Accepted Manuscript Clinical Applications of Free Arterialized Venous Flaps Murat Kayalar , Ass. Prof Levent Kucuk , MD Tahir Sadik Sugun , MD Yusuf Gurbuz , MD Ahmet Savran , MD İbrahim Kaplan , Ass. Prof PII:
S1748-6815(14)00303-9
DOI:
10.1016/j.bjps.2014.05.061
Reference:
PRAS 4245
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 8 May 2013 Revised Date:
14 April 2014
Accepted Date: 29 May 2014
Please cite this article as: Kayalar M, Kucuk L, Sugun TS, Gurbuz Y, Savran A, Kaplan İ, Clinical Applications of Free Arterialized Venous Flaps, British Journal of Plastic Surgery (2014), doi: 10.1016/ j.bjps.2014.05.061. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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CLINICAL APPLICATIONS OF FREE ARTERIALIZED VENOUS FLAPS
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Murat KAYALAR, Ass. Prof 1
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Levent KUCUK, MD 2
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Tahir Sadik SUGUN, MD 1
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Yusuf GURBUZ, MD 1
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Ahmet SAVRAN, MD 3
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İbrahim KAPLAN, Ass. Prof 1
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EMOT Hospital, İzmir, Turkey
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Ege University Medical Faculty, Department of Hand Surgery, İzmir, Turkey
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Tepecik Training Hospital, İzmir, Turkey
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Corresponding Author: Levent Kucuk
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Ege University Medical Faculty, Department of Hand Surgery, İzmir, 35100, Turkey
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Telephone: 00905055250277- 00902323902783
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E-mail: [email protected]
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Clinical Applications of Free Arterialized Venous Flaps
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Abstract Venous flaps are flaps by which tissue perfusion is accessed through the venous
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network. Despite originally being questioned due to potential perfusion problems; as the
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dynamics of tissue perfusion have been more fully comprehended, venous flaps appear to
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have a far wider range of application than first thought. In our study we analyzed the clinical
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results of the applications of free arterialized venous flaps along with the factors that can
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affect flap survival.
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41 flaps were assessed retrospectively. Type of the trauma, traumatized area, the time
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duration between trauma and application of the flap, donor area, type and count of the
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anostomosis, encountered complications, and flap survival rates were analyzed. Regression
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and classification trees were used to study the relationship between flap surface area,
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anastomosis count and flap survival.
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Circulatory abnormalities such as early congestion and edema were seen in 53,6 % of
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the applied flaps. A total of 4 flaps (9,7 %) developed necrosis which presented as full-
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thickness in 3 flaps and partial thickness in 1 flap. It can be said that there was a weak but
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positive correlation between the size of the flap area and the number of anastamosis.
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Although the results of arterialized venous flaps are inconsistent in the literature, those
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flaps can be preferred as an alternative treatment option in single finger defects where tissue
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compatibility and cosmetic results are quite impressive. In the meantime syndactylized
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venous flaps are the preferred method regarding multiple finger soft tissue defects.
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Keywords: hand trauma; hand surgery; microsurgery; free flap
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Clinical Applications of Free Arterialized Venous Flaps
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Introduction Venous flaps are defined as flaps of which blood flow is supplied by afferent and
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efferent veins. Circulation within the flap is maintained by the venous network.[1] It has found
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many application fields since it was first experimentally described in 1981.[2] Due to perfusion
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problems, in the beginning it was used primarily for small defects. But, as the dynamics of
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tissue perfusion have become more clearly understood, so the range of their applications has
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widened.[3-8] Venous flaps can be raised from any area in the superficial venous system. Volar
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forearm, medial surface of arm, dorsum of the hand, medial thigh, medial cruris, dorsal side
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of the foot, thenar and hypothenar areas can all be considered as possible donor sites.[9-13]
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Venous flaps are thin in appearance. There are numerous superficial veins which are
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easy to locate. Dissection involves only superficial tissues so the flap can be dissected
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quickly. Afferent and efferent veins can be harvested in various lengths. Since the flap does
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not contain deep arterial structures donor site morbidity is low. Despite all these advantages
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venous flaps still cannot be used safely. The primary reasons for this are: not completely
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understanding the flap circulation physiology, venous congestion, ischemia and frequent loss
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of flaps.[13,14]
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In our study survival rates of our venous flaps and post-operative microsurgical
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problems were analyzed retrospectively. Relationships between surface dimensions of the
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flap, number of anastamosis and necrosis rate were studied statistically.
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Patients and Methods
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Forty-one arterialized venous flaps in 40 patients performed between the years 1992
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and 2011 were included in our study. Operations were performed by attending hand surgeons
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with at least 5 years of experience.
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Venous flaps were used in following indications;
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a- In fingertip tissue lost where the defect exceeds dimensions of conventional homodigital or
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heterodigital flaps.
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ACCEPTED MANUSCRIPT b- In amputations involving segmental soft tissue defects, as flow through flaps in
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revascularization / replantation
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c- Soft tissue defects on adjacent fingers directly related to multiple finger injuries
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d- For stump closure after unsuccessful revascularization or replantation in multiple finger
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injuries. (as a temporary syndactylized flap involving multiple fingers) (Figure 1)
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e- As salvage operations after unsuccessful local / free flap application attempts.
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f- Circumferential or large longitudinal (volar/dorsal) tissue loss in single finger injury
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Hospital records, nurse clinical observation records, and photographs were analyzed
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retrospectively. Venous flap type, defect and donor site localization, flap sizes, early follow-
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up problems, complications, secondary surgeries, partial and full flap losses were also noted.
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Thirty-four patients were female. Median age was 24,2 (min 2- max 55). One patient
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had soft tissue defect on her first toe. The other patients had hand injuries. Seventeen patients
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had left hand injuries and the other 22 had right hand injuries. Thirty (75%) patients had
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multiple finger injuries. Fourteen patients had tissue defects on palmar side of fingers, nine
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had on dorsal side of fingers and six had both dorsal + palmar side tissue defects. Seven of the
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remaining 11 patients had finger amputations which the flaps used for stump closure, and 4
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patients had defects in the palm of the hand. (Table 1)
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Twenty one (52,5%) patients had crush injuries. Rolling belt, ring injury and burns
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were the other causes of injury. Venous flaps were performed primarily in 29 patients (72,5%)
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and as secondary interventions in 11 patients (27,5%) between days 3 and 25.
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Average flap size was 13,7 cm² ( min 3 cm²- max 30 cm² ). Flap surface area was over
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10 cm² in 22 patients (55%). Forty one flaps were analyzed in our study as one patient had
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two flaps applied. (Table 2) Forearm volar side was the donor area in 38 of 41 flaps. In one
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patient a venous flap designed over saphenous vein which was used for a soft tissue defect
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developed following a traumatic amputation over first toe. Other donor areas were dorsum of
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the hand (n=1) and dorsum of the foot (n=1). One patient was treated simultaneously with
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both posterior interosseous artery flap and venous flap following a gunshot wound.
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30 mmHg over the diastolic blood pressure. Debridement of injured area and identifying the
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recipient artery and veins were the first steps of the procedure. Required lengths of afferent
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and efferent veins were determined in this step in order to make good caliber anastamosis.
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Donor areas were chosen from the sites where superficial venous networks contained
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adequate density of connections. Flaps were designed to involve veins with “H”, “Y” or “ʎ”
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pattern for rectangular shape defects.[6] Forearm fascia has always been added to flaps. Veins
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located at opposite corner of the skin island were selected to prevent short circuit effect. High
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pressure inflow blood has been tried to divert towards flap periphery by using these vein
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patterns. The central vein usually has not been used as a draining vein especially in larger
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flaps. The nearby neighboring veins usually added to subcutaneous tissue during flap
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elevation in order to increase intensity of vascular network of the flap.
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When flap was turned according to its orthodromic flow especially in longitudinal
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finger dorsum defect, efferent vein length must be long enough to reach commissural dorsal
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venous system for a good quality vessel anastomosis. (Figure 2) Retrograde flow or shunt
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restriction haven’t been used.[14-17] Efferent vein and digital artery anastomosis was usually
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performed at least proximal phalanx level in order to obtain maximum arterial flow. The
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recipient vessel’s lumen was assessed before anastomosis under microscope to have a highly
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patent anastomosis. Recommendation about the use of short afferent vein has not been strictly
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taken into consideration.[6,18,19] The valve which was next to presumed anastomosis site was
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usually passed by excising it.
