1
|
Awaida C, Aribert M, Weger N, Keck K, Odobescu A. Venous Free Flap with Interposition Bypass Graft for Arteriovenous Fistula Preservation: A Case Report. Arch Plast Surg 2023; 50:568-572. [PMID: 38143846 PMCID: PMC10736209 DOI: 10.1055/a-2122-6029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/27/2023] [Indexed: 12/26/2023] Open
Abstract
Cutaneous squamous cell carcinoma (CSCC) overlying an arteriovenous fistula (AVF) is rare and presents unique challenges. This case report describes a method of fistula preservation after CSCC excision using a flow-through venous free flap. The saphenous vein of the venous flap was used as flow-through segment for AVF preservation. The flap was inserted along the dorsal aspect of the forearm wound and microvascular anastomosis of the arterial inflow was completed using a vein just proximal to the radiocephalic fistula anastomosis. Venous outflow was established by creating an end-to-end vascular anastomosis between the cephalic vein and the greater saphenous vein. A separate subcutaneous vein was used to provide a low-pressure outflow for the flap to avoid congestion. This case demonstrates an option for AVF preservation that has not been previously described. It also highlights the importance of a multidisciplinary approach for the safe treatment of CSCCs overlying AVFs.
Collapse
Affiliation(s)
- Cyril Awaida
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Marion Aribert
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Natalie Weger
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Kendall Keck
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Andrei Odobescu
- Department of Plastic Surgery, University of Texas-Southwestern, Dallas, Texas
| |
Collapse
|
2
|
Reverse Flow Shunt Restricted Free Venous Flap for a Ring Avulsion Injury. Plast Reconstr Surg Glob Open 2022; 10:e4511. [PMID: 36148030 PMCID: PMC9489152 DOI: 10.1097/gox.0000000000004511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022]
Abstract
Arterialized venous flaps can be an excellent option for reconstruction of digital defects. Previously, they remained unpopular owing to the high rate of venous congestion. Different techniques of restriction of the arteriovenous shunting have been described to mitigate this problem. In this article, the authors discuss a unique case whereby a reverse flow shunt restricted venous flap was used in an Urbaniak type III ring avulsion.
Collapse
|
3
|
Giesen T, Politikou O, Tami I, Calcagni M. Retrograde Free Venous Flaps for Extremity Reconstruction: A Roadmap. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081065. [PMID: 36013532 PMCID: PMC9416256 DOI: 10.3390/medicina58081065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/23/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6−15). The flap dimensions ranged from 6 cm2 to 136 cm2. All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm2). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats.
Collapse
Affiliation(s)
- Thomas Giesen
- Centro Manoegomito, Clinica Ars Medica, 6900 Gravesano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
| | - Olga Politikou
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Ivan Tami
- Centro Manoegomito, Clinica Ars Medica, 6900 Gravesano, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| |
Collapse
|
4
|
Xu L, Liu Z, Liu S, Jorgensen AM, Hou R, Ju J. Repair of Compound Dorsal Defects of the Digits Using a Free Antegrade Palmaris Longus Tendocutaneous Venous Flap. J Hand Surg Am 2022; 48:510.e1-510.e5. [PMID: 35031123 DOI: 10.1016/j.jhsa.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 09/10/2021] [Accepted: 11/10/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the clinical effect of repairing small dorsal digit compound tissue defects using a free palmaris longus tendocutaneous flap nourished by venous blood. METHODS In a retrospective analysis of patients treated between March 2010 and October 2017, 18 patients were identified as having small compound tissue defects, which were repaired using a free palmaris longus tendocutaneous flap nourished by venous blood. The average age of the patients, including 15 male and 3 female patients, was 34 years (range, 22-55 years). The mean wound size was 6 cm2 (range, 2.0 × 1.5 to 3.5 × 2.0 cm2). All the patients had dorsal defects. The average length of extensor tendon defect was 2.0 cm (range, 1.0-3.0 cm). The mean area of the flap was 7 cm2 (range, 2.5 × 2.0 to 4.0 × 3.5 cm2). The donor sites were primarily closed. RESULTS All 18 flaps survived. A vascular crisis due to a venospasm occurred within 48 hours in 3 flaps, but ultimately, all the flaps survived. The patients were followed-up for a mean period of 10 months (range, 3-15 months). All the patients returned to their previous work after 10-12 weeks. No pain or scar contracture was reported in either the recipient or donor site. CONCLUSIONS The free antegrade palmaris longus tendocutaneous venous flap enabled the repair of compound tissue defects of the dorsal digit, resulting in acceptable aesthetics, repaired tendon defects, and wound coverage. This surgical method is an option for the reconstruction of small compound defects of digits with extensor defects. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
Affiliation(s)
- Lei Xu
- Department of Hand surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhijin Liu
- Department of Hand surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou, China
| | - Shenzhe Liu
- Department of Hand surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou, China
| | - Adam M Jorgensen
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Ruixing Hou
- Department of Hand surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou, China.
