SYNDACTYLIZING ARTERIALIZED VENOUS FLAPS FOR MULTIPLE FINGER INJURIES MURAT KAYALAR, M.D.,1 LEVENT KUCUK, M.D.,2* TAHIR SADIK SUGUN, M.D.,1 YUSUF GURBUZ, M.D.,1 AHMET SAVRAN, M.D.,3 and IBRAHIM KAPLAN, M.D.1
Multiple soft tissue finger defects in different shapes and locations are usually difficult to manage. Such defects commonly involve tendons and bones. Palmar soft tissue defects may also lead to vascular compromise. In this retrospective report, we report the results of seven patients with multiple soft tissue finger defects that were covered by syndactylizing arterialized venous flaps. Six of the patients suffered hot-pressing machine and crushing injuries, one patient had a rolling belt injury. All patients presented with soft tissue defects on palmar or dorsal sides involving at least two digits. The palmar forearm was donor site for all patients. At least one afferent artery and two efferent veins were selected for the anastomosis. Lengths of afferent and efferent veins were long enough to perform healthy anastomosis outside the injury zone. The afferent vessels were anastamosed to the digital arteries with the largest possible diameter or to the common digital arteries to maximize flow. The efferent veins were anastamosed to dorsal veins. Separations of the digits were performed after three weeks by longitudinal incisions. The mean follow-up period was 12 months. None of our patients suffered a flap loss. Syndactylizing arterialized venous flaps may be used for composite or single tissue reconstruction for multiple finger defects with satisfactory cosmetic C 2014 Wiley Periodicals, Inc. Microsurgery 34:527–534, 2014. and functional outcomes. V
Venous flaps have been an available option for reconstruction since their first use in 1981.1 As a result of subsequent contributions, the survival rate of venous flaps has increased to over 90%.2–13 For complex multiple fingertip injuries, including palmar and dorsal longitudinal oblique defects, extending to the proximal end of the distal interphalangeal joint (DIP) crease cannot always be achieved using local homodigital/heterodigital island flaps due to accompanying soft tissue injuries and extension of injury zone to the donor area.14 Partial skin necrosis after multiple finger replantation surgery, crush injuries, rolling belt injuries, dorsal friction injuries are the most common causes of complex soft tissue defects. The difficulty of covering these complex defects sometimes leads the surgeon to decide shortening of finger or making a stump in some institutions. In such cases, arterialized venous flaps can be a good reconstructive option for optimal functional results.15,16 The surgeon must decide early whether the soft tissue reconstruction should be performed on every single digit separately or using a single syndactylizing flap. There are limited publications in the literature on the performance of syndactylizing venous flaps in hand surgery.16–20 In this report, we evaluated the results of the use of syndactylizing venous flaps for reconstruction of multiple finger injuries. We tried to analyze this flap not as a 1
EMOT Hospital, Izmir, Turkey Faculty of Medicine, Department of Orthopedics, Ege University, Izmir, Turkey 3 Tepecik Training Hospital, Izmir, Turkey *Correspondence to: Levent Kucuk, Faculty of Medicine, Department of Orthopedics, Izmir, Ege University, Turkey. E-mail: [email protected] Received 23 August 2013; Revision accepted 1 April 2014; Accepted 14 April 2014 Published online 30 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22267 2
Ó 2014 Wiley Periodicals, Inc.