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It is possible to perform arterial anastomosis either proximally or distally in palmar
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longitudinal defects of the fingers. Proximal arterial anastomosis preferred in our series to
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reach high caliber arteries. (Figure 3) Efferent vein is directed towards finger dorsum
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especially to proximal interphalangeal joint where a diffuse venous network can be found for
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anastomosis.
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Lengths of the afferent and efferent veins were taken at lengths that would help to
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perform anastomosis out of injury zone. (Figure 4) After dissection, the flap was flipped over
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in the direction of venous flow, and afferent - efferent vein anastomoses was performed. An
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attempt was made to connect the small afferent vein to the largest artery possible.
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flap such as color changes, pinpricks etc., especially in the early afferent phase of reperfusion,
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immediately after finishing the anastomosis. When the sign of insufficient circulation was
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noticed, one or more extra anastomoses were tried to be added considering the type of
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deficiency especially in larger flaps. If it was an early cyanosis, one more efferent
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anastomosis was added, or if it was a pallor flap an extra afferent anastomosis was performed.
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One afferent and two efferent anastomoses were usually sufficient for small flaps.
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To avoid the risk of developing postoperative peripheral necrosis, skin islands should
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be slightly larger than the defect area. Fingers can be syndactylized for multiple finger
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defects. Accompanying extensor tendon defects can be treated either with tendocutaneous
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venous flaps, or with tendon grafts covered with venous flaps. Tendocutaneous venous flaps
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were applied to two patients in our series. These patients had tangential skin and tendon
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defects typically in the dorsum of the fingers. Flexor carpi radialis and palmaris longus (PL)
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tendons were included to the flap for tendon repairs. (Figure 5)
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According to Chen’s venous flap classification; 5 type IV (A-V-A) flow through, and
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36 type III (A-V-V) arterialized venous flaps were used.[20] Along the valve pattern flow
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through flaps were used for replantation/ revascularization in 3 patients and for soft tissue
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defects in 2 patients. Post-operative flap follow up was carried out by nurses, as clinical
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observations. Anticoagulant therapy was administered and bed rest was recommended.
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Patients were discharged on the 5th postoperative day. They were strongly advised against
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smoking, or consuming caffeinated drinks.
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Results were analyzed with IBM SPSS 20.0. Regression and classification trees were
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used to study the relationship between flap surface area, number of anastomosis and necrosis.
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This classification algorithm was used to summarize how explanatory variables took place in
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the dependent variable. Since we were dealing with a limited number of cases, only
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nonparametric tests were used.
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Results
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When flap losses were analyzed; 1 patient had superficial, and 3 patients presented
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with full-thickness (9,7%) flap necrosis. Surface areas of the unsuccessful flaps were 9, 6, 4, 8
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cm². Average flap surface area within the entire group was 13,2 cm². Three of the flaps which 6
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developed necrosis were applied with 1 afferent artery and 2 efferent vein anastomosis. The
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other flap with necrosis was a flow through flap with 1 afferent and 1 efferent artery
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anastomosis which had been used for finger revascularization. In their etiologies, two of the patients with full-thickness flap necrosis had suffered
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from rolling belt injuries and 1 patient had a press injury. The etiology of the flap with
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superficial necrosis was rolling belt injury. Ages of the patients with necrosis were 55, 18, 4
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and 3. Flaps that were unsuccessful were the flaps applied in the acute phase.
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Defect of the flap with superficial necrosis was covered with full-thickness skin
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grafting on the 10th day. Two of the patients that developed full-thickness necrosis were
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treated with stump closure, including bone shortening, whereas one patient underwent
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reconstruction through retrograde flow island flap application on the same finger.
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Three patients were re-operated in the early stage due to circulatory failure. There was
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a kinking of the afferent artery with a thrombus at the 5th postoperative hour in the first
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patient. In the second patient, efferent vein anastomosis was added at 9th hour post-
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operatively; and in the third patient, thrombosis was detected in the efferent vein at the 18th
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hour post operatively which was treated with re-anastomosis. All of these three flaps survived.
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Survival rate after re-exploration was 100%.
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The relationships between flap surface area, number of anastomosis and necrosis were
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analyzed statistically. According to this analysis, no necrosis was seen in flaps with surface
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area larger than 9,5 cm². It can be said that there is a weak but positive correlation between
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number of anostomosis and flap surface area (Sperman’s Rho = 0,33). However, due to
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having limited number of cases it was not possible to observe a correlation between number
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of anostomosis and necrosis.
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When nurses’ clinical observation notes were assessed, 19 (46,3%) of patients suffered
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no circulatory problems during the early postoperative period; whilst, with regard to the
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remaining flaps, (53,6%) early venous congestion and edema was observed, but with only 3
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requiring re-operation, as mentioned above.
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Discussion
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Indications of venous flaps in hand reconstruction has been evolving steadily through
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the years.[5,6,12,21,22] They can be used
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arterialized venous flaps in soft tissue reconstruction.[23-30] Yan et al reported very good results
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of pulp reconstruction with sensate arterialized venous flaps.[5] Alternatively supra-
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microsurgery gives some options for covering small hand defects with perforator based flaps,
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but these are more complex and technically demanding procedures than venous flaps.[21,22,31]
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Iwasawa et al also concluded that hypothenar and thenar flaps might be good alternatives for
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pulp reconstruction.[12] Dorsum of the hand is also a good donor area for pedicled venous
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flaps in order to cover finger defects. Recently neuro-veno-cutaneous flaps based on great
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saphenous vein has also offered promising results with larger flap dimensions.[32-34]
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Venous flaps have thinner tissue and they can be used as composite flaps especially in
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finger dorsal tissue defects.[6] If there is extensor tendon or bone loss, it can be reconstructed
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primarily or secondarily based on the contamination level of the wound. We achieved
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tendocutaneous compound flap coverage in two of our cases with extensor tendon defect.
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Venous flaps can also be applied after unsuccessful finger replantations or local flap
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surgery. Thus bone length can be maximized in stump closure and morbidity can be reduced
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as the flap can be harvested away from the affected area.[5,6,8,29] Venous flaps therefore have
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the advantage of not causing donor area morbidity in the hand.
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Arterializing the venous network causes a high-pressure flow in the central vein in the
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flap. Congestion and cyanotic appearance usually develop during the early postoperative
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period. This is generally the main source of concern with regard to venous flaps. In our study,
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half of the patients presented with these problems but most of them healed without requiring
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an additional treatment.
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Regulation of high flow cannot be maintained easily since vein walls have limited
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contractile characteristics; thus eodema and congestion in the flap can develop.[13,35,36] To
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increase the flap survival rate, decreasing the high arterial flow could be attempted. High
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arterial flow in the venous system can cause an arteriovenous short circuit effect which
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decreases tissue perfusion.[28,29] Therefore the retrograde arterializations which causes blood
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to be resisted in the vein wall valve system and consequently, pushed into the flap periphery.
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Through this method, a flap perfusion increase can be obtained, thus avoiding the short circuit
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effect.[16,17] This situation occurs especially in short and narrow flaps.[27] 8
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as to reduce high inflow blood pressure eg. involvement of rich venous plexus, and draining
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via maximum efferent veins, establishing dual venous anastomosis.[2,3,5,19,23,34,35,37] Shunt
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restriction and retrograde flow flaps with their encouraging results are used as well.[14-17,28]
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Whilst ossilating veins maintain both the low pressure and low oxygen tension blood flow,
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the main goal is to change unphysiological flow characteristics in to physiological one, during
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early postoperative period until neovascularization develops.[1,4,37,38] Prearterialisation,
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chemical and surgical delay and expansion procedures are also shortens this unstable “to fro”
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or plasmatic imbibition period. Both prearterialisation and tissue expansion have positive
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effect on flap survival by increasing vascular channels.[39-47] Although we don’t know the
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exact haemodynamic mechanism, those inherently unstable flaps may become as more
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reliable as conventional flaps with these efforts. It is generally accepted that larger flaps need
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more vein containment and the more flow diverting policies towards flap periphery.[7,18,33,36]
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In this study, we analyzed the results of arterialized venous flap survival rates in
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different indications. We only found that our total failures (9.7%) have seen in smaller flaps
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less than 9.5 cm2. Woo et al. have also obtained similar results (4.2%) in small flaps less than
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10 cm2.[6] We observed slight positive correlation between number of anastomosis and flap
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surface. This high survival rate can be depend on some factors such as; a- Rich venous plexus
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especially H, Y and ʎ pattern, b- Adding forearm fascia to the flap, c- Adding per venous cuff
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to the afferent and efferent veins, d- Small caliber afferent vein, e- Good quality and largest
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possible donor artery selection, f- Not to choose central vein as a draining vein, g- The more
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larger flap the more efferent anastomosis h- Involvement of all possible veins nearby in order
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to increase available vessels for anastomosis when necessary, ı-Per operative observation of
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afferent phase of perfusion i-Healthy anastomosis outside of injury zone by taking afferent
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and efferent veins long enough.