| | - Jihui Ju
- Department of Hand surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou, China.
| |
Collapse
|
5
|
Venkatramani H, Sabapathy SR, Zhang D. Revascularization of a Circumferential Hand and Forearm Degloving Injury Using an Arteriovenous Shunt. J Hand Surg Am 2021; 46:629.e1-629.e6. [PMID: 33012618 DOI: 10.1016/j.jhsa.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 06/10/2020] [Accepted: 08/05/2020] [Indexed: 02/02/2023]
Abstract
Major upper-extremity degloving injuries with distal dysvascularity are rare and challenging surgical problems. When these degloving injuries occur over nonexpendable regions, such as the glabrous skin of the palm and digits, revascularization or replantation may be the treatment of choice. Because the degloved skin flap is often separated in the suprafascial plane, direct arterial repair may be impossible. We present a rare case of circumferential degloving of the hand and forearm with distal dysvascularity, treated successfully with revascularization with arterial anastomosis, venous anastomosis, and arteriovenous shunt creation. The patient required reoperation for partial flap loss and ligation of the arteriovenous fistula. At final follow-up 16 months after the injuries, she showed independence in activities, reported good functional use of the hand, and worked full-time at her original occupation.
Collapse
Affiliation(s)
- Hari Venkatramani
- Department of Plastic, Hand, and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - S Raja Sabapathy
- Department of Plastic, Hand, and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, Tamil Nadu, India.
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
6
|
Distal Arterialized Venous Supercharging Improves Perfusion and Survival in an Extended Dorsal Three-Perforasome Perforator Flap Rat Model. Plast Reconstr Surg 2021; 147:957e-966e. [PMID: 34019505 DOI: 10.1097/prs.0000000000007990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps are commonly applied for a variety of skin defects. Many strategies (e.g., hyperbaric oxygen and preconditioning) have been investigated to improve flap survival, but a postoperative 2.03 to 18.2 percent flap necrosis frequency remains a major complication. The authors hypothesized that a distal arterialized venous supercharged (DAVS) flap procedure might improve perfusion and survival in an extended three-perforasome perforator flap rat model and rescue flap ischemia intraoperatively. METHODS One hundred twenty male Sprague-Dawley rats (200 to 300 g) were divided into the thoracodorsal artery (TDA) flap group and the DAVS flap group (n = 60 per group). An approximately 11 × 2.5-cm2 flap based on the TDA perforasome was designed in the TDA flap. A DAVS flap was designed based on the TDA flap and supercharged by anastomosing the rat caudal artery with the deep circumflex iliac vein. At postoperative times 1, 3, 6, and 12 hours and 1, 3, 5, and 7 days, perfusion and angiography were compared. On day 7, flap viability and angiogenesis were assessed using histology and Western blotting. RESULTS The DAVS flap showed a higher survival rate compared with the TDA flap (100 percent versus 81.93 ± 5.38 percent; p < 0.001). All blood flow ratios of deep circumflex iliac artery to TDA perforasome and of choke zone II to choke zone I were higher in the DAVS flap (all p < 0.05). Angiography qualitatively revealed that choke vessels in choke zone II dilated earlier and extensively in the DAVS flap group. CD34+ vessels (68.66 ± 12.53/mm2 versus 36.82 ± 8.99/mm2; p < 0.001) and vascular endothelial growth factor protein level (0.22 ± 0.03 versus 0.11 ± 0.03; p < 0.001) were significantly increased in the DAVS flap group. CONCLUSIONS The DAVS procedure improves three-perforasome perforator flap survival and can be used for rescuing flap ischemia intraoperatively. Further study is needed before possible clinical adoption for reconstructive operations.