subgroup of multiple finger injuries, but as a separate group which was different from previous reports in the literature. We also tried to give some technical details for flap harvest and inset. PATIENTS AND METHODS
Between 1999 and 2010, we performed 32 venous flaps in various defects. Seven syndactylizing arterialized venous flaps, which were applied for multiple finger defects, were included in this report. The inclusion criteria for the report were primarily multiple finger injuries involving soft tissue defects on the accompanying digits. Six of the patients were female. The average age was 27 (minimum 2, maximum 41). Two patients had right hand injuries, and the other five had left hand injuries. Hot-pressing machine injuries and crushing injuries were the most common cause (n 5 6), and one patient suffered a rolling belt injury. All of the patients presented with soft tissue defects on palmar or dorsal sides involving at least 2 digits. According to the Chen classification, our arterialized venous flaps were generally type III artery-vein-vein (AV-V) except one patient (A-V-A).21 All of the arterialized venous flaps in our series had an antegrade flow, along the valve pattern. Arterialized venous flaps measuring from 2 cm 3 4 cm to 5 cm 3 6 cm were utilized in seven cases. The venous flap technique was initially performed for three of our patients immediately after the injury, while the other four patients received surgery on the 3rd, 7th, 20th, and 22nd days. Surgical Technique
For all of our patients, the palmar forearm was used for the donor site to match the vessel diameter of digital
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vascular system. We tried to select the areas with the greatest venous plexus intensity when harvesting the flap. Regarding subdermal plexus, we add forearm fascia to the flap as well. The major large size veins were not included in any flaps. For palmar and dorsal defects that involved at least 2 digits, at least one afferent artery and two efferent veins were selected for the anastomosis. Flaps were designed always little wider than defect. For wider flap coverage, especially for three finger’s defect, the numbers of efferent anastomosis were increased. Therefore, the number of afferent and efferent anastomosis was increased in the rectangular, transversely located flaps. Hence the vessels entered to the skin island always clamped little longer than needed in order to increase available number of vessel for anastomosis. Those flaps usually contained “Y or H” pattern venous network. Generally, the vessels located on two opposite polar sides of the flap were chosen as afferents and efferents. While centering the flap skin island over the maximum vein containing area, flap margins were not determined strictly. Horizontal flap margins of the presumed skin island were incised first to detect maximum number of afferent and efferent veins. During elevation, flap skin island sometimes has been moved toward both side (ulnar/radial) to capture that diffuse territory. We dissected loose fatty tissue in neighboring of flap area to find out nearby vessels which could be contributed to the flap venous network. Thus the vessels located on the boundaries of the flap without any contribution to flap territory were not included into the flap and not used for anastamosis. During flap dissection, skin island was closely inspected and finally turned upside down in order to identify venous territory before any suitable anastomosis. The circulating blood within the flap was tried to enrich by this manner. Arterialized venous flaps along the valve pattern (orthodromic flow) were used for all cases. Therefore afferent veins are relatively smaller than efferents. An adequate length of afferent and efferent veins, to enable a healthy anastomosis outside of the injury zone, was also a major consideration. The length of afferent vessel was generally long enough to reach healthy digital arterial system which means further than web spaces proximally. The afferent vessel was anastamosed to the digital artery with the largest possible diameter or to the common digital artery to maximize flow. The efferent veins were anastamosed to dorsal veins. When the flap was used for a palmar defect, the efferent vessel was connected to the dorsal side of the hand either using a small incision or subcutaneous tunnels (Fig. 1). Antegrade venous flow drainage was achieved using commissural veins for the defects located near the web space. We routinely controlled the patency, filling characteristics of vessels under microscope peroperatively. After Microsurgery DOI 10.1002/micr
Figure 1. Illustration of flap inset for volar side defect. Afferent veins were coloured red and efferent veins blue. Efferent vessels were anastomesed to dorsal veins. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
completion of all anastomosis, flaps were observed in the first moments of their revascularization. If there was arterial insufficiency in their afferent phase, an extra anastomosis was added. After deflation of tourniquet and finishing afferent anastomosis, efferent’s outflow were checked under microscopic magnification. Close observation of flap circulation was undertaken without closure of skin in that early period. Donor sites closures were performed by primary closure or skin grafts with respect to narrow widths of the flaps in our series. In case of compound flap necessities, donor area closure was performed by using adjacent muscle bellies carefully without leaving any tendinous bare area. Post-operative flap monitoring was performed by the nurses every half hour for the first 6 hours and then hourly for the following 18 hours. Our post-operative protocol involves continuous elevation and immobilization. We didn’t use compression wrapping in the early post-operative period. Bulky dressings and short arm cast applied for immobilization. Patients were not allowed to mobilize for five days post-operatively for continuous elevation. Post-operative antibiotics and anticoagulation were given for the first 5 days. At the end of this period, if no complications were present, the patients were
Satisfactory Satisfactory 2 7 Same day 22th day
Satisfactory Satisfactory Satisfactory Satisfactory 6 6 48 11 7th day 3rd day Same day 20th day
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28 24 6 7
A: artery, V: vein, PIP: proximal interphalangeal joint. A-V-A: afferent arterial anastomosis–venous flap–Efferent arterial anastomosis. A-V-V: afferent arterial anastomosis–venous flap–Efferent venous anastamosis.