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Although flap monitorization is quite difficult in venous flaps, anastomoses were re-
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explored in %7 of our patients. The primary reason given by the physician to review the
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anostomosis was, “a progressive and rapid disruption in the positive signs of flap circulation”.
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It does not seem possible to determine a set criterion for exploration in this situation. It seems
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to depend extensively on the surgeon’s clinical experience.
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The primary limitation in our study is the limited number of flaps, and not having
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compared the other types of venous flap methods with the arterialized antegrade venous flap 9
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method. Venous flaps definitely require more detailed studies to fully assess their applicable
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uses in terms of reliability. As flap hemodynamics are becoming more fully comprehended, venous flaps are
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finding a place for themselves in free style flap application. Regardless of the fact there are no
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homogenous results, they can certainly be used in multiple finger defects as syndactylized
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flap, or in single finger defects, due to their ability to quickly adapt to the surrounding tissue.
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Conflict of Interest or Funding: None
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Ethical approval: Not required
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28- Kamei K, Ide Y. The pedicled arterialized venous flap. J Reconstr Microsurg 1993;9:287-
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30- Inada Y, Fukui A, Tamai S, Mizumoto S. The arterialised venous flap: Experimental
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studies and a clinical case. Br J Plast Surg 1993;46:61-7.
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31- Ho Am, Chang J, Radial artery perforator flap J Hand Surg 2010;35A;308-11.
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32- Chang S, Gu Y, Li F.Comparison of different management of large superficial veins in
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study using a rabbit model. Microsurgery 2003;23:555-60.
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33- Nayak BB, Thatte RL, Thatte MR, Baliarsing AS, Jagannathan M, Pandit SP.
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A microneurovascular study of the great saphenous vein in man and the possible implications
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for survival of venous flaps. Br J Plast Surg 2000;53:230-33.
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34- Rozen WM, Tıng JW, Gilmour RF, Leong J. The arterialized saphenous venous flow
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through flap with dual venous drainage. Microsurgery 2012;32:281-8.
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35- Chow SP, Chen DZ, Gu YD. A comparison of arterial and venous flaps. J Hand Surg Br
346
1992;17:59-64.
347
36-
348
Effect of venous superdrainage on a four-territory skin flap survival in rats.Plast Reconstr
349
Surg 2007;119:2046-51.
350
37- Krishnan KG. The venous flaps: an experimental study of the microvascular architecture,
351
the area of perfusion and their correlation. Br J Plast Surg 2002;55:340-50.
352
38- Tang YB, Simchon S, Chen HC. Microcirculation of a venous flap: an experimental study
353
with microspheres in rabbits. Scand J Plast Reconstr Surg Hand Surg 2000;34:207-12.
354
39- Rhyu H. The role of chemical delay in the survival of the arterialized venous flap. J
355
Korean Soc Plast Reconstr Surg 1996;23:942.
AC C
EP
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Chang
H,
Minn
KW,
Imanishi
12
N,
Minabe
T,
Nakajima
H.
ACCEPTED MANUSCRIPT 40- Alexander G. Multistage type 3 venous flap or ‘pre-arterialisation of an arterialised
357
venous flap’. Br J Plast Surg 2001;54:734.
358
41- Fukui A, Inada Y, Murata K, Ueda Y, Tamai S. A method for prevention of arterialized
359
venous flap necrosis. J Reconstr Microsurg 1998;14:67-74.
360
42- Wungcharoen B, Pradidarcheep W, Santidhananon Y, Chongchet V. Pre-arterialisation of
361
the arterialised venous flap: an experimental study in the rat. Br J Plast Surg 2001;54:621-30.
362
43- Shin HJ, Woo SH, Jeong JH, Seul JH. Survival pattern of previously expanded
363
arterialized venous flaps. J Korean Soc Plast Reconstr Surg 1997;24:459-67.
364
44- Mutaf M, Tasaki Y, Fujii T. Expansion of venous flaps: An experimental study in rats. Br
365
J Plast Surg 1998;51:393-401.
366
45-
367
an arterialised venous flap: clinical cases. Br J Plast Surg 2001;54:112-6.
368
46- Karacalar A, İdil O, Demir A, Güneren E, Şimşek T, Özcan M. Delay in neurovenous
369
flaps. Ann Plast Surg 2004;53:481-7.
370
47- Başer NT, Silistreli OK, Sişman N, Oztan Y. Effects of surgical or chemical delaying
371
procedures on the survival of proximal predicled venous island flaps: an experimental study in
372
rats. Scand J Plast Reconstr Surg Hand Surg 2005;39:197-203.
Santidhananon
376 377 378 379 380 381 382 383
EP
375
AC C
374
TE D
373
Y,
SC
B,
Chongchet
M AN U
Wungcharoen
RI PT
356
384 385 386 387 388 13
V.
Pre-arterialisation of
ACCEPTED MANUSCRIPT
Number of Patients
Finger palmar side
14
Finger dorsal side
9
Finger palmar + dorsal side
6
Finger stump closure
7
Hand palm
4
Table 1: Location of flap application areas and number of patients are seen.
391 392
397 398 399
EP
396
AC C
395
TE D
393 394
RI PT
Location of the Defect
SC
390
Table 1
M AN U
389
400 401 402 14
ACCEPTED MANUSCRIPT Table 2 Flap dimension cm2
Numbers of anastamosis
Flap type
Recipient site
1
6(2x3)
a*
A-V-V
Toe -stump closure
2
28(4x7)
b**
A-V-A
3
6(2x3)
a
A-V-A
4
9(3x3)
c***
A-V-A
5
8(4x2)
c
A-V-V
6
4(2x2)
b
A-V-V
4. MP joint- stump closure 4.middle phalanxpalmar+dorsal 3.middle phalanxpalmar+dorsal- flow through 3.proximal phalanxpalmar- flow through 2.proximal phalanxpalmar+dorsal
7
6(2x3)
a
A-V-V
Hand palm
Donor site
Outcome
Saphenous vein Forearm
Congestion for 14 hours, survived Palor for 13 hours, survived No post op problem, survived
Forearm Forearm Forearm
Forearm
Forearm
8
7,5(1,5x5)
a
A-V-V
3. proximal and middle phalanx-palmar
9
10(4x2,5)
a
A-V-V
3. finger-stump closure
10
8(2x4)
a
A-V-V
11
20(5x4)
b
A-V-V
12
18(4,5x4)
b
A-V-V
3,4. middle phalanx- dorsal
Forearm
13
10(2x5)
b
A-V-V
5. proximal phalanxpalmar
Forearm
14
9(3x3)
b
A-V-A
Thumb- stump closure
Forearm
Dorsum of foot Forearm
SC
M AN U
3. proximal and middle phalanx-palmar 2,3,4. middle phalanxpalmar
Forearm Forearm
4(2x2)
b
A-V-V
3. middle phalanx- palmar
16
22,5(5x4,5)
b
A-V-V
Hand palm
Forearm
17
12(4x3)
c
A-V-V
18
30(5x6)
b
A-V-A
19
8(4x2)
20
24(3x8)
21
21(3,5x6)
TE D
15
Dorsum of hand
b
A-V-V
c
A-V-V
c
A-V-V
14(4x3,5)
23
27,5(2,5x11)
a
A-V-V
24
12(6x2)
b
A-V-V
25
30(3x10)
b
A-V-V
17,5(5x3,5)
a
A-V-V
24(6x4)
c
A-V-V
9(3x3)
a
A-V-V
3,75(2,5x1,5)
b
A-V-V
26 27 28 29
b
EP
22
A-V-V
30
3(2x1,5)
a
A-V-V
31
3(2x1,5)
a
A-V-V
32
8(2x4)
b
A-V-V
33
4,5(3x1,5)
a
A-V-V
34
21(3x7)
c
A-V-V
2. web space- volar- flow through 4,5. proximal phalanxdorsal 3. proximal phalanxpalmar 3,4,5. proximal phalanxdorsal Thumb- stump closure
