Goro Inoue, Noboru Maeda, and Kiyoshi Suzuki
CLOSURE OF BIG TOE DEFECTS AFTER WRAP-AROUND FLAP ARTERIALIZED VENOUS FLAP ABSTRACT Sixteen arterialized venous flaps, free flaps that have arterial blood onlyflowingthrough the vein of the flap, were applied to reconstruct skin defects of the big toe resulting from wrap-around flap transfers. There were seven complete successes, six partial successes, and three complete failures. The clinical course of the cases indicated that the donor site itself and flap tension due to postoperative edema might play key roles in flap survival. The success rates of the flap from the leg and foot donor sites (including partial survival cases) were 75 percent and 87.5 percent, respectively. Flaps from the leg donor site appeared to develop more extensive postoperative congestion and edema than those from the foot donor site, which had a negative effect on flap survival. Covering the big toe with this flap causes no significant morbidity. The technique may have potential indications for closing a big-toe defect after a wrap-around flap transfer.
A free neurovascular wrap-around flap (WAF) from the big toe has now become the preferred procedure for reconstruction of an amputated thumb. 1 This technique allows preservation of the big toe; however, there is some morbidity at the secondary defect, including skin ulceration, flexion and adduction deformity, and long-term scar problems. To minimize such problems and to improve the cosmetic appearance of the donor big toe, we applied an arterialized venous flap (AVF), with arterial blood only flowing through the vein of the flap, for management of the donor defect resulting from a WAF transfer. The authors previously reported small samples of this method in this journal with a low success rate.2 We subsequently used an alternative donor site in an attempt to improve the success rate. This study reports 16 patients with skin defects of the big toe after a WAF, using arterialized venous flaps for coverage.
MATERIALS AND METHODS Between 1986 and 1989, 16 AVFs were applied to the donor defect of the big toe, from which a WAF had been harvested. There were 13 males and three females, with an average age of 30 years (range-. 12 to 55 years). The average follow-up was 18 months (range: five to 46 months). We used two flap donor sites, the medial aspect of the leg in eight cases and the dorsum of the foot in eight cases, both types taken from the ipsilateral leg or foot. The size of the flaps ranged from 4.0 x 7.0 cm to 6.0 x 12.0 cm. Two procedures, one for preparing the recipient thumb and another for taking a WAF from the big toe, were started simultaneously. After taking a WAF, the flap for the AVF was raised from the ipsilateral leg or foot, taking skin and subcutaneous tissue containing the vein. At the leg donor site, the flap was taken from
Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University School of Medicine Reprint requests: Dr. Inoue, Dept. of Orthopaedic Surgery, Division of Hand Surgery (Bun-in), Nagoya University School of Medicine, 1-1-20 Daikominami, Higashi-ku, Nagoya 461, Japan Accepted for publication July 10, 1990 Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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RESULTS Results are summarized in Table I. Of eight flaps from the leg donor site, there were two complete successes, four 60 to 90 percent partial successes, and two complete failures. Of eight flaps from the foot donor site, there were five complete successes, two 70 to 90 percent partial successes, and one complete failure in which the flap was not reversed, creating retrograde arterial flow through the venous system. The success rates of the flap from the dorsum of the foot and from the medial aspect of the leg (including partial survival cases) were 87.5 percent and 75 percent, respectively. There were statistically significant differences in success rates between the two donor sites (X2 = 5.604, p < 0.05). The time required for wound healing of the big toe varied from one to three months, with an average of seven weeks. There were no patients requiring defatting of the flaps. All patients were reviewed to quantify big toe morbidity. Thirteen patients with complete or partial flap survival could walk and run normally, but two of them complained of mild pain with distance walking or running. Two of three patients whose donor defects were covered with a split-thickness skin graft after complete necrosis of the AVF had cicatricial hardness and contraction of the big toe, with mild pain on running or distance walking.
