Use of non-enhanced angiography to assist the second toetip flap transfer for reconstruction of the fingertip defect

Application of Artificial Dermis Combined With a Medial Flap From the Second Toe to Repair Degloving Injury of the Fingertip

There is no standard technique for repairing degloving injuries of the fingertip. Nail bed flap transplantation is a common surgical technique to address this injury, but this procedure inevitably damages the donor site in the toe. This article describes a surgical technique that can restore the appearance of the injured fingernail and preserve the length and function of the injured finger without damaging the toenail.

Domino Free Flap Transfer Using a Superficial Circumflex Iliac Artery Perforator Flap for the Toe Flap Donor Site

BACKGROUND

Toe-to-hand transfer is a favorable option for finger reconstruction, but donor site healing can be challenging. The superficial circumflex iliac artery perforator (SCIP) flap has yet to be used widely for toe reconstruction. The purpose of this report was to validate the efficacy of the sequential simultaneous free SCIP flap transfer for the toe flap donor site in a consecutive case series.

METHODS

The medical records of 18 consecutive patients who underwent a simultaneous SCIP flap transfer and a toe-to-hand transplant were reviewed. Free SCIP flap reconstruction was performed in a simultaneous 2-team approach. The SCIP flaps were transferred to various toe flap donor sites: a great toe wraparound flap in 9 cases, a second toe distal phalangeal flap in 4 cases, a great toe osteo-onycho-cutaneous flap in 3 cases, a twisted wraparound flap in 1 case, and a great toe hemipulp flap in 1 case.

RESULTS

The size of the SCIP flap ranged from 5 × 3 to 16 × 8 cm. A mean of the total operative time was 229.2 minutes (range, 118-441 minutes; SD, 75.8 minutes). All the SCIP and toe flaps survived completely. Minor wound dehiscence was seen in 2 cases, and the wound healed by conservative treatment. The mean follow-up period was 23.7 months (range, 7-44 months; SD, 9.7 months). No patient had gait dysfunction postoperatively.

CONCLUSIONS

A sequential SCIP flap transfer was performed simultaneously without additional time, allowing secure soft tissue coverage of the toe flap donor even with avascular tissue such as bone or tendon exposed. The sequential SCIP flap transfer can be a useful option for reconstruction of toe flap donor site, when multiple microsurgeons and microscopes are available.

Free double-paddle superficial circumflex iliac perforator flap transfer for partial maxillectomy reconstruction: A case report

Partial maxillectomy for maxillary sinus cancer treatment requires soft tissue reconstruction with enough bulk to occupy the large-volume defect. Deep inferior epigastric artery-based flaps and subscapular artery-based flaps are commonly used, but necessitate invasive muscle dissection or position change and a large recipient vessel. The aim of this report was to present a case of partial maxillectomy defect successfully reconstructed with a superficial circumflex iliac artery (SCIA) perforator (SCIP) flap, to address these drawbacks. A 67-year-old female underwent partial maxillectomy for maxillary sinus cancer. The defects included the medial and the caudal aspects of the maxillary sinus with unilateral palate loss. A double-paddle SCIP flap (19 × 9 cm and 10 × 6 cm) was elevated in a free-style manner based on the superficial branches of the SICA. The SCIP and its concomitant vein were anastomosed to a facial artery perforator and the angular vein with supermicrosurgical perforator-to-perforator anastomosis. Two skin paddles were utilized to reconstruct the defects of the nasal wall and the oral aspects of the palate. Postoperative course was uneventful, and the patient could resume normal oral diet 5 days after surgery. Three years after surgery, there was no cancer recurrence or any postoperative complication, and the patient was satisfied with normal speech and diet, and with concealable donor and recipient scars. Double-paddle SCIP flap transfer may be an option for reconstruction of a partial maxillectomy defect.

Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site

BACKGROUND

Free hypothenar flap (HTF) transfer allows sensible soft tissue reconstruction of the fingertip. However, HTF is basically indicated for a relatively small soft tissue defect, as width of an HTF is limited up to approximately 20 mm to allow primary donor site closure. Combined with sequential local flap to an HTF donor site, a larger HTF can be used without the contracture risk. The aim of this study was to evaluate feasibility of free HTF transfer and sequential ulnar palm flap (UPF) transfer (HTF-UPF) for relatively large fingertip reconstructions.

METHODS

Medical charts of patients who underwent HTF-UPF for fingertip reconstruction were reviewed. An HTF was designed transversely proximal to the proximal palmar crease, and a slightly smaller hemi-spindle-shaped UPF was designed longitudinally on the mid-lateral aspect of the ulnar palm; the UPF was used to close the HTF donor site. Patient and flap characteristics, intra-operative findings, and postoperative results were evaluated.

RESULTS

Twelve patients with average age of 42.7 years were included. HTF-UPF procedure was performed on 12 fingers. HTF's length/width ranged from 45/20 to 70/40 mm (average, 52.5/32.1 mm). UPF's length/width ranged from 40/20 to 55/30 mm (average, 46.7/24.2 mm). Time for sequential UPF transfer ranged from 3 to 9 min (average, 5.1 min). All HTFs and UPFs survived without flap necrosis or scar contracture. Postoperative sensation was comparable with the contralateral fingertip.

CONCLUSIONS

HTF-UPF procedure allows relatively large fingertip reconstruction with a minimum risk of HTF donor site contracture.

Radical reduction and reconstruction for male genital elephantiasis: Superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection

BACKGROUND

Treatment of elephantiasis, the most severe lymphedema, is challenging. Management of male genital elephantiasis (MGE) is even more challenging than extremity elephantiasis due to its complicated shape and high risk of lymphorrhea and cellulitis. Complete resection of fibrous tissue and lymphatic reconstruction is considered to be ideal for the treatment of MGE. The aim of this study was to evaluate the feasibility of radical reduction and reconstruction (3R) for isolated MGE.

METHODS

Medical charts of patients who underwent 3R were reviewed. The 3R operation consisted of genital fibrous tissue resection and reconstruction of soft tissue and lymphatic structure using superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer (LFT). No compression was applied postoperatively. Patient and flap characteristics, intraoperative findings, and postoperative results were evaluated.

RESULTS

Seven patients were included. MGE included isolated scrotal elephantiasis in 4 cases, and scrotal and penile elephantiasis in 3 cases. Resected tissue volume ranged from 609 to 2304 grams (average, 1511.0 grams). SCIP-LFT was performed in all cases; pedicled full-thickness SCIP-LFT for scrotal reconstruction in all cases, and SCIP pure-skin-perforator flap transfer for penile reconstruction in 3 cases. There was no postoperative genital complication or evidence of genital lymphedema recurrence in the mean follow-up period of 22.7 months. Genital lymphedema scores significantly improved postoperatively (6.7 ± 1.8 vs. 0.3 ± 0.5, P <0.001).

CONCLUSIONS

3R operation allowed one-stage curative treatment for MGE. LFT has the potential to play an essential role in the prevention of postoperative wound complications and lymphedema recurrence after radical resection of fibrotic tissue.

A triple-component deep inferior epigastric artery perforator chimeric free flap for three-dimensional reconstruction of a complex knee defect complicated with patella osteomyelitis

Reconstruction of a complex knee defect is challenging, especially when complicated with osteomyelitis. Complex knee defect requires multi-component three-dimensional reconstruction using a chimeric flap. Although anterolateral thigh (ALT) flap is the most workhorse chimeric flap, another chimeric flap is required when ALT flap is not available. In this report, we present a case of complex knee defect successfully treated with a free triple-component chimeric deep inferior epigastric artery perforator (DIEP) flap transfer. A 36 year-old male sustained right above-knee amputation and Gustilo IIIB open fracture of the left patella after being run over by a train. Stump formation was performed for the right limb amputation, and the left knee wound resulted in skin necrosis complicated with patella osteomyelitis. After debridement, the left knee wound showed a 3 × 2 cm articular capsule defect, 5 × 2 cm exposed patella stump, and a 16 × 9 cm skin defect. A triple-component chimeric DIEP flap, containing a 7 × 3 cm rectus abdominis muscle (RAM), a 3 × 2 cm RAM's fascia, and a 23 × 10 cm skin was transferred. The RAM's fascia was used to reconstruct the joint, the RAM to cover the exposed patella's stump and the reconstructed joint, and the skin paddle to cover the skin defect. Six months after the surgery, the patient could walk without osteomyelitis recurrence, and there was no limitation in the left knee joint's range of motion. Although indication is limited, a multi-component chimeric DIEP flap may be an option for three-dimensional reconstruction of a complex defect.