2. proximal phalanxpalmar 3. proximal, middle phalanx- palmar+dorsal 2,3. proximal phalanxpalmar 2. proximal, middle phalanx- dorsal 4. proximal and middle phalanx-palmar+dorsal 3. middle phalanx- stump closure 3. proximal phalanxstump closure 3. proximal phalanxpalmar 3. proximal phalanxdorsal 4. proximal phalanxdorsal 3,4. middle phalanxpalmar 2. proximal phalanxdorsal 5. proximal phalanxdorsal
15
No post op problem, survived Congestion for 18 hours, survived Afferent reanastomosis in 5. hour, survived Congestion for 5 hours, survived No post op problem, survived Congestion for 12 hours, survived No post op problem, survived Efferent reanastomosis in 18. hour, survived Congestion for 5 hours, survived No post op problem, survived Congestion for 3 hours, survived No post op problem, survived Congestion for 8 hours, survived Congestion for 120 hours, survived Congestion for 24 hours, survived
RI PT
Flap no
AC C
403
Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm
Total necrosis No post op problem, survived Congestion for 2 hours, survived Palor for 2 hours, survived Congestion for 14 hours, survived No post op problem, survived No post op problem, survived Congestion for 12 hours, survived No post op problem, survived Efferent one more anastomosis in 9. hour, survived Superficial necrosis No post op problem, survived No post op problem, survived Palor for 2 hours, survived No post op problem, survived No post op problem, survived
ACCEPTED MANUSCRIPT 35
27(3x9)
c
A-V-V
36
6(3x2)
c
A-V-V
37
20(5x4)
b
A-V-V
38
10,5(3,5x3)
a
A-V-V
39
9(6x1,5)
b
40
19,25(3,5x5,5)
b
24(6x4)
a
Hand palm
Forearm
No post op problem, survived
Forearm
Total necrosis
Forearm
A-V-V
3. middle phalanxpalmar+dorsal Hand palm
Forearm
A-V-V
4. middle phalanx- palmar
Forearm
A-V-V
2,3,4. middle phalanxpalmar
Forearm
404
Forearm
No post op problem, survived No post op problem, survived Total necrosis No post op problem, survived No post op problem, survived
RI PT
41
3. proximal phalanxdorsal 3. proximal phalanxpalmar
Table 2: Surface areas, anastamosis count, flap types, recipient and donor areas, outcomes of
406
the flaps in our series.(MP: metacarpophalangeal, op: operation)
407
*a; 1 Afferent - 1 efferent anastamosis,
408
**b; 1 Afferent - 2 efferent anastamosis,
409
***c; 2 Afferent - 2 and more efferent anastamosis
414 415 416
M AN U
EP
413
AC C
412
TE D
410 411
SC
405
417 418 419 420 16
ACCEPTED MANUSCRIPT Subtexts of the Figures
422
Figure 1: Images of the patient with right hand 2nd and 3rd finger injuries. A- Preoperative
423
dorsal views. B- Preoperative dorsal view. C- Rectangular shaped venous flap harvested from
424
volar forearm with long afferent and efferent veins. Second and third fingers syndactilized by
425
flap inset. Afferent vein anastomosed to digital artery at proximal phalanx level in volar side.
426
Efferent veins anastomosed to superficial veins at metacarpal level on dorsal side. D- Dorsal
427
view of the hand before separation of the digits in the 5th week. E- Dorsal view after
428
separation.
429
Figure 2: Schematic view of an arterialized venous flap which applied to dorsal defect of
430
finger.
431
Figure 3: Images of a flap applied for fifth finger palmar defect. A- Flap harvested from
432
forearm. B-
433
view after flap inset. E- Palmar view after flap inset.
434
Figure 4: Images of the patient with left hand 2nd finger injury. A- Preoperative dorsal view.
435
B- Preoperative volar view. C- Dorsal view after debridement, it is seen that proximal
436
interphalangeal joint and extensor tendon need flap closure D- Image of the flap planned to be
437
harvested from forearm volar side, skin island is planned to be larger than the defect E- Image
438
of the flap after dissection, afferent and efferent veins are prepared long enough for a healthy
439
anastomosis F- Image of the injured finger after the operation G,H- Images of the injured
440
finger 1 month after the operation
441
Figure 5: A-Image of the injury in right hand 2nd, 3rd and 4th fingers distal interphalangial
442
joint dorsal. Soft tissue defect which leaves the bone and joint structures open in 3rd and 4th
443
fingers can be seen. B- Image of the flap prepared from same side volar forearm. Sutured area
444
in the flap’s distal is first flap’s donor area. C- Images of the injured fingers after recovery.
efferent vein. C- Venous network inside the flap. D- Dorsal
AC C
EP
TE D
Afferent vein,
M AN U
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RI PT
421
445 446 447 448
17
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
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ACCEPTED MANUSCRIPT
S1748-6815(14)00303-9
DOI:
10.1016/j.bjps.2014.05.061
Reference:
PRAS 4245
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 8 May 2013 Revised Date:
14 April 2014
Accepted Date: 29 May 2014
Please cite this article as: Kayalar M, Kucuk L, Sugun TS, Gurbuz Y, Savran A, Kaplan İ, Clinical Applications of Free Arterialized Venous Flaps, British Journal of Plastic Surgery (2014), doi: 10.1016/ j.bjps.2014.05.061. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
CLINICAL APPLICATIONS OF FREE ARTERIALIZED VENOUS FLAPS
3
Murat KAYALAR, Ass. Prof 1
4
Levent KUCUK, MD 2
5
Tahir Sadik SUGUN, MD 1
6
Yusuf GURBUZ, MD 1
7
Ahmet SAVRAN, MD 3
8
İbrahim KAPLAN, Ass. Prof 1
RI PT
2
SC
9 1
EMOT Hospital, İzmir, Turkey
11
2
Ege University Medical Faculty, Department of Hand Surgery, İzmir, Turkey
12
3
Tepecik Training Hospital, İzmir, Turkey
13
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Corresponding Author: Levent Kucuk
15
Ege University Medical Faculty, Department of Hand Surgery, İzmir, 35100, Turkey
16
Telephone: 00905055250277- 00902323902783
17
E-mail: [email protected]
20 21 22
EP
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ACCEPTED MANUSCRIPT 26
Clinical Applications of Free Arterialized Venous Flaps
27
Abstract Venous flaps are flaps by which tissue perfusion is accessed through the venous
29
network. Despite originally being questioned due to potential perfusion problems; as the
30
dynamics of tissue perfusion have been more fully comprehended, venous flaps appear to
31
have a far wider range of application than first thought. In our study we analyzed the clinical
32
results of the applications of free arterialized venous flaps along with the factors that can
33
affect flap survival.
SC
RI PT
28
41 flaps were assessed retrospectively. Type of the trauma, traumatized area, the time
35
duration between trauma and application of the flap, donor area, type and count of the
36
anostomosis, encountered complications, and flap survival rates were analyzed. Regression
37
and classification trees were used to study the relationship between flap surface area,
38
anastomosis count and flap survival.
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Circulatory abnormalities such as early congestion and edema were seen in 53,6 % of
40
the applied flaps. A total of 4 flaps (9,7 %) developed necrosis which presented as full-
41
thickness in 3 flaps and partial thickness in 1 flap. It can be said that there was a weak but
42
positive correlation between the size of the flap area and the number of anastamosis.
TE D
39
Although the results of arterialized venous flaps are inconsistent in the literature, those
44
flaps can be preferred as an alternative treatment option in single finger defects where tissue
45
compatibility and cosmetic results are quite impressive. In the meantime syndactylized
46
venous flaps are the preferred method regarding multiple finger soft tissue defects.