A-V-V A-V-V 5 cm 3 6 cm 3 cm 3 8 cm Dredge machine Falling pipe Dorsal Dorsal
38 41 2 25 2 3 4 5
4,5 2,3,4
Dorsal Dorsal Palmar Palmar
35 1
2,3 3,4 2,3,4,5 2,3,4,5
1 afferent-2 efferent 2 afferent-2 efferent
Survived/No complication Survived/No complication Survived/Lost of 3rd fingertip Survived/PIP flexion contracture Survived/No complication Survived/No complication efferent efferent efferent efferent afferent-2 afferent-2 afferent-2 afferent-2 1 1 3 1 A-V-V A-V-V A-V-A A-V-V 5 cm 3 4 cm 4.5 cm 3 4 cm 4 cm 3 2 cm 2 cm 3 5 cm
4 Same day Survived/No complication 1 afferent-1 efferent A-V-V 6 cm 3 4 cm
Leather dredge machine Hot-press Pressing in machine Rolling belt Press Palmar
Age No.
2,3,4,5
Vessel anastamosis Etiologic factor
Defect size
Venous flap type
Case 1: A 2-year-old female patient was referred to us following a rolling belt injury. She had friction injury on the palmar side of fingers which created 2 cm 3 4 cm soft tissue defect involving neurovascular bundles and tendons (Figs. 2A and 2B). Distal amputated parts were examined under microscopic magnification and considered suitable for replantation. We performed a type III A-V-A flow-through flap for this patient. The 3rd and 4th fingers were replanted using a venous flap. Therefore, the 2nd to 4th digit palmar defects were able to be closed through syndactylizing, placing the flap obliquely on the palmar side at the same time (Fig. 2C). Although the distal part of the 3rd finger was lost later, there was minimal bone shortening because of survival of the flap. The PIP was preserved which would have been able to use for further toe transfer in order to get better result. But patient family didn’t accept this intervention. The flap adaptation for that patient at the 4-year follow-up was determined to be very good (Figs. 2D and 2E). Case 2: A 24-year old male patient was referred to us with a crush injury on the 2nd, 3rd, and 4th fingers, resulting from an iron pipe falling on his hand (Fig. 3A). This patient had a large damage zone, including the PIP
Defect location
Case Reports
Injured fingers
Neither cyanosis nor venous congestion was observed in any of the flaps post-operatively. Anastomotic revision was not recorded. The mean follow-up period was 12 months (minimum 2 months, maximum 48 months). None of our patients suffered a flap loss (Table 1). Congestion and swelling, which are the most common early post-operative complications of arterialized venous flaps, were not observed. Proximal interphalangeal joint (PIP) flexion contracture developed as a late complication in one patient. This complication was corrected via arthrolysis and pulley reconstruction. A further flap-thinning operation was suggested after the 6th month; however, this proposal was rejected because the patient was satisfied with the cushioning effect. With reference to the Semmes Weinstein monofilament test, all of the flaps were rated to have a general level of protective sensation of approximately 4.31.22
Table 1. Demographic Data, Characteristics of Injuries, and Flaps
RESULTS
Survival/Complications
Timing of Venous Flap
Total follow-up (months)
Outcomes
discharged from the hospital with outpatient clinic follow-up. The wound dressings were changed every 2 to 3 days, using interdigital gauze, to prevent maceration and infection. After waiting for the recipient site to adapt and flap monitoring for viability, interdigital flap separations were performed in the 4th week by longitudinal incisions.