Collapse
|
7
|
Wang H, Hong S, Lu S, Wu T, Chai Y, Wen G. Role of Arterial Perfusion in Early Survival of Arterialized Venous Flaps: A Mechanism Study and Clinical Application. Ann Plast Surg 2021; 86:89-95. [PMID: 32568753 DOI: 10.1097/sap.0000000000002419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The arterialized venous flap (AVF) is appropriate as a flap for hand and foot resurfacing meet the aesthetic demands in the same time. However, the inconsistency of survival rate limited its popularization in clinical settings. The purpose of this study was to investigate the role played by the caliber and location of the artery. METHODS Arterialized venous flaps were designed on the abdomen of New Zealand rabbits, and the animals were randomized into 3 groups and 2 groups in experiment 1 and 2, respectively. In experiment 1, the artery flow was restricted with vascular staplers of different calibers. In experiment 2, the artery was anastomosed with the afferent vein in the center or at the margin of the flap. Blood perfusion state, water content, epidermal metabolite levels, and flap survival status were observed in both experiments. Furthermore, outcomes of 12 patients received AVF to resurface soft tissue defects in the digits, hands, and feet between January 2016 and February 2018 were analyzed. RESULTS In experiment 1, compared with the control group, groups with restricted artery showed poor results regarding blood perfusion state, water content, epidermal metabolite levels, and flap survival status. In experiment 2, group with the afferent vein in the center of the flap showed better results mentioned previously. All the flaps survived uneventfully in this study. Two flaps partially failed (20% of the flap area) because of insufficient perfusion. Generally, larger caliber and center-located vein helped the survival of AVF. CONCLUSIONS Experimental findings suggested that increased arterial perfusion and center-located vein are beneficial for the survival of AVF. Clinical series proved the findings previously. The problem of inconsistency of AVF can be partially solved by increasing arterial perfusion and dissecting afferent vein into the center of flap, and still, further studies are needed to shed light on the mechanism behind.
Collapse
Affiliation(s)
- Hongshu Wang
- From the Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | | | | | | | | | | |
Collapse
|
8
|
Besmens IS, Guidi M, Frueh FS, Uyulmaz S, Lindenblatt N, Reissner L, Calcagni M. Finger reconstruction with dorsal metacarpal artery perforator flaps and dorsal finger perforator flaps based on the dorsal branches of the palmar digital arteries - 40 consecutive cases. J Plast Surg Hand Surg 2020; 54:248-254. [PMID: 32493082 DOI: 10.1080/2000656x.2020.1762624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Since the first description many variations of the dorsal metacarpal reverse island flap have been published but there is still uncertainty about which vascular component should be included for an optimal result. Therefore, it was the aim of this study to analyze vascular reliability and ischemic complications of dorsal metacarpal artery perforator (DMAP) flaps and dorsal finger perforator (DFP) flaps in our patient collective. We performed 40 of these flaps from the dorsum of hand and fingers for finger injuries. The choice of donor site was made according to the defect's location. Patients were analyzed with respect to flap necrosis, ischemic complications and achievement of overall reconstruction goals. In addition, we divided our patients in two groups, one group where we raised the flap from the dorsum of the proximal phalanx and a second one where the flaps were raised from the intermetacarpal space to identify complication rates based on the pedicles location. Of the 40 flaps, 36 survived completely. 4 partial necroses were observed in flaps transferred to more distal defects and in one flap that was used in a wrap-around technique for both dorsal and palmar proximal phalanx. These perforator flaps are a reliable method to cover finger defects and the dorsal metacarpal artery is not necessary for their survival, since the blood supply comes from perforating branches of the palmar vascular system. There is a clear trend for a higher complication rate in flaps raised from the dorsum of the fingers compared to the intermetacarpal space.