Free superficial circumflex iliac artery perforator fascial flap for reconstruction of upper abdominal wall with extensive infected herniation: A case report

Complex abdominal wall reconstruction is challenging, and vascularized fascia is preferred for active infection cases. Pedicled tensor fascia lata flap is commonly used for lower abdominal wall reconstruction, and free vascularized fascial flap based on the lateral circumflex femoral artery (LCFA) is used for upper abdominal wall reconstruction. However, LCFA-based flap transfer requires invasive and time-consuming muscle dissection and a large recipient vessel. The purpose of this report was to present a new application of superficial circumflex iliac artery (SCIA) perforator (SCIP)-based fascial flap for upper abdominal wall reconstruction. A 70-year-old male suffered from a long-lasting extensive abdominal wall herniation complicated with mesh infection and cutaneous fistulae following multiple herniation repair with synthetic mesh. After complete debridement of infected tissues, there was a 29 x 26 cm full-thickness abdominal wall defect. Components separation was performed to minimize the defect size, after which 12 x 7 cm defect remained in the upper abdominal wall. A 20 x 10 cm SCIP deep fascial flap was elevated based on the deep branch of the SCIA. The SCIP flap was transferred to the defect to reconstruct the upper abdominal wall. The SCIP was anastomosed to the deep inferior epigastric artery perforator with supermicrosurgical perforator-to-perforator anastomosis. Postoperative course was uneventful with good functional and esthetic results of the donor and recipient sites 11 months after the surgery. Although further studies are required, SCIP fascial flap may be an option for upper abdominal wall reconstruction.

Split-Thickness Nail Bed Flap Graft in the Management of Distal Partial Defect of the Nail Bed Combined With Soft Tissue

PURPOSE

We report a surgical procedure for the management of nail bed injuries combined with soft tissue defects.

METHODS

We reviewed the records of patients with a nail bed injury combined with a soft tissue defect, who were surgically treated at our hospital from 2015 through 2018. According to the Allen classification, 5 patients were characterized as type 2 and 3 were characterized as type 3. Two also had partial defects of the distal phalanx. In all cases, we created a split-thickness nail bed flap of the great toe to reconstruct the nail bed injury. All patients underwent supervised postoperative rehabilitation. We reviewed patients' medical records for the Michigan Hand Outcomes Questionnaire, 2-point discrimination, and postoperative healing in the donor area.

RESULTS

Both the nails and flaps of all patients survived. No complications were observed after surgery. The nail was completely attached to the nail bed. In addition, there were no deformities, and the nail plate appearance was close to normal. A nail with an unsatisfactory appearance was noted in one patient. The shape, texture, and elasticity of the flaps of all patients were acceptable. All patients were capable of normal pinching, gripping, and grasping. Twelve months after the operation, 3 of 8 patients had 2-point discrimination of 6 mm or less. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire. The toenail of the donor site grew well, and no deformity or pain with walking was noted.