Satisfactory
Syndactylizing Venous Flaps
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Figure 2. A 2-year-old girl was presented with third and fourth finger amputation and pulp defect in second finger after a rolling belt injury (A). Dorsal view after the injury (B). Replantations and pulp defect reconstruction were performed with a flow-through venous flap (C). Volar view after 4 years (D). Dorsal view after 4 years (E). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
and distal interphalangeal (DIP) joints, with volar and dorsal injuries (Fig. 3B). The wound had been contaminated by soil. Therefore debridement and irrigation was undertaken before any bony fixation (Fig. 3C). We decided to perform a staged procedure like long bone open fracture treatment accepting bony gaps and bone graft necessity later (Fig. 3D). The flexor mechanism had been severely lacerated, and the integrity of the extensor tendons was compromised. Because of the joint damage, we performed PIP arthrodesis and flexor tendon/extensor tendon repairs during the first operation (Figs. 3E and 3F). We didn’t make extra dissection of vascular bundles not to disturb existing good circulatory status. The wounds were loosely closed using the local skin flaps. Then, we waited, performed wound care and gave antibiotics until the 22nd day. In the second evaluation, some skin margin necrosis developed due to crush injury as expected. Second debridement made skin closure more difficult. Measured defect was 3 cm 3 8 cm. Thus we decided to cover it with a venous flap (Fig. 4). Flap was harvested from the Microsurgery DOI 10.1002/micr
same forearm (Fig. 5A). A healthy well nourished tissue would also have affected bone graft incorporation and infection control positively (Fig. 5B). Bone grafting and venous flap coverage was undertaken at the same time (Figs. 5C and 5D). At the final follow-up examination, patient was satisfied with his hand and he was able to return his job (Fig. 5E). He had stable PIP on account of PIP arthrodesis and full metacarpophalangeal joint mobility (Fig. 5F). His follow-up duration was 7 months. DISCUSSION
Multi-finger injuries occur as a result of various accidents. They can present as crushing injuries that completely disrupt the finger circulation or as injuries that do not disrupt finger circulation but rather are visible as a pronounced tissue defect. Crushing injuries generally cause segmental loss of tissue viability in all of the fingers that are affected in transverse or oblique patterns. The preferable approach in these types of complex soft tissue injuries is to repair all of the damaged tissue in a one-stage procedure. When an injury involves more than
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Figure 3. A 24-year-old male patient was presented with a crush injury on the 2nd, 3rd, and 4th fingers, resulting from an iron pipe falling on his hand (A). Volar view of crush injuries to the 2nd, 3rd, and 4th fingers. There was no arterial injury that compromises circulation (B). There were severe PIP damage and segmental bone fragmentation. Debridement and bone and tendon repairs were performed in the first operation (C, D). Volar and dorsal views of the hand prior to bone grafting and flap application on the 22nd day (E, F). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
one finger on the palmar side, providing circulation by vein grafts, reconstructing the soft tissue for each finger individually at the same time generally require a more complex, time-consuming reconstructive procedure, which is sometimes not feasible. The complex nature of this procedure is often the cause of additional complications and potentially unsuccessful results. For some multi-finger injuries with only soft tissue defects, the distal circulation is preserved. A local flap is intended to cover the open areas of a finger’s vital tissues, such as the tendons, nerves, and bones, but the traditional local flaps commonly used for single finger injuries may not be an option. These convenient flaps include direct-flow homodigital neurovascular flaps; reverse-flow, homodigital, dorsal, proximal phalanx skin flaps; and homo/heterodigital middle phalanx island flaps.14,23 Unfortunately, often in multi-finger injuries, using any of the aforementioned flaps is not possible because of damaged donor areas. The defects with the dimensions and location that require venous flap coverage are also generally larger than the classic
limits for these flaps. Other potential harvesting sites include the dorsal hand, thenar/hypothenar area, and forearm.22,24–26