Collapse
Affiliation(s)
- Inga S Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Marco Guidi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Florian S Frueh
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Semra Uyulmaz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lisa Reissner
- Division of Hand Surgery, University Hospital Balgrist, Zurich, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
9
|
Muntean M, Oradan A, Achimas-Cadariu P. Using noncontact vein visualization to optimize venous flap design. J Plast Reconstr Aesthet Surg 2020; 73:608-620. [DOI: 10.1016/j.bjps.2019.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/22/2019] [Indexed: 10/25/2022]
|
10
|
Liu M, Hu C. Retrograde versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis. Asian J Surg 2020; 43:1062-1068. [PMID: 31959576 DOI: 10.1016/j.asjsur.2019.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/07/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND/OBJECTIVES The advance in the microvascular surgeries has made successful replantation of amputee fingertip or toe. Anterograde palm venous anastomosis is generally preferred in avulsion distal fingertip trauma surgeries but is technically challenging. The retrograde venous anastomosis is proved to be easy and effective in larger defects hand reconstruction surgeries. The purposes of the analysis were to compare functional and therapeutic outcomes of retrograde palm venous anastomosis against anterograde palm venous anastomosis in the avulsion distal fingertip and thumb microvascular surgery. METHODS Digits were replanted by retrograde palm venous anastomosis (n = 130, RPVA cohort) or anterograde palm venous anastomosis (n = 220, APVA cohort). The data regarding the survival of transplanted tissues, analgesia, 2-points discrimination, and total active movement after 2-years of surgeries were collected and analyzed. RESULTS A higher percentage of digits with survived transplanted tissues found in the RPVA cohort than the APVA cohort (p = 0.004). 2-points discrimination found higher in the APVA cohort than the RPVA cohort (5.22 ± 1.56 mm vs. 4.81 ± 1.39 mm, p = 0.014). The pain was fewer in the RPVA cohort than the APVA cohort (p = 0.041). A total active motion was higher in the RPVA cohort than the APVA cohort (p = 0.025). Anterograde palm venous anastomosis (p = 0.021) were associated with the failure of transplanted digits tissues. CONCLUSIONS Retrograde palm venous anastomosis had better functional and therapeutic outcomes than anterograde palm venous anastomosis in avulsion distal fingertip trauma. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Minghui Liu
- Department of Trauma, Tianjin Union Medical Center, Tianjin, 300191, China.
| | - Chunhe Hu
- Department of Hand Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050017, China.