47
Keywords: hand trauma; hand surgery; microsurgery; free flap
AC C
48
EP
43
49 50 51
2
ACCEPTED MANUSCRIPT 52
Clinical Applications of Free Arterialized Venous Flaps
53
Introduction Venous flaps are defined as flaps of which blood flow is supplied by afferent and
55
efferent veins. Circulation within the flap is maintained by the venous network.[1] It has found
56
many application fields since it was first experimentally described in 1981.[2] Due to perfusion
57
problems, in the beginning it was used primarily for small defects. But, as the dynamics of
58
tissue perfusion have become more clearly understood, so the range of their applications has
59
widened.[3-8] Venous flaps can be raised from any area in the superficial venous system. Volar
60
forearm, medial surface of arm, dorsum of the hand, medial thigh, medial cruris, dorsal side
61
of the foot, thenar and hypothenar areas can all be considered as possible donor sites.[9-13]
SC
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54
Venous flaps are thin in appearance. There are numerous superficial veins which are
63
easy to locate. Dissection involves only superficial tissues so the flap can be dissected
64
quickly. Afferent and efferent veins can be harvested in various lengths. Since the flap does
65
not contain deep arterial structures donor site morbidity is low. Despite all these advantages
66
venous flaps still cannot be used safely. The primary reasons for this are: not completely
67
understanding the flap circulation physiology, venous congestion, ischemia and frequent loss
68
of flaps.[13,14]
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In our study survival rates of our venous flaps and post-operative microsurgical
70
problems were analyzed retrospectively. Relationships between surface dimensions of the
71
flap, number of anastamosis and necrosis rate were studied statistically.
72
Patients and Methods
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73
EP
69
Forty-one arterialized venous flaps in 40 patients performed between the years 1992
74
and 2011 were included in our study. Operations were performed by attending hand surgeons
75
with at least 5 years of experience.
76
Venous flaps were used in following indications;
77
a- In fingertip tissue lost where the defect exceeds dimensions of conventional homodigital or
78
heterodigital flaps.
3
ACCEPTED MANUSCRIPT b- In amputations involving segmental soft tissue defects, as flow through flaps in
80
revascularization / replantation
81
c- Soft tissue defects on adjacent fingers directly related to multiple finger injuries
82
d- For stump closure after unsuccessful revascularization or replantation in multiple finger
83
injuries. (as a temporary syndactylized flap involving multiple fingers) (Figure 1)
84
e- As salvage operations after unsuccessful local / free flap application attempts.
85
f- Circumferential or large longitudinal (volar/dorsal) tissue loss in single finger injury
SC
RI PT
79
Hospital records, nurse clinical observation records, and photographs were analyzed
87
retrospectively. Venous flap type, defect and donor site localization, flap sizes, early follow-
88
up problems, complications, secondary surgeries, partial and full flap losses were also noted.
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Thirty-four patients were female. Median age was 24,2 (min 2- max 55). One patient
90
had soft tissue defect on her first toe. The other patients had hand injuries. Seventeen patients
91
had left hand injuries and the other 22 had right hand injuries. Thirty (75%) patients had
92
multiple finger injuries. Fourteen patients had tissue defects on palmar side of fingers, nine
93
had on dorsal side of fingers and six had both dorsal + palmar side tissue defects. Seven of the
94
remaining 11 patients had finger amputations which the flaps used for stump closure, and 4
95
patients had defects in the palm of the hand. (Table 1)
TE D
89
Twenty one (52,5%) patients had crush injuries. Rolling belt, ring injury and burns
97
were the other causes of injury. Venous flaps were performed primarily in 29 patients (72,5%)
98
and as secondary interventions in 11 patients (27,5%) between days 3 and 25.
AC C
99
EP
96
Average flap size was 13,7 cm² ( min 3 cm²- max 30 cm² ). Flap surface area was over
100
10 cm² in 22 patients (55%). Forty one flaps were analyzed in our study as one patient had
101
two flaps applied. (Table 2) Forearm volar side was the donor area in 38 of 41 flaps. In one
102
patient a venous flap designed over saphenous vein which was used for a soft tissue defect
103
developed following a traumatic amputation over first toe. Other donor areas were dorsum of
104
the hand (n=1) and dorsum of the foot (n=1). One patient was treated simultaneously with
105
both posterior interosseous artery flap and venous flap following a gunshot wound.
4
ACCEPTED MANUSCRIPT Surgical technique, operations were performed with a tourniquet which was inflated
107
30 mmHg over the diastolic blood pressure. Debridement of injured area and identifying the
108
recipient artery and veins were the first steps of the procedure. Required lengths of afferent
109
and efferent veins were determined in this step in order to make good caliber anastamosis.
110
Donor areas were chosen from the sites where superficial venous networks contained
111
adequate density of connections. Flaps were designed to involve veins with “H”, “Y” or “ʎ”
112
pattern for rectangular shape defects.[6] Forearm fascia has always been added to flaps. Veins
113
located at opposite corner of the skin island were selected to prevent short circuit effect. High
114
pressure inflow blood has been tried to divert towards flap periphery by using these vein
115
patterns. The central vein usually has not been used as a draining vein especially in larger
116
flaps. The nearby neighboring veins usually added to subcutaneous tissue during flap
117
elevation in order to increase intensity of vascular network of the flap.
M AN U
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106
When flap was turned according to its orthodromic flow especially in longitudinal
119
finger dorsum defect, efferent vein length must be long enough to reach commissural dorsal
120
venous system for a good quality vessel anastomosis. (Figure 2) Retrograde flow or shunt
121
restriction haven’t been used.[14-17] Efferent vein and digital artery anastomosis was usually
122
performed at least proximal phalanx level in order to obtain maximum arterial flow. The
123
recipient vessel’s lumen was assessed before anastomosis under microscope to have a highly
124
patent anastomosis. Recommendation about the use of short afferent vein has not been strictly
125
taken into consideration.[6,18,19] The valve which was next to presumed anastomosis site was
126
usually passed by excising it.
EP
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118
It is possible to perform arterial anastomosis either proximally or distally in palmar
128
longitudinal defects of the fingers. Proximal arterial anastomosis preferred in our series to
129
reach high caliber arteries. (Figure 3) Efferent vein is directed towards finger dorsum
130
especially to proximal interphalangeal joint where a diffuse venous network can be found for
131
anastomosis.
AC C
127
132
Lengths of the afferent and efferent veins were taken at lengths that would help to
133
perform anastomosis out of injury zone. (Figure 4) After dissection, the flap was flipped over
134
in the direction of venous flow, and afferent - efferent vein anastomoses was performed. An
135
attempt was made to connect the small afferent vein to the largest artery possible.
5
ACCEPTED MANUSCRIPT One of our important tricks was to control anastomosis and filling characteristics of
137
flap such as color changes, pinpricks etc., especially in the early afferent phase of reperfusion,
138
immediately after finishing the anastomosis. When the sign of insufficient circulation was
139
noticed, one or more extra anastomoses were tried to be added considering the type of
140
deficiency especially in larger flaps. If it was an early cyanosis, one more efferent
141
anastomosis was added, or if it was a pallor flap an extra afferent anastomosis was performed.
142
One afferent and two efferent anastomoses were usually sufficient for small flaps.
RI PT
136
To avoid the risk of developing postoperative peripheral necrosis, skin islands should
144
be slightly larger than the defect area. Fingers can be syndactylized for multiple finger
145
defects. Accompanying extensor tendon defects can be treated either with tendocutaneous
146
venous flaps, or with tendon grafts covered with venous flaps. Tendocutaneous venous flaps
147
were applied to two patients in our series. These patients had tangential skin and tendon
148
defects typically in the dorsum of the fingers. Flexor carpi radialis and palmaris longus (PL)
149
tendons were included to the flap for tendon repairs. (Figure 5)
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According to Chen’s venous flap classification; 5 type IV (A-V-A) flow through, and
151
36 type III (A-V-V) arterialized venous flaps were used.[20] Along the valve pattern flow
152
through flaps were used for replantation/ revascularization in 3 patients and for soft tissue
153
defects in 2 patients. Post-operative flap follow up was carried out by nurses, as clinical
154
observations. Anticoagulant therapy was administered and bed rest was recommended.
155
Patients were discharged on the 5th postoperative day. They were strongly advised against
156
smoking, or consuming caffeinated drinks.
EP
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150
Results were analyzed with IBM SPSS 20.0. Regression and classification trees were
158
used to study the relationship between flap surface area, number of anastomosis and necrosis.
159
This classification algorithm was used to summarize how explanatory variables took place in
160
the dependent variable. Since we were dealing with a limited number of cases, only
161
nonparametric tests were used.