Figure 4. Illustration of flap inset for dorsal side defect. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Figure 5. A flap was harvested from the forearm. Note the length of the afferent and efferent vessels (A,B). Post-operative view of the syndactylizing flap (C). Post-operative view of the hand after finger separation (D).Views of the donor area and the hand (E, F). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Using arterialized venous flaps by syndactylizing fingers for multi-finger injuries is possible. In previous studies, while successful venous flap reconstruction for the revascularization and reconstruction of single finger defects has been noted, there are limited publications available on syndactylizing venous flaps for soft tissue reconstruction of multiple finger defects.16–18,20 Recently, it has become possible to use venous flaps on larger, multi-digit, asymmetric defects because of an increased understanding of venous flap perfusion dynamics and advances in preparation.4,8,15,16,20 Yan et al. reported their use of arterialized sensate/ insensate flaps for every single pulp defect without syndactylizing. Both along the valve pattern and against the valve pattern flaps have been preferred in their study. Their results showed that comparable functional and aesthetic outcomes can be obtained by using venous flap in pulp defect of more than 2.5 cm.22 Lin et al. reported 100% flap survival in their 15 cases by using shunt restricted arterialized venous flaps. There was only one syndactylizing flap application in their series. They found higher rate of congestion especially “I” pattern venous Microsurgery DOI 10.1002/micr
network. They concluded that shunt restriction can be a solution for flap peripheral perfusion.27 While covering the defect, especially for single digit palmar tissue loss, venous flaps are also a good vessel carrier for revascularization.19,28–30 Multi-finger soft tissue injuries occasionally present with a longitudinal loss of the rectangular shape only on the palmar or dorsal side. In these cases, finger length and function can be maximally protected by using a venous flap. The tendon can also be included in the flap for injuries involving extensor defects, especially on the finger dorsum.31,32 Preserving finger length is very important for stump closure following unsuccessful multi-finger replantations. In such cases, individual stump closure of each finger generally requires bone shortening. A venous flap can be used in such cases for the distal end of the finger/fingers, without the need for bone shortening, providing a net gain of preserved bone of 0.5–1 cm. In multi-finger injuries, venous flaps also have some disadvantages. The greatest disadvantage is that a circulation defect in a single finger can detrimentally affect the
Syndactylizing Venous Flaps
entire flap, especially if the flap is being used as a flowthrough flap. Unfortunately, this situation is also frequently difficult to monitor. As venous flaps do not involve perfusion like standard flaps, if they do develop venous congestion and arterial ischemia, the primary cause is very difficult to identify (i.e., checking all of the anastomoses and venous/arterial thrombosis). The use of dual venous outflows via separate venous networks may be useful for minimizing venous congestion in larger flaps but it would be technically demanding to separate venous network in smaller flaps.33 In smaller flaps, we think that increasing the number of efferent veins and rigid post-operative protocols involving continuous elevation and immobilization are the major factors preventing venous congestion and edema. Kakinoki et al. found that smaller flaps less than 763 mm2 have been more likely survived. We also thought that maximum vein containment and small flap size as Kakinoki pointed out may be the reasons of our high flap survival.34 Replantation was performed using a flow-through flap in only one patient in our series, who presented with a rolling belt injury. While the distal part of one finger could not be saved, the fact that the flap remained viable was crucial for the overall healing process. Flap survival rates and patients’ satisfaction outcomes were significantly high in our series. These results might be an unexpected condition with respect to previous reports. Unfortunately, the small number of our patient group could prevent us to make some precise determinations about the factors that might be effective in outcomes. Nevertheless in the light of our limited experience, high survival rates of arterialized venous flap may be related to the following factors: (1) diffuse venous network, (2) at least 2–3 efferent anastomosis, (3) peroperative early circulatory observation and if necessary additional anastomosis in afferent phase, (4) not to use parallel veins for anastomosis, (5) always use polar vein for anastomosis, (6) good quality maximum flow for arterial anastomosis, (7) small diameter afferent vessel, (8) small flap size. CONCLUSIONS
Using a single flap to close multiple defects on two or more fingers is slowly becoming a more attractive option. Achieving the same results using more than one flap greatly increases the complexity of the procedure, leading to increased risk. This report focuses on a technically demanding procedure in the treatment of complex hand injuries with high satisfactory outcomes as distinct from some previous reports. We believe that as the preparation and application of single arterialized venous flaps become more widely studied, these flaps may become an important salvage procedure for surgeons treating multifinger injuries.