| |
Collapse
|
11
|
Zhang Y, Gazyakan E, Bigdeli AK, Will‐Marks P, Kneser U, Hirche C. Soft tissue free flap for reconstruction of upper extremities: A meta‐analysis on outcome and safety. Microsurgery 2019; 39:463-475. [DOI: 10.1002/micr.30460] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 03/29/2019] [Accepted: 04/05/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Ying Zhang
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn CenterBG Trauma Center, Department of Plastic and Hand Surgery, University of Heidelberg Ludwigshafen Germany
| | - Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn CenterBG Trauma Center, Department of Plastic and Hand Surgery, University of Heidelberg Ludwigshafen Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn CenterBG Trauma Center, Department of Plastic and Hand Surgery, University of Heidelberg Ludwigshafen Germany
| | - Patrick Will‐Marks
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn CenterBG Trauma Center, Department of Plastic and Hand Surgery, University of Heidelberg Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn CenterBG Trauma Center, Department of Plastic and Hand Surgery, University of Heidelberg Ludwigshafen Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn CenterBG Trauma Center, Department of Plastic and Hand Surgery, University of Heidelberg Ludwigshafen Germany
| |
Collapse
|
12
|
Chen J, Chen Q, Li S, Wang Y, Wang W, Tan J. [Repair of soft tissue defect of fingers with modified arterialized venous flap]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:475-478. [PMID: 30983198 DOI: 10.7507/1002-1892.201811114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the effectiveness of modified arterialized venous flaps in repairing soft tissue defect of fingers. Methods Between January 2017 and April 2018, 16 patients with soft defects of fingers were treated. There were 12 males and 4 females, with an average age of 41 years (range, 24-74 years). One case was resulted from resection of cicatricial contracture and 15 cases was caused by mechanical strangulation. The defects located at thumb in 3 cases, index finger in 5 cases, middle finger in 4 cases, ring finger in 2 cases, and little finger in 2 cases; and at the palmar aspect in 4 cases, and dorsal aspect in 12 cases. The size of defect ranged from 3 cm×2 cm to 10 cm×3 cm. All flaps were harvested from the palmar aspect of the ipsilateral forearm. The distal ports of the two veins were ligation. Partial fat was eliminated and the all connecting minute branches between the two veins were ligation under microscope in order to achieve the thorough shunt restriction. Then the flaps were positioned over the recipient site without inversion. The size of flap ranged from 3.5 cm×2.5 cm to 10.5 cm×3.5 cm. All donor sites were directly sutured except that 1 case was recovered with free skin graft. Results All flaps survived entirely except that 1 case happened vein crisis. Three flaps demonstrated mild-to-moderate venous congestion without any treatment and the swelling of flaps gradually subsided after 1 week. Skin grafting at donor site survived and all incisions healed by first intension. Thirteen patients were followed up 8-16 months (mean, 11 months). The textures and appearances of the flaps were satisfactory. At last follow-up, the mean size of the Semmes-Weinstein (SW) monofilament test of the flaps was 4.01 g (range, 2.83-4.56 g); the mean static two-point discrimination of the flaps was 12 mm (range, 6-20 mm). Conclusion Modified arterialized venous flaps with thoroughly restriction of arteriovenous shunting can offer decreased congestion of venous flaps and improve survival rate. Better effectiveness can be achieved by using this flap to repair soft tissue defect of finger.
Collapse
Affiliation(s)
- Jing Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, P.R.China
| | - Qingzhong Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, P.R.China
| | - Shuang Li
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, P.R.China
| | - Yang Wang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, P.R.China
| | - Weifeng Wang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, P.R.China
| | - Jun Tan
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001,
| |
Collapse
|
13
|
Adani R, Mugnai R, Petrella G. Reconstruction of Traumatic Dorsal Loss of the Thumb: Four Different Surgical Approaches. Hand (N Y) 2019; 14:223-229. [PMID: 29039226 PMCID: PMC6436130 DOI: 10.1177/1558944717736396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This article outlines our methods for thumb reconstruction following dorsal skin loss injury located between the metacarpophalangeal joint (MPj) and the entire nail affecting skin, nail, tendon, and bone in different combinations but with intact sensate palmar skin. METHODS Between 1990 and 2015, 24 patients were treated for dorsal thumb defects using 4 different surgical techniques. Five cases of dorsal compound traumatic loss were reconstructed by custom-made dorsal great toe transfer. Four patients with dorsal skin and nail loss located at the distal phalanx level were covered with the homodigital flap with reverse flow vascularization. In 9 patients presenting skin defects between the MPj and the nail, reconstruction was achieved by means of the kite flap. Six cases suffered extensive dorsal skin loss, and reconstruction was performed using different types of radial forearm flaps (cutaneous, tendineocutaneous, osteocutaneous, and fascial). RESULTS Flap survival was obtained in all cases. No vascular complications occurred with free vascularized compound toe transfer. CONCLUSIONS Reconstruction of dorsal thumb defects is imperative and its approach is strictly correlated to type of defect, patient's requests, and flap alternatives. For defects with nail involvement, the free osteo-onychocutaneous flap harvested from the great toe provides the best aesthetic result in selected young and well-motivated patients. An alternative is represented by the dorsoulnar flap, when the defect is located distally, or the fascial pedicle radial forearm flap, for major dorsal thumb defects, in patients refusing microsurgical reconstruction. The kite flap still represents a feasible solution for medium-size defects with an intact nail.