CONCLUSIONS

We demonstrate that this approach is a safe means of repairing a nail bed injury combined with a soft tissue defect.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Anatomic and Histological Features of the Extensor Digitorum Longus Tendon Insertion in the Proximal Nail Matrix of the Second Toe

Background: Anatomic and histological landmarks of the extensor digitorum longus (EDL) tendon insertion in the proximal nail matrix may be key aspects during surgery exposure in order to avoid permanent nail deformities. Objective: The main purpose was to determine the anatomic and histological features of the EDL’s insertion to the proximal nail matrix of the second toe. Methods: A sample of fifty second toes from fresh-frozen human cadavers was included in this study. Using X25-magnification, the proximal nail matrix limits and distal EDL tendon bony insertions were anatomically and histologically detailed. Results: The second toes’ EDLs were deeply located with respect to the nail matrix and extended superficially and dorsally to the distal phalanx in all human cadavers. The second toe distal nail matrix was not attached to the dorsal part of the distal phalanx base periosteum. Conclusions: The EDL is located plantar and directly underneath to the proximal nail matrix as well as dorsally to the bone. The proximal edge of the nail matrix and bed in human cadaver second toes are placed dorsally and overlap the distal EDL insertion. These anatomic and histological features should be used as reference landmarks during digital surgery and invasive procedures.

Supermicrosurgery for oncologic reconstructions

With advancement of microsurgical techniques, supermicrosurgery has been developed. Supermicrosurgery allows manipulation (dissection and anastomosis) of vessels and nerves with an external diameter of 0.5 mm or smaller. Because quality of life of cancer survivors is becoming a major issue, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques attracts attention. Conventional free flap reconstruction usually sacrifices major vessels and muscle functions, whereas supermicrosurgical free flaps can be transferred from anywhere using innominate vessels without sacrifice of major vessel/muscle. Since a 0.1-0.5 mm vessel can be anastomosed, patient-oriented least invasive reconstruction can be accomplished with supermicrosurgery. Another important technique is lymphatic anastomosis. Only with supermicrosurgery, lymph vessels can be securely anastomosed, because lymph vessel diameter is usually smaller than 0.5 mm. With clinical application of lymphatic supermicrosurgery, various least invasive lymphatic reconstruction has become possible. Lymphatic reconstruction plays an important role in prevention and treatment of lymphatic diseases following oncologic surgery such as lymphedema, lymphorrhea, and lymphocyst. With supermicrosurgery, various tissues such as skin/fat, fascia, bone, tendon, ligament, muscle, and nerves can be used in combination to reconstruct complicated defects; including 3-dimensional inset with multi-component tissue transfer.

Onco-reconstructive supermicrosurgery

Supermicrosurgery is sophisticated microsurgical technique, which allows dissection and anastomosis of blood/lymphatic vessels and nerves with external diameter of 0.5 mm or smaller. With increasing attention to quality of life of cancer survivors, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques is warranted. Unlike conventional free flap reconstruction, supermicrosurgical free flaps can be elevated from anywhere using innominate vessels with diameter of 0.1 mm or larger, allowing patient-oriented least invasive reconstruction. Since lymphatic vessels can be anastomosed, lymphatic reconstruction is possible with supermicrosurgery, which plays an important role in management of cancer-related lymphedema. Supermicrosurgeons can harvest vascularized tissues such as skin, fat, fascia, tendon, ligament, bone, muscle, and nerve separately, and reconstruct complicated defects with three-dimensionally-inset multi-component tissue transfer.

The Observation of the Vein Distribution of a Partial Toe-Transfer Flaps with a Short Vascular Pedicle

BACKGROUND

When performing partial toe-transfer flaps with a short vascular pedicle, as the flap becomes smaller, the likelihood of securing veins in the flap decreases. The purpose of this study was to clarify how frequently the partial toe-transfer flap with a short pedicle (free vascularized half-big toenail flap) contains veins and elucidate how frequently we can secure the veins with an artery via the first web space approach alone, using the Genial Viewer (a near-infrared light transmission imaging device).

METHODS

We observed the dorsal vein images of the bilateral big toes of 250 volunteers (male, n = 125; female, n = 125) using the device. We counted the total number of dorsal veins in the big toe, the veins that crossed the margin of the region equivalent to the half-big toenail flap, and the veins that branched off from the fibular side of the flap area. An unpaired Student's t-test was used for the statistical analyses.