162
Results
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163
When flap losses were analyzed; 1 patient had superficial, and 3 patients presented
164
with full-thickness (9,7%) flap necrosis. Surface areas of the unsuccessful flaps were 9, 6, 4, 8
165
cm². Average flap surface area within the entire group was 13,2 cm². Three of the flaps which 6
ACCEPTED MANUSCRIPT 166
developed necrosis were applied with 1 afferent artery and 2 efferent vein anastomosis. The
167
other flap with necrosis was a flow through flap with 1 afferent and 1 efferent artery
168
anastomosis which had been used for finger revascularization. In their etiologies, two of the patients with full-thickness flap necrosis had suffered
170
from rolling belt injuries and 1 patient had a press injury. The etiology of the flap with
171
superficial necrosis was rolling belt injury. Ages of the patients with necrosis were 55, 18, 4
172
and 3. Flaps that were unsuccessful were the flaps applied in the acute phase.
RI PT
169
Defect of the flap with superficial necrosis was covered with full-thickness skin
174
grafting on the 10th day. Two of the patients that developed full-thickness necrosis were
175
treated with stump closure, including bone shortening, whereas one patient underwent
176
reconstruction through retrograde flow island flap application on the same finger.
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173
Three patients were re-operated in the early stage due to circulatory failure. There was
178
a kinking of the afferent artery with a thrombus at the 5th postoperative hour in the first
179
patient. In the second patient, efferent vein anastomosis was added at 9th hour post-
180
operatively; and in the third patient, thrombosis was detected in the efferent vein at the 18th
181
hour post operatively which was treated with re-anastomosis. All of these three flaps survived.
182
Survival rate after re-exploration was 100%.
TE D
177
The relationships between flap surface area, number of anastomosis and necrosis were
184
analyzed statistically. According to this analysis, no necrosis was seen in flaps with surface
185
area larger than 9,5 cm². It can be said that there is a weak but positive correlation between
186
number of anostomosis and flap surface area (Sperman’s Rho = 0,33). However, due to
187
having limited number of cases it was not possible to observe a correlation between number
188
of anostomosis and necrosis.
AC C
189
EP
183
When nurses’ clinical observation notes were assessed, 19 (46,3%) of patients suffered
190
no circulatory problems during the early postoperative period; whilst, with regard to the
191
remaining flaps, (53,6%) early venous congestion and edema was observed, but with only 3
192
requiring re-operation, as mentioned above.
193
Discussion
7
ACCEPTED MANUSCRIPT 194
Indications of venous flaps in hand reconstruction has been evolving steadily through
195
the years.[5,6,12,21,22] They can be used
196
arterialized venous flaps in soft tissue reconstruction.[23-30] Yan et al reported very good results
197
of pulp reconstruction with sensate arterialized venous flaps.[5] Alternatively supra-
198
microsurgery gives some options for covering small hand defects with perforator based flaps,
199
but these are more complex and technically demanding procedures than venous flaps.[21,22,31]
200
Iwasawa et al also concluded that hypothenar and thenar flaps might be good alternatives for
201
pulp reconstruction.[12] Dorsum of the hand is also a good donor area for pedicled venous
202
flaps in order to cover finger defects. Recently neuro-veno-cutaneous flaps based on great
203
saphenous vein has also offered promising results with larger flap dimensions.[32-34]
SC
RI PT
either flow through flaps as a vessel carrier or
Venous flaps have thinner tissue and they can be used as composite flaps especially in
205
finger dorsal tissue defects.[6] If there is extensor tendon or bone loss, it can be reconstructed
206
primarily or secondarily based on the contamination level of the wound. We achieved
207
tendocutaneous compound flap coverage in two of our cases with extensor tendon defect.
M AN U
204
Venous flaps can also be applied after unsuccessful finger replantations or local flap
209
surgery. Thus bone length can be maximized in stump closure and morbidity can be reduced
210
as the flap can be harvested away from the affected area.[5,6,8,29] Venous flaps therefore have
211
the advantage of not causing donor area morbidity in the hand.
TE D
208
Arterializing the venous network causes a high-pressure flow in the central vein in the
213
flap. Congestion and cyanotic appearance usually develop during the early postoperative
214
period. This is generally the main source of concern with regard to venous flaps. In our study,
215
half of the patients presented with these problems but most of them healed without requiring
216
an additional treatment.
AC C
217
EP
212
Regulation of high flow cannot be maintained easily since vein walls have limited
218
contractile characteristics; thus eodema and congestion in the flap can develop.[13,35,36] To
219
increase the flap survival rate, decreasing the high arterial flow could be attempted. High
220
arterial flow in the venous system can cause an arteriovenous short circuit effect which
221
decreases tissue perfusion.[28,29] Therefore the retrograde arterializations which causes blood
222
to be resisted in the vein wall valve system and consequently, pushed into the flap periphery.
223
Through this method, a flap perfusion increase can be obtained, thus avoiding the short circuit
224
effect.[16,17] This situation occurs especially in short and narrow flaps.[27] 8
ACCEPTED MANUSCRIPT According to studies about venous flaps, some positive factors have been determined
226
as to reduce high inflow blood pressure eg. involvement of rich venous plexus, and draining
227
via maximum efferent veins, establishing dual venous anastomosis.[2,3,5,19,23,34,35,37] Shunt
228
restriction and retrograde flow flaps with their encouraging results are used as well.[14-17,28]
229
Whilst ossilating veins maintain both the low pressure and low oxygen tension blood flow,
230
the main goal is to change unphysiological flow characteristics in to physiological one, during
231
early postoperative period until neovascularization develops.[1,4,37,38] Prearterialisation,
232
chemical and surgical delay and expansion procedures are also shortens this unstable “to fro”
233
or plasmatic imbibition period. Both prearterialisation and tissue expansion have positive
234
effect on flap survival by increasing vascular channels.[39-47] Although we don’t know the
235
exact haemodynamic mechanism, those inherently unstable flaps may become as more
236
reliable as conventional flaps with these efforts. It is generally accepted that larger flaps need
237
more vein containment and the more flow diverting policies towards flap periphery.[7,18,33,36]
M AN U
SC
RI PT
225
In this study, we analyzed the results of arterialized venous flap survival rates in
239
different indications. We only found that our total failures (9.7%) have seen in smaller flaps
240
less than 9.5 cm2. Woo et al. have also obtained similar results (4.2%) in small flaps less than
241
10 cm2.[6] We observed slight positive correlation between number of anastomosis and flap
242
surface. This high survival rate can be depend on some factors such as; a- Rich venous plexus
243
especially H, Y and ʎ pattern, b- Adding forearm fascia to the flap, c- Adding per venous cuff
244
to the afferent and efferent veins, d- Small caliber afferent vein, e- Good quality and largest
245
possible donor artery selection, f- Not to choose central vein as a draining vein, g- The more
246
larger flap the more efferent anastomosis h- Involvement of all possible veins nearby in order
247
to increase available vessels for anastomosis when necessary, ı-Per operative observation of
248
afferent phase of perfusion i-Healthy anastomosis outside of injury zone by taking afferent
249
and efferent veins long enough.
EP
AC C
250
TE D
238
Although flap monitorization is quite difficult in venous flaps, anastomoses were re-
251
explored in %7 of our patients. The primary reason given by the physician to review the
252
anostomosis was, “a progressive and rapid disruption in the positive signs of flap circulation”.
253
It does not seem possible to determine a set criterion for exploration in this situation. It seems
254
to depend extensively on the surgeon’s clinical experience.
255
The primary limitation in our study is the limited number of flaps, and not having
256
compared the other types of venous flap methods with the arterialized antegrade venous flap 9
ACCEPTED MANUSCRIPT 257
method. Venous flaps definitely require more detailed studies to fully assess their applicable
258
uses in terms of reliability. As flap hemodynamics are becoming more fully comprehended, venous flaps are
260
finding a place for themselves in free style flap application. Regardless of the fact there are no
261
homogenous results, they can certainly be used in multiple finger defects as syndactylized
262
flap, or in single finger defects, due to their ability to quickly adapt to the surrounding tissue.
263
Conflict of Interest or Funding: None
264
Ethical approval: Not required
265
References
266
1- Cho BC, Lee JH, Byun JS, Baik BS. Clinical applications of the delayed arterialized
267
venous flap. Ann Plast Surg 1997;39:145-7.
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2- Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous
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system: An experimental investigation. Plast Reconstr Surg 1981;67:328-34.