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REFERENCES 1. Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous system: An experimental investigation. Plast Reconstr Surg 1981;67:328–334. 2. Alexander G. Multistage type 3 venous flap or ‘pre-arterialisation of an arterialised venous flap’. Br J Plast Surg 2001;54:734. 3. Fukui A, Inada Y, Murata K, Ueda Y, Tamai S. A method for prevention of arterialized venous flap necrosis. J Reconstr Microsurg 1998;14:67–74. 4. Goldschlager R, Rozen WM, Ting JW, Leong J. The nomenclature of venous flow-through flaps: Updated classification and review of the literature. Microsurgery 2012;32:497–501. 5. Inada Y, Fukui A, Tamai S, Mizumoto S. The arterialised venous flap: Experimental studies and a clinical case. Br J Plast Surg 1993; 46:61–67. 6. Inoue G, Maeda N. Arterialized venous flap coverage for skin defects of the hand or foot. J Reconstr Microsurg 1988;4:259–266. 7. Kamei K, Ide Y. The pedicled arterialized venous flap. J Reconstr Microsurg 1993;9:287–291. 8. Koch H, Scharnagl E, Schwarzl FX, Haas FM, Hubmer M, Moshammer HE. Clinical application of the retrograde arterialized venous flap. Microsurgery 2004;24:118–124. 9. Moshammer HE, Schwarzl FX, Haas FM, Maechler H, Pierer G, Wiltgen M, Koch H. Retrograde arterialized venous flap: An experimental study. Microsurgery 2003;23:130–134. 10. Mutaf M, Tasaki Y, Fujii T. Expansion of venous flaps: An experimental study in rats.Br J Plast Surg 1998;51:393–401. 11. Woo SH, Kim SE, Lee TH, Jeong JH, Seul JH. Effects of blood flow and venous network on survival of the arterialized venous flap. Plast Reconstr Surg 1998;101:1280–1289. 12. Woo SH, Seul JH. Pre-expanded arterialised venous free flaps for burn contracture of the cervicofacial region. Br J Plast Surg 2001; 54:390–395. 13. Wungcharoen B, Pradidarcheep W, Santidhananon Y, Chongchet V. Pre-arterialisation of the arterialised venous flap: An experimental study in the rat. Br J Plast Surg 2001;54:621–630. 14. Kayalar M, Bal E, Toros T, Sugun ST, Ozaksar K, Gurbuz Y. The outcome of direct-flow neurovascular island flaps in pulp defects. Acta Orthop Traumatol Turc 2011;45:175–184. 15. Yan H, Zhang F, Akdemir O, Songcharoen S, Jones NI, Angel M, Brook D. Clinical applications of venous flaps in the reconstruction of hands and fingers. Arch Orthop Trauma Surg 2011;131:65–74. 16. Woo SH, Kim KC, Lee GJ, Ha SH, Kim KH, Dhawan V, Lee KS. A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: An 11-year experience. Plast Reconstr Surg 2007; 119:1823–1838. 17. Hyza P, Vesely J, Stupka I, Cigna E, Monni N. The bilobed arterialized venous free flap for simultaneous coverage of 2 separate defects of a digit. Ann Plast Surg 2005;55:679–683. 18. Inoue G, Suzuki K. Arterialized venous flap for treating multiple skin defects of the hand. Plast Reconstr Surg 1993;91:299–302. 19. Takeuchi M, Sakurai H, Sasaki K, Nozaki M. Treatment of finger avulsion injuries with innervated arterialized venous flaps. Plast Reconstr Surg 2000;106:881–885. 20. Trovato MJ, Brooks D, Buntic RF, Buncke GM. Simultaneous coverage of two separate dorsal digital defects with a syndactylizing venous free flap. Microsurgery 2008;28:248–251. 21. Chen HC, Tang YB, Noordhoff MS. Four types of venous flaps for wound coverage: A clinical appraisal. J Trauma 1991;31:1286–1293. 22. Yan H, Gao W, Zhang F, Li Z, Chen X, Fan C. A comparative study of finger pulp reconstruction using arterialised venous sensate flap and insensate flap from forearm. J Plast Reconstr Aesthet Surg 2012;65:1220–1226. 23. Rahmanian-Schwarz A, Schiefer J, Amr A, Schaller HE, Hirt B. Vascularized tendon incorporated in reverse homodigital and heterodigital island flaps for the reconstruction of dorsal digital defects. Microsurgery 2012;32:178–182.
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24. Iwasawa M, Ohtsuka Y, Kushima H, Kiyono M. Arterialized venous flaps from the thenar and hypothenar regions for repairing finger pulp tissue losses. Plast Reconstr Surg 1997;99:1765–1770. 25. Murata K, Inada Y, Fukui A, Tamai S, Takakura Y. Clinical application of the reversed pedicled venous flap containing perivenous areolar tissue and/or nerve in the hand. Br J Plast Surg 2001;54: 615–620. 26. Yan H, Fan C, Gao W, Chen Z, Li Z, Chi Z. Finger pulp reconstruction with free flaps from the upper extremity. Microsurgery 2012;32: 406–414. 27. Lin YT, Henry SL, Lin CH, Lee HY, Lin WN, Wei FC. The shuntrestricted arterialized venous flap for hand/digit reconstruction: Enhanced perfusion, decreased congestion, and improved reliability. J Trauma 2010;69:399–404. 28. Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins. J Hand Surg Am 2008;33:1802–1806. 29. Nakazawa H, Kikuchi Y, Honda T, Isago T, Morioka K, Itoh H. Use of an arterialised venous skin flap in the replantation of an
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amputated thumb. Scand J Plast Reconstr Surg Hand Surg 2004;38: 187–191. 30. Titley OG, Chester DL, Park AJ. A-a type, arterialized, venous, flow-through, free flap for simultaneous digital revascularization and soft tissue reconstruction-revisited. Ann Plast Surg 2004;53:185–191. 31. Chen CL, Chiu HY, Lee JW, Yang JT. Arterialized tendocutaneous venous flap for dorsal finger reconstruction. Microsurgery 1994;15: 886–890. 32. Cho BC, Byun JS, Baik BS. Dorsalis pedis tendocutaneous delayed arterialized venous flap in hand reconstruction. Plast Reconstr Surg 1999;104:2138–2144. 33. Rozen WM, Ting JW, Gilmour RF, Leong J. The arterialized saphenous venous flow-through flap with dual venous drainage. Microsurgery 2012;32:281–288. 34. Kakinoki R, Ikeguchi R, Nankaku M, Nakamua T. Factors affecting the success of arterialised venous flaps in the hand. Injury 2008;39 (Suppl 2):18–24.
