Chain-linked directional vascular plexuses of the integument and link-pattern vascularized flaps in distal extremities

A randomized trial of use of a modified reverse sural neurofasciocutaneous flap to extend the reconstruction range

Background

When a reverse sural neurofasciocutaneous flap is used to reconstruct a forefoot defect, usually, the transverse length of the flap is increased or the pivot point is lowered to ensure the reconstruction range. Therefore, proximal partial necrosis leading to surgery failure is sometimes caused by insufficient arterial supply if the flap is too long or the pivot point is too low and has no a reliable perforator in the pedicle. Herein, we describe a new method for extending the reconstruction range of the reverse sural neurofasciocutaneous flap that can provide a higher survival rate.

Methods

Between July 2010 and July 2014, 24 patients with forefoot defect were randomly assigned into two groups. In the research group, 12 modified reverse sural neurofasciocutaneous flaps with extended reconstruction range were used to reconstruct forefoot defect. We dissected the septum along the last perforator to locate the main trunk of the peroneal artery, disconnected the proximal end of the peroneal artery at the root of the perforator, and separated the peroneal artery more distally to obtain a lower rotation point to extend the reconstruction range. The last perforator and a section of the peroneal artery were contained in the pedicle. In the control group, 12 traditional reverse sural neurofasciocutaneous flap procedures were performed.

Results

In the research group, 11 flaps survived with good quality and esthetic contours. Partial distal necrosis occurred in 1 flap. In the control group, 7 flaps survived. Partial necrosis occurred in the other 5 flaps. Compared with control group, the survival rate in the research group was significantly higher while the healing time was significantly shorter. All patients were satisfied with the therapeutic outcome in the research group.

Conclusions

Our modified method proved efficacious in extending the reconstruction range of the reverse sural neurofasciocutaneous flap. Meanwhile, partial necrosis was avoided because the length of the flap was shortened, and a reliable perforator was preserved in the artery pedicle.

Trial Registration

Chictr.org Identifier: ChiCTR2100046323.

Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region

BACKGROUNDS

Distally based perforator propeller flap from the lower leg region is a versatile local reconstructive technique for the foot and ankle defects. However, flap venous congestion remains a tough nut to crack. We hypothesize that raising an adipofascial flap with turnover mode of transposition can improve venous drainage and enhance flap safety.

METHODS

Based on the 2 rows of septocutaneous perforators in the posterior distal third of the lower leg, distally based adipofascial flap was raised from medial sural region nourished by 1 perforator bundle from the posterior tibial artery or from the lateral sural region from the peroneal artery. The superficial dissection was performed in subdermal plane and deep in to the subfascial space. The flap was nourished by perforator-plus-adipofascial pedicle and turned over 180 degrees upside down to reach the distal wounds. One week later, a split-skin graft was used to cover the exposed fascial flap. Postoperatively, flap survival, complications, and patient functional recovery were evaluated.

RESULTS

Distally based sural turnover adipofascial flaps were used in 12 cases with complicated wounds of the distal third lower leg, foot, and ankle region. All wounds were caused by trauma and experienced fracture implants fixation and 5 with osteomyelitis. The comorbidities include diabetes in 9 cases and smoking in 7. There were 8 medial ural flaps and 4 lateral sural flaps. The adipofiscial flaps measured from 6.0 cm × 5.0 cm to 17.0 cm × 6.0 cm (mean, 61.3 cm). Postoperatively, all flaps survived uneventfully without any complication such as flap ischemia and/or necrosis. Two minor donor site complications were encountered, one was postoperative hematoma, and another was hyperproliferative scar. After a mean of 14.6 months of follow-up, the adipofascial flap plus skin graft showed a durable esthetic coverage, with normal shoe wearing and walking.

CONCLUSIONS

Distally based sural adipofascial turnover flap is a simple and reliable wound coverage technique. It avoids venous congestion as usually seen in distally based fasciocutaneous flaps.

Anatomical Basis and Clinical Application of the First Metatarsal Proximal Perforator-Based Neurocutaneous Vascular Flap