Collapse
Affiliation(s)
- Roberto Adani
- University Hospital of Modena, Italy,Roberto Adani, Department of Hand Surgery and Microsurgery, University Hospital of Modena, Policlinico, Largo del Pozzo 71, Modena 41124, Italy.
| | | | | |
Collapse
|
14
|
Lombardo GAG, Tamburino S, Tarico MS, Perrotta RE. Reverse Flow Shunt Restricted Arterialized Venous Free Flap. J Hand Surg Am 2018; 43:492.e1-492.e5. [PMID: 29728214 DOI: 10.1016/j.jhsa.2018.02.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/12/2017] [Accepted: 02/18/2018] [Indexed: 02/02/2023]
Abstract
Several technical modifications have been described to avoid complications of venous flaps. The authors describe a technical variation of the venous flap to reduce the risk of venous congestion and the likelihood of shunting, thus increasing venous flap reliability.
Collapse
Affiliation(s)
- G A G Lombardo
- Department of Plastic and Reconstructive Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - S Tamburino
- Department of Plastic and Reconstructive Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy.
| | - M S Tarico
- Department of Plastic and Reconstructive Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - R E Perrotta
- Department of Plastic and Reconstructive Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| |
Collapse
|
15
|
Wharton R, Creasy H, Bain C, James M, Fox A. Venous flaps for coverage of traumatic soft tissue defects of the hand: a systematic review. J Hand Surg Eur Vol 2017; 42:817-822. [PMID: 28605949 DOI: 10.1177/1753193417712879] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED A PRISMA-guided systematic review was performed of all published cases that detail the use of venous flaps for soft tissue reconstruction of the hand following trauma. Outcome measures examined included flap survival rates, venous congestion, and return to theatre. Database searches were performed on Medline, Embase, AHMED, CINAHL. A total of 381 articles were identified. Data were extracted from 45 articles that met inclusion criteria. A total of 756 flaps were described and their data analysed. A total of 75% of flaps were arterialized and 25% were pure venous flaps. There was no difference in survival rate for arterialized or pure venous flaps. Unplanned return to theatre occurred in 5.3% due to flap compromise or necrosis. Early venous congestion was present in 60% of cases. Total early failure requiring re-operation occurred in 19 flaps (2.5%) of cases. Venous flaps offer a versatile and well-tolerated reconstructive option. Early venous congestion is common, but can be managed non-operatively. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- R Wharton
- 1 Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Foundation Trust, London, UK.,2 Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - H Creasy
- 2 Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C Bain
- 2 Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M James
- 2 Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Fox
- 2 Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
16
|
Systematic Review and Meta-Analysis of Unconventional Perfusion Flaps in Clinical Practice. Plast Reconstr Surg 2017; 138:459-479. [PMID: 27465169 DOI: 10.1097/prs.0000000000002390] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although unconventional perfusion flaps have been in clinical use since 1975, many surgeons are still deterred from using them, because of some reports of high necrosis rates. METHODS The authors performed a systematic review and meta-analysis of all articles written in English, French, German, Spanish, and Portuguese on the clinical use of unconventional perfusion flaps and indexed to PubMed from 1975 until July 15, 2015. RESULTS A total of 134 studies and 1445 patients were analyzed. The estimated survival rate of unconventional perfusion flaps was 89.5 percent (95 percent CI, 87.3 to 91.3 percent; p < 0.001). Ninety-two percent of unconventional perfusion flaps (95 percent CI, 89.9 to 93.7 percent; p < 0.001) presented complete or nearly complete survival. Most defects mandating unconventional perfusion flap reconstruction were caused by trauma (63.6 percent), especially of the hand and fingers (75.1 percent). The main complication of all types of flaps was a variable degree of necrosis (7.5 percent of all unconventional perfusion flaps presented marginal necrosis; 9.2 percent and 5.5 percent had significant and complete necrosis, respectively). There was a positive correlation between the rate of postoperative infection and the need for a new flap (Pearson coefficient, 0.405; p = 0.001). Flaps used to reconstruct the upper limb showed better survival than those transferred to the head and neck or to the lower limb (p < 0.001). CONCLUSION Unconventional perfusion flaps show high survival rates and should probably be used more liberally, particularly in the realm of upper limb reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