CASE REPORTS
Oorsalis pedis artery
Subcutaneous vein
CASE I. A 27-year-old man sustained traumatic amputation of the left thumb at the MP joint, with unsuccessful replantation elsewhere. Six weeks after initial injury, thumb reconstruction with a WAFtransfer from the left big toe was carried out. A big toe defect was closed with a 3.5 x 15 cm AVF, as previously described. The donor site of the flap in the medial aspect of the leg was closed primarily. To avoid undue tension on the flap, a 1.5 x 5.0 cm skin defect on the dorsal aspect of the big toe was covered with additional split-thickness skin grafting. Areas of 10 percent necrosis of the AVF and 90 percent necrosis of the split-
Table 1. Summary of Flap Procedures
Figure I. Operative procedure. The proximal vein of the flap is anastomosed with the dorsalis pedis artery, and the distal vein of the flap is anastomosed with the subcutaneous vein of the foot.
Donor Site
No.
Complete Survival
Partial Survival
Medial leg
8
2
Dorsal foot
8
5
16
7
2 (90%) 1 (70%) 1 (60%) 1 (80%) 1 (70%) 6
Necrosis 2 1 3
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the medial aspect containing the greater saphenous vein on the proximal and distal side and at the foot donor site, the flap was taken from the dorsal aspect containing the dorsal venous arch. The flap was reversed. The proximal vein of the flap was anastomosed with the dorsalis pedis artery, and the distal vein of the flap was anastomosed with the subcutaneous vein of the foot in the dorsomedial aspect of the big toe, thus creating an arteriovenous fistula (Fig. I). The flap was sutured loosely without undue tension. The AVF clearly demonstrated a pink color immediately after operation but gradually showed a cyanotic tinge. Flap congestion and edema, often accompanied by blistering, continued for about two weeks, but these conditions resolved within three weeks. The average operation time for this procedure was two hours and 40 minutes (range: two hours and 30 minutes to three hours). Thumb reconstruction and closure of the donor defect were thus accomplished at the same time. All patients received postoperative anticoagulation therapy, including 60,000 IU/day of urokinase and 500 ml/day of dextran for one week. When partial or marginal necrosis of the flap occurred, secondary closure with or without a free skin graft was carried out four to six weeks postoperatively. At that time, the A-V fistula was usually ligated distal to the flap to avoid development of an A-V tumor.
JANUARY 1991
thickness skin graft required regrafting six weeks later. At a three year follow-up, the patient's big toe had a good appearance, and he had no difficulty walking or running (Fig. 2). CASE 2. A 17-year-old man was referred to us 10 months after a conventional thumb reconstruction with osteoplastic bone graft and tubed pedicle flap. A WAF transfer was performed. The big toe defect was closed with a 6 x 12 cm AVF which was raised from the same foot. The foot donor site was closed with free skin grafting. A small area of the toe tip was left open to avoid tension on the flap. The flap showed mild congestion for one week, but survived completely. At one year follow-up, the young man reported no difficulty with the big toe (Fig. 3). CASE 3. A 42-year-old woman underwent onestage thumb reconstruction using a WAF for her left amputated thumb. A big toe defect was closed with a 7 x 7 cm AVF from the same foot. The foot donor site was closed with free skin grafting. The toe tip was closed loosely but developed marginal necrosis, which required resuturing five weeks later. Five months postoperative, the patient was pleased with her thumb and big toe (Fig. 4). CASE 4. A 44-year-old man sought treatment for his left thumb which had been lost traumatically at the MP joint 20 years earlier. The thumb was reconstructed by a WAF. The big toe defect was closed with a 7 x 8 cm AVF from the medial aspect of the leg. The leg donor site was closed with free skin grafting. The flap had a cyanotic appearance and marked edema for two weeks following the operation, but finally survived with 10 percent necrosis in its distal portion. Five months postoperative, the appearance was good and the big toe caused no problems (Fig. 5).