Forefoot defects caused by accidents are very common, but their reconstruction remains a substantial challenge for plastic surgeons. The purpose of this study is to determine the anatomical structure of the first metatarsal proximal perforator-based flap and to propose its clinical application. The study was divided into two parts: an anatomical study and a clinical application. Thirty preserved lower limbs injected with red latex were chosen for observation, and the following were recorded: the course and distribution of the medialis dorsalis pedis cutaneous nerve; the origin, course, branching and distribution of the first metatarsal proximal perforator; and the communication of the perforator and the dorsal medial vessels. Clinically, six cases of forefoot skin defects were reconstructed with the first metatarsal proximal perforator-based neurocutaneous vascular flap. The medialis dorsalis pedis cutaneous nerve mainly arose from the medial branch of the superficial peroneal nerve and proceeded forward for a distance of 2.5 ± 0.4 cm under the surface of the inferior extensor retinaculum; then, the nerve divided into the medial dorsal branch and the first and second dorsal metatarsal branches. The first metatarsal proximal perforator-based neurocutaneous vessels were multisegmented and multisourced, and the first branch was closely related to the operative procedure. In terms of the clinical application, all flaps of the six cases survived completely with good appearance, texture and elasticity. The first metatarsal proximal perforators present as constant. The first metatarsal proximal perforator-based neurocutaneous vascular flap may become a useful supplemental material for the reconstruction of forefoot defects. Clin. Anat., 33:653-660, 2020. © 2019 Wiley Periodicals, Inc.

Saphenous Artery Perforator Flaps in Minipigs: Anatomical Study and a New Experimental Model

This study describes the anatomy of the saphenous artery (SA) perforators in minipigs and the development of a new animal model. First, the anatomic characteristics of the SA and perforators in minipigs were examined after latex-lead oxide perfusion. Subsequently, the right hind limbs of 10 minipigs were used to generate capillary perforator flaps (group A; utilizing the SA and 5.5 cm of deep fascia above the knee), while all perforators of the left hind limbs were reserved (group B). Four additional minipigs were used to evaluate SA perforator flaps with capillary perforators plus sarcolemma and a small amount of muscle (group C). Preoperative and postoperative CTA of both hind limbs confirmed that all perforators were ligated in groups A and C. The average length of the SA was 14.86 ± 0.76 mm. The diameters of the SA at initiation, the medial tibial condyle, and the medial malleolus were 1.73 ± 0.15 mm, 1.50 ± 0.12 mm, and 1.30 ± 0.13 mm, respectively. There were 7.09 ± 1.16 perforators per hind limb, with an average diameter of 0.40 ± 0.13 mm (range, 0.10-0.78 mm), and the majority (96.2%) had a diameter >0.2 mm. The survival rates of the flaps in groups A, B, and C were 32 ± 39%, 100%, and 60.2 ± 17%, respectively. The position of the SA in minipigs is constant, its diameter is relatively large, and it has many perforators, allowing it to be used as a reliable model of perforator flaps, including capillary perforator flaps.

Fasciocutaneous flap with perforating branches of peroneal artery repairing soft tissue loss in anterior and middle parts of children's feet: A STROBE-compliant article

Repairing soft tissue loss in feet's anterior and middle parts has become a problem, especially for children. We observed the feasibility and clinical effects of superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery for repairing children's feet.Between January 2015 and December 2016, soft tissue loss in anterior and middle regions of feet were repaired using superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery in 8 children with a median age of 6.5 [4-9, interquartile range (IQR) = 3] years. The skin of lower leg was intact, and the soft tissue loss area was located in the anterior and middle regions of feet with a size of 5 cm × 4 cm to 11 cm × 7 cm combined with the exposure of tendons and joints in all the 8 children. On the basis of the conditions above, there were no indications of free skin grafting. Foot wounds were repaired all with the superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery (6 cm × 5 cm to 12 cm × 8 cm), and then the donor area was sutured to narrow the donor area followed by intermediate split thickness skin graft. The perforating branch trunk of peroneal artery was used as a rotation point (4 cm above the lateral malleolus) in 5 children and descending branch of perforating branch of peroneal artery as a rotation point (2 cm under the lateral malleolus) in 3 children.All flaps survived with primary healing in the 8 children. Postoperative median 7.5-month (3-12, IQR = 4.5) follow-up indicated that flap color and texture were fine, the appearances of donor and recipient areas were satisfactory, wearing shoes was not affected, and walking function and foot blood circulation were normal.For intractable soft tissue loss in the anterior and middle regions of children's feet, superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery can improve recipient area appearance and walking function because it has the characteristics of reliable blood supply and convenient rotation. It is worth using this method widely in clinics.

Anatomic basis and clinical application of the distally based medialis pedis flaps

BACKGROUND

Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability.

METHODS

Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap.

RESULTS

The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft.

CONCLUSION

The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.

