap affords a practical method to address two reconstructive challenges in a single procedure.

An alternative and new approach to free flap in treatment of calcaneal region and lower third of the lower extremity reconstruction: reverse flow posterior tibial fasciocutaneous skin island flaps

BACKGROUND

Fasciocutaneous flaps, whether of the upper or lower extremity, have certain distinct advantages. These flaps are very simple to raise, quick to execute, and have a high reliability. On the basis of experimental studies, it is reasonable to accept that a fasciocutaneous flap has a 15% to 20% increased survival over comparable cutaneous flaps.

METHODS

The distal-based posterior tibial fasciocutaneous flap was designed and successfully transferred clinically to cover lower leg and foot defects in four patients.

RESULTS

No complications, including distal ischemia, infection, and failure, in flaps were seen. Although donor site of fasciocutaneous flaps is significant and can often be justified, it is not as significant as the donor area of the free flaps.

CONCLUSIONS

The versatility, advantages, and disadvantages of this new flap in the reconstruction of defects of the lower leg and foot are discussed.

Microsurgical nonmicrovascular flaps in forearm and hand reconstruction

Relatively new method in flap's surgery, perforator flaps tends to monopolize nowadays the surgeon's interest. The question is: could these flaps be used not only as free flaps, as were mainly used until now, but also as local or regional flaps? On the basis of our experience with 115 operated cases, we will try to demonstrate that a lot of simple or composite defects in the forearm and hand could be covered, in selected cases, by using local or regional perforator flaps. This may have as result, in the future, a dramatic decrease in the indication for free flap transfers. Because these flaps need a microsurgical dissection, but do not need microvascular sutures, they could be defined as "microsurgical nonmicrovascular flaps." The main advantages of these flaps could be summarized as: no microsurgical sutures, no main vascular pedicles sacrifice, same surgical field, shorter hospitalization time.

[Why think about tendons allotransplantation in hand surgery in 1989?]

Two cases of a human vascularized allotransplant of a complete digital flexion system are reported with detailed descriptions of the dissection technique and postoperative treatment. Satisfactory functional results open new prospects for this type of transplantation surgery.

A reverse-flow composite flap in the rat

Reverse-flow flaps are currently particularly used for the reconstruction of defects of the distal part of the extremities. Despite their common usage there have been many reports of postoperative complications, especially resulting in partial or total flap necrosis. There is insufficient knowledge of flap haemodynamics, physiology and wound healing properties in reverse-flow flaps. Development of the proper experimental models is needed to investigate these issues. The purpose of this study was to describe a new reverse-flow flap model in the rat. A total of 20 adult Wistar rats weighing 200-250 g were used in this experiment. In five rats, the vascular anatomy of the auricle of the rat was determined by anatomic dissection and microangiography. In the experimental group (N=5), 1x1 cm reverse-flow composite flaps were harvested as a semi-island shape, based on the distal course of the medial branch of the anterior auricular artery. In the control group, consisting of five rats, the flap was designed and raised based on the proximal course of the medial auricular artery, again in a semi-island shape. In the remaining five animals, a square-shaped composite tissue of the whole layer of the auricle, 1x1 cm in size, was harvested dividing all the bases circumferentially. The composite tissue was replaced in situ. While the former was considered a conventional antegrade-flow flap subgroup, the latter was designated as a graft subgroup. All flaps were replaced in situ. The survival of the flap was evaluated on postoperative day 7 by direct observation and microangiography. The skin island of all the reverse-flow flaps and conventional antegrade-flow flaps survived completely giving a success rate of 100%, whereas all grafts in the control group underwent complete necrosis. Microangiographic studies revealed the vascularity of the reverse-flow and antegrade-flow flaps, identifying the course of the auricular arteries. In conclusion, with its evident advantages of easy to design and harvesting, reliable survival pattern and consistent vascular structure, our new flap model will provide a means for future studies on flap haemodynamics, physiology in reverse-flow flaps.

Limb salvage of infected diabetic foot ulcers with free deep inferior epigastric perforator flaps

Soft-tissue reconstruction of the feet in diabetic patients with angiopathy, sensorial neuropathy, and immunopathy is a complicated problem. Until the mid-1980s, chronic foot ulcers in diabetic patients were treated conservatively, because flap surgery was regarded as too risky. However, in recent years, early debridement and flap coverage have become popular reconstructive methods for diabetic foot wounds. Several flap donor sites are available, depending on the nature of the defect. The deep inferior epigastric artery perforator (DIEP) flap is a relatively new flap that developed as a modification of the transverse rectus abdominis muscle (TRAM) flap. It provides a large amount of skin and subcutaneous tissue, without the donor-site morbidity of the ordinary TRAM flap. Furthermore, using the DIEP flap avoids the loss of major vessels. In this study, we report on the successful use of the DIEP flap in four cases of diabetic foot ulceration.