DISCUSSION Since Nakayama et al.3 in 1981 first reported their experimental study validating the possibility of new flap transfers that were nourished by arterial blood flowing through the venous network, there have been many successful reports of the "arterialized venous flap", both clinically and experimentally.4-7 The present authors in 19882 presented a preliminary report of small samples of AVF coverage for skin defects of the hand or foot, and suggested that success appeared to be influenced by the donor site itself and by the size of the flap. Since that time, we changed the donor site from the medial aspect of the leg to the dorsum of the foot, which appeared to have a richer venous plexus. The first seven cases used flaps from the medial aspect of the leg, measuring 3 to 4 cm in width, because the donor defect could be closed primarily. However, the flap was too small to close the big toe defect primarily.
In the two cases where the big toe defect was closed primarily with an AVF, the flaps failed, while in the remaining five cases where a small area of the big toe defect was left open or closed with additional skin graft, the flaps survived partially or completely. One flap from the leg donor site and eight flaps from the foot donor site were tailored to a big toe defect, taking a flap 6 to 7 cm wide. All but one (which failed because of reverse flow) survived partially or completely. Flaps from the leg donor site showed more extensive congestion and edema than those from the foot donor site, suggesting that success seems to be influenced by the donor site and by flap tension. We therefore recommend that the flap be generously larger than the size of the defect, so that extensive increased tension of the flap following postoperative edema can be lessened. The surgeon need not hesitate to leave a small defect open, if there is any question of extensive postoperative increase in flap tension. Regarding closure of the big toe defect after a WAF, Morrison et al.1 reported that a distal phalanx was resected, the remaining area of bare bone was closed by a cross-toe flap from the plantar surface of the second toe, and the remaining weight-bearing surface was covered with a split-thickness skin graft. In our earlier cases, we applied a wet dressing on the donor defect for two weeks, followed by a split-thickness skin graft. Both techniques could not provide sufficient soft-padded skin over the plantar weight-bearing surface of the big toe, so that long-term skin problems were possible, resulting in skin erosion and pain on distance walking. Aesthetically, the big toe covered in this manner may develop adduction-flexion contracture, with an irregular contour on the split-thickness skin, creating an ugly appearance. Hashimoto et al.8 reported that a donor defect closed with free peroneal flaps resulted in a good appearance and less morbidity of the big toe. However, this technique is technically demanding when harvesting the flap; moreover, most flaps need defatting, while our harvesting technique is easy and does not require defatting. Immediate coverage of the donor defect with an AVF assures good skin quality with underlying subcutaneous fat, produces a good appearance, and is less vulnerable to trauma. It also allows earlier return to unprotected weight-bearing and full functional recovery of the toe. A further benefit of this technique is preservation of an undisturbed second toe. As disadvantages, the success rate of this technique is inferior to that of Hashimoto, and wound healing of the big toe requires two or three months because of marginal or partial necrosis and/or remaining defect. However, these drawbacks do not compare unfavorably with those of a split-thickness skin graft. We indicated in a previous report that the palmar aspect of the forearm might be most preferable donor site for the AVF. However, we were reluctance to use
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ARTERIALIZED VENOUS FLAP/INOUE, MAEDA, SUZUKI
JANUARY 1991
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 1
•H D Figure 2. Case I. A, B, Immediately after transfer of an arterialized venous flap on the big toe. Remaining defect was covered with a split-thickness skin graft. C, D, Six weeks after operation, showing distal portion of the flap and most of a splitthickness skin graft became necrotic. (Figure continued on next page)
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ARTERIALIZED VENOUS FLAP/INOUE, MAEDA, SUZUKI
Figure 2, cont. E, F, Postoperative appearance of the big toe at three years. G, Postoperative appearance of reconstructed thumb at three years.
JANUARY 1991
Figure 3. Case 2. A, Outline of the flap on the dorsum of the same foot. B, Nine days postoperative, showing complete survival of the flap without marked edema.