RESULTS

All of the dorsal big toes contained veins. The mean number of the veins was 2.3 (range, 1-4). Branched-off veins were observed in the area equivalent to the half-big toenail flap in 496 (99.2%) of the big toes, and the mean number of veins was 1.9 (range, 0-4). In four cases, the region contained no veins (unilaterally). Branched-off veins were observed in the first web space in 440 (88.0%) of the big toes, and the mean number of veins was 0.9 (range, 0-2).

CONCLUSIONS

The present study indicated high consistency of the veins in partial toe-transfer flaps with a short vascular pedicle and the high possibility of harvesting a flap with only exposing the first web space. In addition, in most cases, the flap will include one or, at most, two veins in the first web space.

Comparison of Lymphovenous Shunt Methods in a Rat Model: Supermicrosurgical Lymphaticovenular Anastomosis versus Microsurgical Lymphaticovenous Implantation

BACKGROUND

Lymphaticovenular anastomosis and lymphaticovenous implantation are the most popular lymphovenous shunt operations for the treatment of obstructive lymphedema. However, no study has been reported regarding direct comparison between lymphaticovenular anastomosis and lymphaticovenous implantation. This study aimed to compare postoperative patency of lymphaticovenular anastomosis and lymphaticovenous implantation using a rat model.

METHODS

Twelve Wistar rats were used for the study. The rats were randomized into the lymphaticovenular anastomosis group (n = 6) or the lymphaticovenous implantation group (n = 6). In the lymphaticovenular anastomosis group, the largest femoral lymphatic vessel was anastomosed to a similar-size vein in an end-to-end intima-to-intima coaptation manner, and the other lymphatics were ligated. In the lymphaticovenous implantation group, the femoral lymphatic vessel and surrounding tissue were inserted into the short saphenous vein with a telescopic anastomosis technique. Patency was evaluated intraoperatively and 1 week postoperatively with patent blue dye and indocyanine green lymphography.

RESULTS

The mean diameters of the lymphatic vessels and the veins were 0.242 mm (range, 0.20 to 0.35 mm) and 0.471 mm (range, 0.30 to 0.75 mm), respectively. Intraoperative patency was 100 percent (six of six) in both groups (p = 1.000). Postoperative patency was significantly higher in the lymphaticovenular anastomosis group compared with the lymphaticovenous implantation group [100 percent (six of six) versus 33.3 percent (two of six); p = 0.014] CONCLUSION:: Postoperative patency of the lymphaticovenular anastomosis group was higher than that of the lymphaticovenous implantation group, although intraoperative patency rates of the lymphaticovenular anastomosis and lymphaticovenous implantation groups were comparable.

The role of non-enhanced angiography in toe tip transfer with small diameter pedicle

BACKGROUND

Toe tip transfer allows functional and esthetic reconstruction of the lost fingertip, but it is still uncommon because identification and dissection of donor and recipient veins can be challenging. Nonenhanced angiography (NEA) is a device that emits infrared light at a wavelength of 850 nm, which is exclusively absorbed by hemoglobin. The light penetrates the bones and other soft tissues, effectively visualizing veins in real time. The aim of this report is to present the experience on the preoperative use of nonenhanced angiography for visualization of donor and recipient veins in toe tip transfers in a series of patients.

PATIENTS AND METHODS

Four cases of toe tip transfer and one case of free nail flap were performed for reconstruction of the tips of thumb and finger with preoperative examination using NEA. Patients' age ranged from 29 to 52 years old (average, 29.2 years old). Before the operation, the veins in the donor and recipient sites were marked using NEA, and the blood flow of the veins in the recipient site was confirmed.

RESULTS

Pedicles in all transferred toe tips were less than 2 cm in length, with diameters smaller than 0.8 mm. The postoperative courses were uneventful, and all transferred toe tips survived completely, with satisfying functional and aesthetic results.

CONCLUSIONS

NEA may facilitate venous dissection of the donor and the recipient sites, allowing safe and efficient toe tip transfer with a small pedicle.