Collapse
|
17
|
Giesen T, Adani R, Carmes S, Dumontier C, Elliot D, Calcagni M. IFSSH scientific committee on skin coverage: 2015 report. HAND SURGERY & REHABILITATION 2016; 35:307-319. [PMID: 27781975 DOI: 10.1016/j.hansur.2016.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 05/15/2016] [Accepted: 07/26/2016] [Indexed: 11/20/2022]
Abstract
Skin coverage in hand reconstruction is a challenging and vast chapter in hand surgery; covering every aspect of it in a report is simply not feasible. Therefore, this report focuses on a few specific topics. The coverage of anatomical regions like the fingertips is common ground for hand surgeons worldwide, but in the last 10 years, various refinements have been published in order to optimize the reconstruction of this organ. Nevertheless, in many emergency departments, the amputation of badly injured fingertips, including the thumb, remains the preferred treatment. The main focus of this report is to counter this tendency by providing alternatives to surgeons. Large defects in the fingers involving more than one segment, defects in the palm and in the dorsum of the hand are currently debated in international meetings. The use of skin substitutes vs. the use of extremely refined microsurgical procedures vs. classic island flaps has generated animated discussions, which are also influenced by cultural and socioeconomic factors around the world. This report offers the views of six surgeons from four different countries, in the hope of animating discussions and suggesting new approaches.
Collapse
Affiliation(s)
- T Giesen
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - R Adani
- Department of Hand Surgery, University Hospital of Modena, Modena, Italy
| | - S Carmes
- Department of Plastic Surgery and Hand Surgery, Nice University Hospital, Nice, France
| | - C Dumontier
- Department of Plastic Surgery and Hand Surgery, Nice University Hospital, Nice, France
| | - D Elliot
- Hand Surgery Department, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, Essex, UK
| | - M Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| |
Collapse
|
18
|
Fakin R, Gazzola R, Calcagni M, Giovanoli P, Giesen T. Replantation by palmar arteriovenous anastomosis in complex finger amputations. ACTA ACUST UNITED AC 2015; 34:240-4. [PMID: 26404796 DOI: 10.1016/j.main.2015.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 07/18/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
Digital replantation is a well-established and increasingly common procedure in specialized hand surgery units worldwide. Replantation after complex trauma is often challenging due to severely injured, small-diameter vessels, especially at the distal level. Digit salvage by arteriovenous anastomosis has been inadequately described in the literature for such cases. The objective of this study was to evaluate the outcomes and complications of arteriovenous digital replantation in complex amputations. We reviewed five cases of digital replantation using a single palmar afferent arteriovenous anastomosis and drainage via a dorsal vein. The postoperative protocol followed our standard replantation protocol. All digits survived with no revision procedures. No major complications were observed. One digit developed partial epidermolysis and one thumb developed marginal skin necrosis, both treated conservatively. The color of the replanted digits was not a reliable monitoring parameter but capillary refill was consistently visible. Microangiography performed four months after surgery demonstrated good digit perfusion. Our results support palmar arteriovenous anastomosis as a reliable alternative in digital replantation if distal arteries are unavailable for anastomosis. The results also suggest that this digit salvage procedure can be carried out at a more proximal level than previously reported.