6
Figure 4. Case 3. A, Immediately after operation. B, C, Two weeks postoperative, showing mild edema with blistering at distal portion of the dorsal aspect of the flap. (Figure continued on next page)
B
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Figure 4, cont. D, E, Five months postoperative, showing a good appearance.
Figure 5. Case 4. A, Outline of the flap on the medial aspect of the leg, which was tailored to the big toe defect. B, One week after operation, showing marked congestion and swelling. (Figure continued on next page)
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ARTERIAUZED VENOUS F1 AP/INOUE, MAEDA, SUZUKI
JANUARY 1991
Figure 5, cont. C, D, One month postoperative, showing about 10 percent necrosis of the flap. E, F, Postoperative appearance at five months.
this area as donor for closure of a big toe defect because of poor cosmetic sequelae. In summary, more clinical experience with this technique is necessary before advocating it as the treatment of choice. However, we believe that the technique does have great potential for wider clinical use.
REFERENCES Morrison WA, O'Brien BM, MacLeod AM: Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. ) Hand Surg 5:575, 1980
Inoue G, Maeda N: Arterialized venous flap coverage for skin defects of the hand or foot. I Reconstr Microsurg 4: 259,1988 Nakayama Y, Soeda S, Kasai Y: Flaps nourished by arterial inflow through the venous system: An experimental investigation. Plast Reconstr Surg 67:328, 1981 |i SY, Chia SL, Chen HH: Free transplantation of venous network pattern skin flap: An experimental study in rabbits. Microsurgery 5:151, 1984 Mundy )C, Panje WR: Creation of free flaps by arterialization of the venous system Arch Otolaryngol 110:221, 1984 Nichter LS, Haines PC: Arterialized venous perfusion of composite tissue. Am I Surg 150:191, 1985 Yoshimura M, Shimada T, Imura S, et al: The venous skin graft method for repairing skin defects of the fingers. Plast Reconstr Surg 79:243, 1987 Hashimoto F, Nomura S, Yamauchi S, et al.: Free peroneal flap coverage of the great toe defect resulting from a wraparound flap transfer. Microsurgery 7:199, 1986
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CLOSURE OF BIG TOE DEFECTS AFTER WRAP-AROUND FLAP ARTERIALIZED VENOUS FLAP ABSTRACT Sixteen arterialized venous flaps, free flaps that have arterial blood onlyflowingthrough the vein of the flap, were applied to reconstruct skin defects of the big toe resulting from wrap-around flap transfers. There were seven complete successes, six partial successes, and three complete failures. The clinical course of the cases indicated that the donor site itself and flap tension due to postoperative edema might play key roles in flap survival. The success rates of the flap from the leg and foot donor sites (including partial survival cases) were 75 percent and 87.5 percent, respectively. Flaps from the leg donor site appeared to develop more extensive postoperative congestion and edema than those from the foot donor site, which had a negative effect on flap survival. Covering the big toe with this flap causes no significant morbidity. The technique may have potential indications for closing a big-toe defect after a wrap-around flap transfer.
A free neurovascular wrap-around flap (WAF) from the big toe has now become the preferred procedure for reconstruction of an amputated thumb. 1 This technique allows preservation of the big toe; however, there is some morbidity at the secondary defect, including skin ulceration, flexion and adduction deformity, and long-term scar problems. To minimize such problems and to improve the cosmetic appearance of the donor big toe, we applied an arterialized venous flap (AVF), with arterial blood only flowing through the vein of the flap, for management of the donor defect resulting from a WAF transfer. The authors previously reported small samples of this method in this journal with a low success rate.2 We subsequently used an alternative donor site in an attempt to improve the success rate. This study reports 16 patients with skin defects of the big toe after a WAF, using arterialized venous flaps for coverage.