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3- Yan H, Brooks D, Ladner R, Jackson WD, Gao W, Angel MF. Arterialized venous flaps: A
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review of literature. Microsurgery 2010;30:472-8.
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4- Kakinoki R, Ikequchi R, Nankaku M, Nakamua T. Factors affecting the success of
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arterialised venous flaps in the hand. Injury 2008;39 Suppl 4:18-24.
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5- Yan H, Gao W, Zhang F, Li Z, Chen X, Fan C. A comparative study of finger pulp
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6- Woo SH, Kim KC, Lee GJ, Ha SH, Kim KH, Dhawan V, Lee KS. A retrospective analysis
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7- Murata K, Inada Y, Fukui A, Tamai S, Takamura Y. Clinical application of the reversed
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8- Yan H, Zhang F, Akdemir O, Songcharoen S, Jones NI, Angel M, Brook D. Clinical
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9- Inoue G, Maeda N, Suzuki K. Resurfacing of skin defects of the hand using the arterialised
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10
ACCEPTED MANUSCRIPT 10- Koshima I, Soeda S, Nakayama Y, Fukuda H, Tanaka J. An arterialised venous flap using
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the long saphenous vein. Br J Plast Surg 1991;44:23-6.
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11- Safak T, Akyurek M. Cephalic vein-pedicled arterialized anteromedial arm venous flap
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for head and neck reconstruction. Ann Plast Surg 2001;47:446-9.
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12- Iwasawa M, Ohtsuka Y, Kushima H, Kiyono M. Arterialized venous flaps from the thenar
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1997;99:1765-70.
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13- Pittet B, Quinodoz P, Alizadeh N, Schlaudraff KU, Mahajan AL. Optimizing the
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arterialized venous flap. Plast Reconstr Surg 2008;122:1681-9.
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14- Lin YT, Henry SL, Lin CH, Lee HY, Lin WN, Wei FC. The shunt-restricted arterialized
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venous flap for hand/digit reconstruction: Enhanced perfusion, decreased congestion, and
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improved reliability. J Trauma 2010;69:399-404.
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15- Tan MP, Lim AY, Zhu Q. A novel rabbit model for the evaluation of retrograde flow
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venous flaps. Microsurgery 2009;29:226-31.
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16- Moshammer HE, Schwarzl FX, Haas FM, Maechler H, Pierer G, Wiltgen M, Koch H.
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Retrograde arterialized venous flap: An experimental study. Microsurgery 2003;23:130-4.
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17- Koch H, Scharnagl E, Schwarzl FX, Haas FM, Hubmer M, Moshammer HE. Clinical
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application of the retrograde arterialized venous flap. Microsurgery 2004;24:118-24.
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18- Reynoso R, Haddad JL, Sastré N. A few considerations regarding enhancement of
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arterialized skin flap survival. Microsurgery 2000;20:176-80.
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19-Lam WL, Lin WN, Bell D, Higgins JP, Lin YT, Wei FC. The physiology, microcirculation
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and clinical application of the shunt-restricted arterialized venous flaps for the reconstruction
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of digital defects J Hand Surg Eur 2013:38;352-65.
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20- Chen HC, Tang YB, Noordhof. Four types of venous flaps for wound coverage A clinical
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appraisal. Trauma 1991;31:1286-93.
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21- Yokoyama T, Tosa Y, Hashikawa M, Kadota S, Hosaka Y. Medial plantar venous flap
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technique for volar oblique amputation with no defects in the nail matrix and nail bed. J Plast
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Reconstr Aesthet Surg 2010;63:1870-4.
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22- Yokoyama T, Hosaka Y, Kusano T, Morita M, Takagi S. Finger palmar surface
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reconstruction using medial plantar venous flap: possibility of sensory restoration without
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neurorrhaphy. Ann Plast Surg 2006;57:552-6.
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23- Goldschlager R, Rozen WM, Ting JW, Leong J. The nomenclature of venous flow-
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through flaps: updated classification and review of the literature. Microsurgery 2012;32:497-
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501.
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11
ACCEPTED MANUSCRIPT 24- Brooks D, Buntic RF, Taylor C. Use of the venous flap for salvage of difficult ring
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avulsion injuries. Microsurgery 2008;28:397-402.
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25- Woo SH, Jeong JH, Seul JH. Resurfacing relatively large skin defects of the hand using
325
arterialized venous flaps. J Hand Surg Br 1996;21:222-9.
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26-Yan H, Fan C, Gao W, Chen Z, Li Z, Chi Z. Finger pulp reconstruction with free
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flaps from the upper extremity. Microsurgery 2012;32:406-14.
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27- Karacalar A, Ozcan M. Free arterialized venous flap for the reconstruction of defects of
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the hand: new modifications. J Reconstr Microsurg 1994;10:243-8.
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28- Kamei K, Ide Y. The pedicled arterialized venous flap. J Reconstr Microsurg 1993;9:287-
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91.
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29- Inoue G, Maeda N. Arterialized venous flap coverage for skin defects of the hand or foot.
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J Reconstr Microsurg 1988;4:259-66.
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30- Inada Y, Fukui A, Tamai S, Mizumoto S. The arterialised venous flap: Experimental
335
studies and a clinical case. Br J Plast Surg 1993;46:61-7.
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31- Ho Am, Chang J, Radial artery perforator flap J Hand Surg 2010;35A;308-11.
337
32- Chang S, Gu Y, Li F.Comparison of different management of large superficial veins in
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distally based fasciocutaneous flaps with a veno-neuro-adipofascial pedicle: an experimental
339
study using a rabbit model. Microsurgery 2003;23:555-60.
340
33- Nayak BB, Thatte RL, Thatte MR, Baliarsing AS, Jagannathan M, Pandit SP.
341
A microneurovascular study of the great saphenous vein in man and the possible implications
342
for survival of venous flaps. Br J Plast Surg 2000;53:230-33.
343
34- Rozen WM, Tıng JW, Gilmour RF, Leong J. The arterialized saphenous venous flow
344
through flap with dual venous drainage. Microsurgery 2012;32:281-8.
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35- Chow SP, Chen DZ, Gu YD. A comparison of arterial and venous flaps. J Hand Surg Br
346
1992;17:59-64.
347
36-
348
Effect of venous superdrainage on a four-territory skin flap survival in rats.Plast Reconstr
349
Surg 2007;119:2046-51.
350
37- Krishnan KG. The venous flaps: an experimental study of the microvascular architecture,
351
the area of perfusion and their correlation. Br J Plast Surg 2002;55:340-50.
352
38- Tang YB, Simchon S, Chen HC. Microcirculation of a venous flap: an experimental study
353
with microspheres in rabbits. Scand J Plast Reconstr Surg Hand Surg 2000;34:207-12.
354
39- Rhyu H. The role of chemical delay in the survival of the arterialized venous flap. J
355
Korean Soc Plast Reconstr Surg 1996;23:942.
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EP
TE D
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RI PT
322
Chang
H,
Minn
KW,
Imanishi
12
N,
Minabe
T,
Nakajima
H.
ACCEPTED MANUSCRIPT 40- Alexander G. Multistage type 3 venous flap or ‘pre-arterialisation of an arterialised
357
venous flap’. Br J Plast Surg 2001;54:734.
358
41- Fukui A, Inada Y, Murata K, Ueda Y, Tamai S. A method for prevention of arterialized
359
venous flap necrosis. J Reconstr Microsurg 1998;14:67-74.
360
42- Wungcharoen B, Pradidarcheep W, Santidhananon Y, Chongchet V. Pre-arterialisation of
361
the arterialised venous flap: an experimental study in the rat. Br J Plast Surg 2001;54:621-30.
362
43- Shin HJ, Woo SH, Jeong JH, Seul JH. Survival pattern of previously expanded
363
arterialized venous flaps. J Korean Soc Plast Reconstr Surg 1997;24:459-67.
364
44- Mutaf M, Tasaki Y, Fujii T. Expansion of venous flaps: An experimental study in rats. Br
365
J Plast Surg 1998;51:393-401.
366
45-
367
an arterialised venous flap: clinical cases. Br J Plast Surg 2001;54:112-6.
368
46- Karacalar A, İdil O, Demir A, Güneren E, Şimşek T, Özcan M. Delay in neurovenous
369
flaps. Ann Plast Surg 2004;53:481-7.