Collapse
Affiliation(s)
- R Fakin
- Division of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - R Gazzola
- Division of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - M Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - P Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - T Giesen
- Division of Plastic Surgery and Hand Surgery, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| |
Collapse
|
19
|
Zor F, Yalçın B, Tekin L, Eski M, Işık S, Şengezer M. Palmar contracture release with arterialized venous instep flap: An anatomical and clinical study. J Plast Reconstr Aesthet Surg 2015; 68:984-9. [DOI: 10.1016/j.bjps.2015.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 02/21/2015] [Accepted: 03/19/2015] [Indexed: 11/25/2022]
|
20
|
Tang JB, Elliot D, Adani R, Saint-Cyr M, Stang F. Repair and reconstruction of thumb and finger tip injuries: a global view. Clin Plast Surg 2015; 41:325-59. [PMID: 24996458 DOI: 10.1016/j.cps.2014.04.004] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this review, an international group of senior hand surgeons was asked to provide their currently used methods, views, and advice on thumb and fingertip repair. The basic requirements and methods of thumb and fingertip repair are first outlined, followed by descriptions of the methods favored by individual units or surgeons. More recent innovative methods and modifications are described and challenging topics are discussed. This review ends by illustrating and discussing a few exploratory treatments that hold promise of greatly changing future perspectives of this common clinical problem.
Collapse
Affiliation(s)
- Jin Bo Tang
- Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, Nantong University, 20 West Temple Road, Nantong, Jiangsu 226001, China.
| | - David Elliot
- Hand Surgery Department, St Andrew's Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex CM1 7ET, UK
| | - Roberto Adani
- Department of Hand Surgery and Microsurgery, University Hospital of Verona Policlinico GB Rossi, Piazzale LA Scuro 10, Verona 37126, Italy
| | - Michel Saint-Cyr
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Felix Stang
- Plastic Surgery, Hand Surgery, and Burns Unit, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, Luebeck 23538, Germany
| |
Collapse
|
21
|
Elliot D, Giesen T. Treatment of unfavourable results of flexor tendon surgery: Skin deficiencies. Indian J Plast Surg 2014; 46:325-32. [PMID: 24501469 PMCID: PMC3901914 DOI: 10.4103/0970-0358.118611] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We recently reported a small study at the Federation of European Societies for Surgery of the hand, which was entitled ‘What is secondary flexor tendon surgery’? This study concluded that ‘secondary flexor tendon surgery’ was a generic name encompassing a multitude of pathologies. Between 10% and 15% of cases exhibited pathology of the skin and subcutaneous fat and required flap reconstruction of these tissues. Skin replacement may be used prophylactically at primary surgery or become necessary at secondary surgery after release of scar contractures, to achieve cover of vital structures. The long-term problem of skin deficiency relating to flexor tendon function is one of loss of extension from longitudinal scar shortening of the integument, even if the flexor tendons are primarily concerned with bending the digits, not straightening them. This loss of extension can only be tolerated in a hand to a certain degree without significant loss of function. This paper is largely an analysis of the flaps available and suitable for different degrees of skin deficiency and at different places along the course of the flexor system. It attempts to dispel the idea that ‘any flap will do’ provided the flexors are adequately covered.
Collapse
Affiliation(s)
- David Elliot
- Department of Hand Surgery, St. Andrew's Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - Thomas Giesen
- Department of Hand Surgery, St. Andrew's Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| |
Collapse
|