MATERIALS AND METHODS Between 1986 and 1989, 16 AVFs were applied to the donor defect of the big toe, from which a WAF had been harvested. There were 13 males and three females, with an average age of 30 years (range-. 12 to 55 years). The average follow-up was 18 months (range: five to 46 months). We used two flap donor sites, the medial aspect of the leg in eight cases and the dorsum of the foot in eight cases, both types taken from the ipsilateral leg or foot. The size of the flaps ranged from 4.0 x 7.0 cm to 6.0 x 12.0 cm. Two procedures, one for preparing the recipient thumb and another for taking a WAF from the big toe, were started simultaneously. After taking a WAF, the flap for the AVF was raised from the ipsilateral leg or foot, taking skin and subcutaneous tissue containing the vein. At the leg donor site, the flap was taken from
Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University School of Medicine Reprint requests: Dr. Inoue, Dept. of Orthopaedic Surgery, Division of Hand Surgery (Bun-in), Nagoya University School of Medicine, 1-1-20 Daikominami, Higashi-ku, Nagoya 461, Japan Accepted for publication July 10, 1990 Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 1
RESULTS Results are summarized in Table I. Of eight flaps from the leg donor site, there were two complete successes, four 60 to 90 percent partial successes, and two complete failures. Of eight flaps from the foot donor site, there were five complete successes, two 70 to 90 percent partial successes, and one complete failure in which the flap was not reversed, creating retrograde arterial flow through the venous system. The success rates of the flap from the dorsum of the foot and from the medial aspect of the leg (including partial survival cases) were 87.5 percent and 75 percent, respectively. There were statistically significant differences in success rates between the two donor sites (X2 = 5.604, p < 0.05). The time required for wound healing of the big toe varied from one to three months, with an average of seven weeks. There were no patients requiring defatting of the flaps. All patients were reviewed to quantify big toe morbidity. Thirteen patients with complete or partial flap survival could walk and run normally, but two of them complained of mild pain with distance walking or running. Two of three patients whose donor defects were covered with a split-thickness skin graft after complete necrosis of the AVF had cicatricial hardness and contraction of the big toe, with mild pain on running or distance walking.
CASE REPORTS
Oorsalis pedis artery
Subcutaneous vein
CASE I. A 27-year-old man sustained traumatic amputation of the left thumb at the MP joint, with unsuccessful replantation elsewhere. Six weeks after initial injury, thumb reconstruction with a WAFtransfer from the left big toe was carried out. A big toe defect was closed with a 3.5 x 15 cm AVF, as previously described. The donor site of the flap in the medial aspect of the leg was closed primarily. To avoid undue tension on the flap, a 1.5 x 5.0 cm skin defect on the dorsal aspect of the big toe was covered with additional split-thickness skin grafting. Areas of 10 percent necrosis of the AVF and 90 percent necrosis of the split-
Table 1. Summary of Flap Procedures
Figure I. Operative procedure. The proximal vein of the flap is anastomosed with the dorsalis pedis artery, and the distal vein of the flap is anastomosed with the subcutaneous vein of the foot.
Donor Site
No.
Complete Survival
Partial Survival
Medial leg
8
2
Dorsal foot
8
5
16
7
2 (90%) 1 (70%) 1 (60%) 1 (80%) 1 (70%) 6
Necrosis 2 1 3
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the medial aspect containing the greater saphenous vein on the proximal and distal side and at the foot donor site, the flap was taken from the dorsal aspect containing the dorsal venous arch. The flap was reversed. The proximal vein of the flap was anastomosed with the dorsalis pedis artery, and the distal vein of the flap was anastomosed with the subcutaneous vein of the foot in the dorsomedial aspect of the big toe, thus creating an arteriovenous fistula (Fig. I). The flap was sutured loosely without undue tension. The AVF clearly demonstrated a pink color immediately after operation but gradually showed a cyanotic tinge. Flap congestion and edema, often accompanied by blistering, continued for about two weeks, but these conditions resolved within three weeks. The average operation time for this procedure was two hours and 40 minutes (range: two hours and 30 minutes to three hours). Thumb reconstruction and closure of the donor defect were thus accomplished at the same time. All patients received postoperative anticoagulation therapy, including 60,000 IU/day of urokinase and 500 ml/day of dextran for one week. When partial or marginal necrosis of the flap occurred, secondary closure with or without a free skin graft was carried out four to six weeks postoperatively. At that time, the A-V fistula was usually ligated distal to the flap to avoid development of an A-V tumor.