370
47- Başer NT, Silistreli OK, Sişman N, Oztan Y. Effects of surgical or chemical delaying
371
procedures on the survival of proximal predicled venous island flaps: an experimental study in
372
rats. Scand J Plast Reconstr Surg Hand Surg 2005;39:197-203.
Santidhananon
376 377 378 379 380 381 382 383
EP
375
AC C
374
TE D
373
Y,
SC
B,
Chongchet
M AN U
Wungcharoen
RI PT
356
384 385 386 387 388 13
V.
Pre-arterialisation of
ACCEPTED MANUSCRIPT
Number of Patients
Finger palmar side
14
Finger dorsal side
9
Finger palmar + dorsal side
6
Finger stump closure
7
Hand palm
4
Table 1: Location of flap application areas and number of patients are seen.
391 392
397 398 399
EP
396
AC C
395
TE D
393 394
RI PT
Location of the Defect
SC
390
Table 1
M AN U
389
400 401 402 14
ACCEPTED MANUSCRIPT Table 2 Flap dimension cm2
Numbers of anastamosis
Flap type
Recipient site
1
6(2x3)
a*
A-V-V
Toe -stump closure
2
28(4x7)
b**
A-V-A
3
6(2x3)
a
A-V-A
4
9(3x3)
c***
A-V-A
5
8(4x2)
c
A-V-V
6
4(2x2)
b
A-V-V
4. MP joint- stump closure 4.middle phalanxpalmar+dorsal 3.middle phalanxpalmar+dorsal- flow through 3.proximal phalanxpalmar- flow through 2.proximal phalanxpalmar+dorsal
7
6(2x3)
a
A-V-V
Hand palm
Donor site
Outcome
Saphenous vein Forearm
Congestion for 14 hours, survived Palor for 13 hours, survived No post op problem, survived
Forearm Forearm Forearm
Forearm
Forearm
8
7,5(1,5x5)
a
A-V-V
3. proximal and middle phalanx-palmar
9
10(4x2,5)
a
A-V-V
3. finger-stump closure
10
8(2x4)
a
A-V-V
11
20(5x4)
b
A-V-V
12
18(4,5x4)
b
A-V-V
3,4. middle phalanx- dorsal
Forearm
13
10(2x5)
b
A-V-V
5. proximal phalanxpalmar
Forearm
14
9(3x3)
b
A-V-A
Thumb- stump closure
Forearm
Dorsum of foot Forearm
SC
M AN U
3. proximal and middle phalanx-palmar 2,3,4. middle phalanxpalmar
Forearm Forearm
4(2x2)
b
A-V-V
3. middle phalanx- palmar
16
22,5(5x4,5)
b
A-V-V
Hand palm
Forearm
17
12(4x3)
c
A-V-V
18
30(5x6)
b
A-V-A
19
8(4x2)
20
24(3x8)
21
21(3,5x6)
TE D
15
Dorsum of hand
b
A-V-V
c
A-V-V
c
A-V-V
14(4x3,5)
23
27,5(2,5x11)
a
A-V-V
24
12(6x2)
b
A-V-V
25
30(3x10)
b
A-V-V
17,5(5x3,5)
a
A-V-V
24(6x4)
c
A-V-V
9(3x3)
a
A-V-V
3,75(2,5x1,5)
b
A-V-V
26 27 28 29
b
EP
22
A-V-V
30
3(2x1,5)
a
A-V-V
31
3(2x1,5)
a
A-V-V
32
8(2x4)
b
A-V-V
33
4,5(3x1,5)
a
A-V-V
34
21(3x7)
c
A-V-V
2. web space- volar- flow through 4,5. proximal phalanxdorsal 3. proximal phalanxpalmar 3,4,5. proximal phalanxdorsal Thumb- stump closure
2. proximal phalanxpalmar 3. proximal, middle phalanx- palmar+dorsal 2,3. proximal phalanxpalmar 2. proximal, middle phalanx- dorsal 4. proximal and middle phalanx-palmar+dorsal 3. middle phalanx- stump closure 3. proximal phalanxstump closure 3. proximal phalanxpalmar 3. proximal phalanxdorsal 4. proximal phalanxdorsal 3,4. middle phalanxpalmar 2. proximal phalanxdorsal 5. proximal phalanxdorsal
15
No post op problem, survived Congestion for 18 hours, survived Afferent reanastomosis in 5. hour, survived Congestion for 5 hours, survived No post op problem, survived Congestion for 12 hours, survived No post op problem, survived Efferent reanastomosis in 18. hour, survived Congestion for 5 hours, survived No post op problem, survived Congestion for 3 hours, survived No post op problem, survived Congestion for 8 hours, survived Congestion for 120 hours, survived Congestion for 24 hours, survived
RI PT
Flap no
AC C
403
Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm Forearm
Total necrosis No post op problem, survived Congestion for 2 hours, survived Palor for 2 hours, survived Congestion for 14 hours, survived No post op problem, survived No post op problem, survived Congestion for 12 hours, survived No post op problem, survived Efferent one more anastomosis in 9. hour, survived Superficial necrosis No post op problem, survived No post op problem, survived Palor for 2 hours, survived No post op problem, survived No post op problem, survived
ACCEPTED MANUSCRIPT 35
27(3x9)
c
A-V-V
36
6(3x2)
c
A-V-V
37
20(5x4)
b
A-V-V
38
10,5(3,5x3)
a
A-V-V
39
9(6x1,5)
b
40
19,25(3,5x5,5)
b
24(6x4)
a
Hand palm
Forearm
No post op problem, survived
Forearm
Total necrosis
Forearm
A-V-V
3. middle phalanxpalmar+dorsal Hand palm
Forearm
A-V-V
4. middle phalanx- palmar
Forearm
A-V-V
2,3,4. middle phalanxpalmar
Forearm
404
Forearm
No post op problem, survived No post op problem, survived Total necrosis No post op problem, survived No post op problem, survived
RI PT
41
3. proximal phalanxdorsal 3. proximal phalanxpalmar
Table 2: Surface areas, anastamosis count, flap types, recipient and donor areas, outcomes of
406
the flaps in our series.(MP: metacarpophalangeal, op: operation)
407
*a; 1 Afferent - 1 efferent anastamosis,
408
**b; 1 Afferent - 2 efferent anastamosis,
409
***c; 2 Afferent - 2 and more efferent anastamosis
414 415 416
M AN U
EP
413
AC C
412
TE D
410 411
SC
405
417 418 419 420 16
ACCEPTED MANUSCRIPT Subtexts of the Figures
422
Figure 1: Images of the patient with right hand 2nd and 3rd finger injuries. A- Preoperative
423
dorsal views. B- Preoperative dorsal view. C- Rectangular shaped venous flap harvested from
424
volar forearm with long afferent and efferent veins. Second and third fingers syndactilized by
425
flap inset. Afferent vein anastomosed to digital artery at proximal phalanx level in volar side.
426
Efferent veins anastomosed to superficial veins at metacarpal level on dorsal side. D- Dorsal
427
view of the hand before separation of the digits in the 5th week. E- Dorsal view after
428
separation.
429
Figure 2: Schematic view of an arterialized venous flap which applied to dorsal defect of
430
finger.
431
Figure 3: Images of a flap applied for fifth finger palmar defect. A- Flap harvested from
432
forearm. B-
433
view after flap inset. E- Palmar view after flap inset.
434
Figure 4: Images of the patient with left hand 2nd finger injury. A- Preoperative dorsal view.
435
B- Preoperative volar view. C- Dorsal view after debridement, it is seen that proximal
436
interphalangeal joint and extensor tendon need flap closure D- Image of the flap planned to be
437
harvested from forearm volar side, skin island is planned to be larger than the defect E- Image
438
of the flap after dissection, afferent and efferent veins are prepared long enough for a healthy
439
anastomosis F- Image of the injured finger after the operation G,H- Images of the injured
440
finger 1 month after the operation
441
Figure 5: A-Image of the injury in right hand 2nd, 3rd and 4th fingers distal interphalangial
442
joint dorsal. Soft tissue defect which leaves the bone and joint structures open in 3rd and 4th
443
fingers can be seen. B- Image of the flap prepared from same side volar forearm. Sutured area
444
in the flap’s distal is first flap’s donor area. C- Images of the injured fingers after recovery.
efferent vein. C- Venous network inside the flap. D- Dorsal
AC C
EP
TE D
Afferent vein,
M AN U
SC
RI PT
421
445 446 447 448
17
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