A Modified Technique for Transposition of the Reverse Sural Artery Flap

BACKGROUND

Coverage of a soft-tissue defect of the lower third of the leg is a difficult problem. The reverse sural artery flap, first described by Masquelet, is a random type of flap, based on the superficial sural artery.

METHODS

We treated 10 patients with 11 reverse sural artery flaps. A modification of flap transposition through a subcutaneous tunnel with the aid of a soft-tissue expander was described to prevent venous congestion, especially in longer tunnels, for flap insetting.

RESULTS

Eight flaps survived completely. Distal tip and partial skin necrosis was observed in three flaps in two diabetic patients (27.2 percent). No venous congestion was observed after this modification.

CONCLUSION

The reverse sural artery flap is a reliable alternative for small to moderate size defects and can be used with modifications of the original technique.

[Distally based sural neurocutaneous flap: clinical experience and technical adaptations. Report of 60 cases]

The distally based sural neurocutaneous flap (Masquelet et al., 1992) has proved to be a useful technique for lower limb skin defect reconstruction. We report our experience in a 60 case series for the coverage of foot, ankle, and distal third of the leg with success in 58 cases and 2 failures. For one of these, a total necrosis occurred after a technical problem when harvesting the pedicle, while the second failure was due to a severe inferior limb vascular disability. In 14 cases, a partial venous congestion with a slight epidermolysis or a marginal necrosis was observed but it resolved without sequel. Seventeen patients presented with distal vascular impairment and/or neuropathies (i.e. diabetes mellitus, arteriosclerosis, vascular lesions) of the inferior limb and our experience favour a larger pedicle trimming than in normal cases to avoid venous congestion of the skin paddle. In 18 cases, when undermining of skin between the pivot-point and the defect site to be covered was too hazardous, we used an external pedicle either temporary and severed a few weeks after or skin grafted. This is a helpful mean when local condition of the skin to be undermined for pedicle tunnelling may interfere with the final issue. This one-stage simple technique, without major vascular sacrifice and with minor consequences at the donor site, is reliable for the distal third of the inferior limb, ankle, and dorsal foot aspect reconstruction, the heel-bearing zone excepted.

Use of reverse adipofascial flap in cutaneous defects of the distal third of the lower leg

Lower limb reconstruction, especially for the aquilian and calcaneal regions, represent a great challenge for the plastic surgeon. Among the existing options of cutaneous coverage, the distally pedicled adipofascial flap may reach even the most distal zones. From April 1995 to May 2002, 15 adipofascial flaps to the cutaneous coverage of the distal-third leg were performed. The reconstruction was immediate in eight patients. In one case, partial tissue necrosis was observed.

Reversed saphenous fasciocutaneous island flap in marjolin's ulcers

BACKGROUND

The reconstruction of the heel represents a challenge due to the limited local soft tissue availability and also due to the special structural and functional characteristics of this region. A great number of possibilities have been described; we represent a new flap for heel reconstruction which is a modified form of sural fasciocutaneous flap.

METHODS

Ten patients (two female and eight male; median age 68 years, range 48-76) underwent reversed saphenous fasciocutaneous island flap after wide excision of heel lesion. The causes of heel lesions in all patients were Squamous Cell Carcinoma on the chronic burn's scar. In this new technique, sural nerve and artery were saved and blood supply to flap is based on lesser saphenous vein. Mean lesion surface was 60 cm(2) (range 30-112 cm(2)).

RESULTS

Epidermolysis and flap discoloration were seen in three patients but treated with intermittent wet dressing and conservative managements. One patient showed partial necrosis in flap circumference which recovered with debridment and skin graft. Total flap necrosis was not seen in any patients. Mean hospital stay was 10 days (range 8-15 days). The mean follow up was 12 months (rang 6-18 months).

CONCLUSION

Reversed saphenous fasciocutaneous island flap is an option for heel reconstruction. In contrast with sural flap, sural nerve and artery are saved.

The earlier clinic experience of the reverse-flow anterolateral thigh island flap

Since Song first reported the anterolateral thigh flap in 1984, this flap has been applied widely in clinical practice. In 1997, we found that the proximal end of the vascular pedicle of the anterolateral thigh flap showed active bleeding. We therefore believed that this flap could form the reverse-flow flap, which can be used clinically. From 1997 to 2002, two patients who suffered from soft tissue defects in their lower extremities have been repaired successfully with the reversed flow anterolateral thigh island flaps. The reverse-flow anterolateral thigh island flap with reliable blood supply and long vascular pedicle can be designed to repair soft tissue defects around ipsilateral knee joint or contralateral distal rejoins of the leg, especially in the difficulty cases.