JANUARY 1991
thickness skin graft required regrafting six weeks later. At a three year follow-up, the patient's big toe had a good appearance, and he had no difficulty walking or running (Fig. 2). CASE 2. A 17-year-old man was referred to us 10 months after a conventional thumb reconstruction with osteoplastic bone graft and tubed pedicle flap. A WAF transfer was performed. The big toe defect was closed with a 6 x 12 cm AVF which was raised from the same foot. The foot donor site was closed with free skin grafting. A small area of the toe tip was left open to avoid tension on the flap. The flap showed mild congestion for one week, but survived completely. At one year follow-up, the young man reported no difficulty with the big toe (Fig. 3). CASE 3. A 42-year-old woman underwent onestage thumb reconstruction using a WAF for her left amputated thumb. A big toe defect was closed with a 7 x 7 cm AVF from the same foot. The foot donor site was closed with free skin grafting. The toe tip was closed loosely but developed marginal necrosis, which required resuturing five weeks later. Five months postoperative, the patient was pleased with her thumb and big toe (Fig. 4). CASE 4. A 44-year-old man sought treatment for his left thumb which had been lost traumatically at the MP joint 20 years earlier. The thumb was reconstructed by a WAF. The big toe defect was closed with a 7 x 8 cm AVF from the medial aspect of the leg. The leg donor site was closed with free skin grafting. The flap had a cyanotic appearance and marked edema for two weeks following the operation, but finally survived with 10 percent necrosis in its distal portion. Five months postoperative, the appearance was good and the big toe caused no problems (Fig. 5).
DISCUSSION Since Nakayama et al.3 in 1981 first reported their experimental study validating the possibility of new flap transfers that were nourished by arterial blood flowing through the venous network, there have been many successful reports of the "arterialized venous flap", both clinically and experimentally.4-7 The present authors in 19882 presented a preliminary report of small samples of AVF coverage for skin defects of the hand or foot, and suggested that success appeared to be influenced by the donor site itself and by the size of the flap. Since that time, we changed the donor site from the medial aspect of the leg to the dorsum of the foot, which appeared to have a richer venous plexus. The first seven cases used flaps from the medial aspect of the leg, measuring 3 to 4 cm in width, because the donor defect could be closed primarily. However, the flap was too small to close the big toe defect primarily.
In the two cases where the big toe defect was closed primarily with an AVF, the flaps failed, while in the remaining five cases where a small area of the big toe defect was left open or closed with additional skin graft, the flaps survived partially or completely. One flap from the leg donor site and eight flaps from the foot donor site were tailored to a big toe defect, taking a flap 6 to 7 cm wide. All but one (which failed because of reverse flow) survived partially or completely. Flaps from the leg donor site showed more extensive congestion and edema than those from the foot donor site, suggesting that success seems to be influenced by the donor site and by flap tension. We therefore recommend that the flap be generously larger than the size of the defect, so that extensive increased tension of the flap following postoperative edema can be lessened. The surgeon need not hesitate to leave a small defect open, if there is any question of extensive postoperative increase in flap tension. Regarding closure of the big toe defect after a WAF, Morrison et al.1 reported that a distal phalanx was resected, the remaining area of bare bone was closed by a cross-toe flap from the plantar surface of the second toe, and the remaining weight-bearing surface was covered with a split-thickness skin graft. In our earlier cases, we applied a wet dressing on the donor defect for two weeks, followed by a split-thickness skin graft. Both techniques could not provide sufficient soft-padded skin over the plantar weight-bearing surface of the big toe, so that long-term skin problems were possible, resulting in skin erosion and pain on distance walking. Aesthetically, the big toe covered in this manner may develop