The vascularized sural nerve graft based on a peroneal artery perforator for reconstruction of the inferior alveolar nerve defect

The sural nerve has been described for nerve reconstruction of the maxillofacial region since it provides many advantages. We report a case of a vascularized sural nerve graft based on a peroneal artery perforator for immediate reconstruction after the removal of intraosseous neuroma originating in the inferior alveolar nerve. The patient had a neuroma caused by iatrogenic injury to the inferior alveolar nerve. A 4-cm long neuroma existed in the inferior alveolar nerve and was resected. A peroneal perforator was chosen as the pedicle of the vascularized sural nerve graft for the nerve gap. The graft including the skin paddle for monitoring the perfusion supplied by this perforator was transferred to the lesion. The nerve gap between the two stumps of the inferior alveolar nerve was repaired using the 6-cm long vascularized sural nerve. The perforator of the peroneal artery was anastomosed to the branch of the facial artery in a perforator-to-perforator fashion. There was no need to sacrifice any main arteries. The skin paddle with 1 cm × 3 cm in size was inset into the incised medial neck. Perceptual function tests with a Semmes-Weinstein pressure esthesiometer and two-point discrimination in the lower lip and chin at 10 months after surgery showed recovery almost to the level of the normal side. This free vascularized sural nerve graft based on a peroneal artery perforator may be a good alternative for reconstruction of inferior alveolar nerve defects.

Ulnar artery distal cutaneous descending branch as free flap in hand reconstruction

These authors aimed to evaluate the method and therapeutic effects of surgical hand-wound repair using free vascularised flaps based on the descending ramus of the above-wrist cutaneous branch of the ulnar artery. We retrospectively reviewed records of 75 patients with 79 finger defects who had received hand surgery between January 2001 and December 2007. Soft-tissue defects of the hand were repaired using free flaps with the descending ramus of the above-wrist cutaneous branch of the ulnar artery as the vascular pedicle. Intra-operative and postoperative variations in vascular anatomy were observed and surgical outcomes were compared. All flaps were vascularised and survived, including one in which the distal end showed partial necrosis that healed after skin grafting. Three anatomical variations of the ulnar artery branch were observed intra-operatively, requiring appropriate adaptation of the surgical method. All patients were followed postoperatively for 6-24 months. The texture and appearance of all the flaps were satisfactory (two-point discrimination: 6-11mm) with satisfactory recovery of finger function. The outcomes of surgical hand-wound repair using free vascularised flaps based on the descending branch of the ulnar artery were successful. The operative method was simple, and the method appears to be worthy of clinical application.

Unstable acute and chronic Charcot’s deformity: staged skeletal and soft-tissue reconstruction

Acute and chronic Charcot's foot deformity is a progressive, disabling and disfiguring condition that is prone to ulceration and infection. If conservative treatment is ineffective, bone and soft-tissue reconstruction is a viable option.

Modified distally based sural neuro-veno-fasciocutaneous flap: Anatomical study and clinical applications

The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.

Distally based radial forearm flap with preservation of the radial artery: anatomic, experimental, and clinical studies

In this article we report on the anatomical, experimental, and clinical investigations of the distally adipofascial pedicled radial forearm flap based on the small perforators around the radial styloid process. There are about 10 small perforators (0.3-0.5 mm in diameter) from the distal radial artery around the radial styloid process. The longitudinal chain-linked vascular plexuses (suprafascial, paraneural, and perivenous) formed by the forearm ascending and descending branches of septofasciocutaneous perforators meet and cross over with the transverse carpal vascular plexuses around the radial styloid region. Based on these directional-oriented plexuses, distally based adipofascial pedicled radial forearm fasciocutaneous and adipofascial flaps were designed and successfully applied in 34 clinical cases. The pivot point was located at 1-2 cm above the radial styloid. The skin island plus adipofascial pedicle measured between 9-18 cm in length, with the adipofascial pedicle 3-4 cm in width. The length-to-width ratio is 3-5:1. The venous drainage of this distally based flap was investigated anatomically and experimentally. The cephalic vein has no positive role for venous drainage in distally based flaps. The difference between distally based flaps and reverse-flow flaps, clinical selection of fasciocutaneous and adipofascial flaps, advantages and disadvantages, and technical tips for operative success are discussed.

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.

The Doppler probe for planning septofasciocutaneous advancement flaps on the plantar aspect of the foot: anatomical study and clinical applications

A 5-MHz Doppler probe was utilized to identify the perforating septofasciocutaneous vessels on the plantar aspect of the right and left feet of 10 healthy subjects. Each audible perforator was marked, and each foot was photographed, scanned into a personal computer, and standardized to 8 inches high by 4 inches wide. All 20 feet were then stacked together to create a composite average of all markings. Loupe aided (2.5 x magnification) dissection of a latex cast of the perforating septofasciocutaneous vessels from a fresh frozen cadaveric foot revealed similar location and distribution as the composite average described above. The Doppler probe is capable of accurately identifying the septofasciocutaneous perforating vessels, thereby, creating a vascular map of the plantar aspect of the foot useful for precise planning of advancement flap coverage for full thickness defects. Two representative case examples are presented.