Microcirculation Study of Rabbit Ear Arterial and Venous Flow-Through Flaps Using a Window Chamber Model

Venous flaps are used widely for finger reconstruction because they provide thin tissue, and the flap harvest is associated with less donor-site morbidity. The viability of the venous flap, however, is not as good as that of the ordinary perfused skin flap, and its microcirculation is questionable according to various indirect observations and hypotheses in the literature. Using a window chamber model in a rabbit ear, both arterial and venous flow-through flaps were studied. Factors evaluated were flap viability, flap weight, flap circulation as assessed by laser Doppler flowmetry, and direct observation of the microcirculation. Statistical analysis was performed using the two-sample t test. There was no statistically significant difference in viability between arterial and venous flow-through flaps (p = 0.661). The arterial flow-through flap had better perfusion than thevenous flow-through flap, as measured by laser Doppler perfusion studies (10.40 perfusion units [PU] vs 4.50 PU). However, no statistically significant difference was noted (p = 0.0717). Flap weight assesseed 1 week after surgery and oxygen saturation measured immediately after surgery showed significant differences between the arterial and venous flow-through flaps (p = 0.0001 and 0.0279). These datasuggest that the arterial flow-through flap is subjected to more congestion becauseof the abnormal flow pattern seen, andpossibly because of a superior inflow or nutritional status found in these flaps. Using vital microscopy, direct evaluation of the microcirculation was performed. A to-and-fro phenomenon was noted in both arterial and venous flow-through flaps,which was followed by a reversed direction of flow in part of the microvasculature. With both types of flaps, the blood was directed eventually from the postcapillary venules to the capillaries, through the terminal arterioles, and then to the arterioles. These findings may be explained partially by the normal physiologic pressure gradients present in the microvasculature of these flaps. In this study, direct observation of the microcirculation was used as well as other objective measures to determine the flow patterns and clinical behaviors found in these types of flaps. A model in a rabbit ear for the study of venous and arterial flow-through flaps is described, and clinical correlations are discussed.

Ankle and pantalar arthrodeses using vascularized fibular grafts

From 1989 to 1998 ankle and pantalar arthrodeses using vascularized fibular grafts were performed for seven patients. The indications for surgery were chronic nonunion following fracture of the distal tibia in four patients, rheumatoid arthritis in two, and talus necrosis in one. The ankle joint was fused in the two patients with a pilon fracture, and in the other five patients, both the ankle and subtalar joints were fused. In one patient, additional bone grafting was required for delayed union. In the other six patients, the mean period required to obtain radiographic bone union was 6 months (range, 4-9 months). The time until the patients could walk without braces ranged from 6 to 20 months (mean, 12.3 months). Local infection was not encountered in any patients. This procedure represents a viable option for patients in whom a standard, less complicated arthrodesis cannot be performed.

Comparison of different managements of large superficial veins in distally based fasciocutaneous flaps with a veno-neuro-adipofascial pedicle: An experimental study using a rabbit model

The role of large superficial veins in the survival of a distally based fasciocutaneous flap with a veno-neuro-adipofascial pedicle was studied in a rabbit model. A sural veno-neuro-fasciocutaneous flap model (6 x 2 cm) with a distally based lesser saphenous veno-neuro-adipofascial pedicle (1.5 cm) was established. Fifteen rabbits were randomly divided into three groups with 10 flaps in each group. In group I, the distal lesser saphenous vein was left open (venous inflow remained) after the flap was raised. In group II, the lesser saphenous vein was ligated in the pedicle (no venous inflow). In group III, the venous pedicle was left open in the pedicle, and the proximal end was microsurgically anastomosed to the recipient vein (outflow established). Intravenous pressure, flap survival, and histology were examined. The results showed that the values of intravenous pressure in group I were significantly higher than in group II (P < 0.001). The mean flap survival rate of group III (94.5%) was significantly higher (P < 0.001) than of groups I (22.7%) and II (55.5%). Histology showed that the lesser saphenous vein in group I was extremely dilated and filled with thrombosis. This experiment demonstrated that establishing a superficial venous outflow channel by anastomosis at the proximal end, or interrupting the inflow channel by ligation at the distal pedicle, may significantly improve the survival rate of distally based veno-neuro-fasciocutaneous flaps.

Comparison of venous drainage in reverse-flow island flaps: an experimental study of the rabbit saphenous fasciocutaneous flap

The mechanism of venous drainage in reverse-flow island flaps was investigated using the saphenous fasciocutaneous flap in New Zealand White rabbits. Ten animals were allocated into two groups of 10 flaps. In group I (left limb), the distal vascular pedicle (one saphenous artery and two venae comitantes) was not disturbed, maintaining the communicating and collateral branches intact. In group II (right limb), it was separated microsurgically from each other for 3 cm. Intravenous pressure was measured at 5, 15, 30, and 60 minutes after tourniquet release. The values of group II at 30 and 60 minutes were significantly lower (p<0.01) than those of group I. Ten days after flap elevation, the mean survival area of group I (95%) and group II (100%) was not significantly different. Histological examination of the vascular pedicle showed the saphenous veins in group II were more dilated than those of group I. These findings suggest that venous retrograde return in reverse-flow island flaps can be achieved more easily through a "direct incompetent valves route" than through a "circuitous communicating and collateral bypass route."