adduction-flexion contracture, with an irregular contour on the split-thickness skin, creating an ugly appearance. Hashimoto et al.8 reported that a donor defect closed with free peroneal flaps resulted in a good appearance and less morbidity of the big toe. However, this technique is technically demanding when harvesting the flap; moreover, most flaps need defatting, while our harvesting technique is easy and does not require defatting. Immediate coverage of the donor defect with an AVF assures good skin quality with underlying subcutaneous fat, produces a good appearance, and is less vulnerable to trauma. It also allows earlier return to unprotected weight-bearing and full functional recovery of the toe. A further benefit of this technique is preservation of an undisturbed second toe. As disadvantages, the success rate of this technique is inferior to that of Hashimoto, and wound healing of the big toe requires two or three months because of marginal or partial necrosis and/or remaining defect. However, these drawbacks do not compare unfavorably with those of a split-thickness skin graft. We indicated in a previous report that the palmar aspect of the forearm might be most preferable donor site for the AVF. However, we were reluctance to use
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ARTERIALIZED VENOUS FLAP/INOUE, MAEDA, SUZUKI
JANUARY 1991
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 1
•H D Figure 2. Case I. A, B, Immediately after transfer of an arterialized venous flap on the big toe. Remaining defect was covered with a split-thickness skin graft. C, D, Six weeks after operation, showing distal portion of the flap and most of a splitthickness skin graft became necrotic. (Figure continued on next page)
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ARTERIALIZED VENOUS FLAP/INOUE, MAEDA, SUZUKI
Figure 2, cont. E, F, Postoperative appearance of the big toe at three years. G, Postoperative appearance of reconstructed thumb at three years.
JANUARY 1991
Figure 3. Case 2. A, Outline of the flap on the dorsum of the same foot. B, Nine days postoperative, showing complete survival of the flap without marked edema.
6
Figure 4. Case 3. A, Immediately after operation. B, C, Two weeks postoperative, showing mild edema with blistering at distal portion of the dorsal aspect of the flap. (Figure continued on next page)
B
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Figure 4, cont. D, E, Five months postoperative, showing a good appearance.
Figure 5. Case 4. A, Outline of the flap on the medial aspect of the leg, which was tailored to the big toe defect. B, One week after operation, showing marked congestion and swelling. (Figure continued on next page)
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ARTERIAUZED VENOUS F1 AP/INOUE, MAEDA, SUZUKI
JANUARY 1991
Figure 5, cont. C, D, One month postoperative, showing about 10 percent necrosis of the flap. E, F, Postoperative appearance at five months.
this area as donor for closure of a big toe defect because of poor cosmetic sequelae. In summary, more clinical experience with this technique is necessary before advocating it as the treatment of choice. However, we believe that the technique does have great potential for wider clinical use.
REFERENCES Morrison WA, O'Brien BM, MacLeod AM: Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. ) Hand Surg 5:575, 1980
Inoue G, Maeda N: Arterialized venous flap coverage for skin defects of the hand or foot. I Reconstr Microsurg 4: 259,1988 Nakayama Y, Soeda S, Kasai Y: Flaps nourished by arterial inflow through the venous system: An experimental investigation. Plast Reconstr Surg 67:328, 1981 |i SY, Chia SL, Chen HH: Free transplantation of venous network pattern skin flap: An experimental study in rabbits. Microsurgery 5:151, 1984 Mundy )C, Panje WR: Creation of free flaps by arterialization of the venous system Arch Otolaryngol 110:221, 1984 Nichter LS, Haines PC: Arterialized venous perfusion of composite tissue. Am I Surg 150:191, 1985 Yoshimura M, Shimada T, Imura S, et al: The venous skin graft method for repairing skin defects of the fingers. Plast Reconstr Surg 79:243, 1987 Hashimoto F, Nomura S, Yamauchi S, et al.: Free peroneal flap coverage of the great toe defect resulting from a wraparound flap transfer. Microsurgery 7:199, 1986
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 1