Multiple soft tissue finger defects in different shapes and locations are usually difficult to manage. Such defects commonly involve tendons and bones. Palmar soft tissue defects may also lead to vascular compromise. In this retrospective report, we report the results of seven patients with multiple soft tissue finger defects that were covered by syndactylizing arterialized venous flaps. Six of the patients suffered hot-pressing machine and crushing injuries, one patient had a rolling belt injury. All patients presented with soft tissue defects on palmar or dorsal sides involving at least two digits. The palmar forearm was donor site for all patients. At least one afferent artery and two efferent veins were selected for the anastomosis. Lengths of afferent and efferent veins were long enough to perform healthy anastomosis outside the injury zone. The afferent vessels were anastamosed to the digital arteries with the largest possible diameter or to the common digital arteries to maximize flow. The efferent veins were anastamosed to dorsal veins. Separations of the digits were performed after three weeks by longitudinal incisions. The mean follow-up period was 12 months. None of our patients suffered a flap loss. Syndactylizing arterialized venous flaps may be used for composite or single tissue reconstruction for multiple finger defects with satisfactory cosmetic C 2014 Wiley Periodicals, Inc. Microsurgery 34:527–534, 2014. and functional outcomes. V
Venous flaps have been an available option for reconstruction since their first use in 1981.1 As a result of subsequent contributions, the survival rate of venous flaps has increased to over 90%.2–13 For complex multiple fingertip injuries, including palmar and dorsal longitudinal oblique defects, extending to the proximal end of the distal interphalangeal joint (DIP) crease cannot always be achieved using local homodigital/heterodigital island flaps due to accompanying soft tissue injuries and extension of injury zone to the donor area.14 Partial skin necrosis after multiple finger replantation surgery, crush injuries, rolling belt injuries, dorsal friction injuries are the most common causes of complex soft tissue defects. The difficulty of covering these complex defects sometimes leads the surgeon to decide shortening of finger or making a stump in some institutions. In such cases, arterialized venous flaps can be a good reconstructive option for optimal functional results.15,16 The surgeon must decide early whether the soft tissue reconstruction should be performed on every single digit separately or using a single syndactylizing flap. There are limited publications in the literature on the performance of syndactylizing venous flaps in hand surgery.16–20 In this report, we evaluated the results of the use of syndactylizing venous flaps for reconstruction of multiple finger injuries. We tried to analyze this flap not as a 1
EMOT Hospital, Izmir, Turkey Faculty of Medicine, Department of Orthopedics, Ege University, Izmir, Turkey 3 Tepecik Training Hospital, Izmir, Turkey *Correspondence to: Levent Kucuk, Faculty of Medicine, Department of Orthopedics, Izmir, Ege University, Turkey. E-mail: [email protected] Received 23 August 2013; Revision accepted 1 April 2014; Accepted 14 April 2014 Published online 30 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22267 2
Ó 2014 Wiley Periodicals, Inc.
subgroup of multiple finger injuries, but as a separate group which was different from previous reports in the literature. We also tried to give some technical details for flap harvest and inset. PATIENTS AND METHODS
Between 1999 and 2010, we performed 32 venous flaps in various defects. Seven syndactylizing arterialized venous flaps, which were applied for multiple finger defects, were included in this report. The inclusion criteria for the report were primarily multiple finger injuries involving soft tissue defects on the accompanying digits. Six of the patients were female. The average age was 27 (minimum 2, maximum 41). Two patients had right hand injuries, and the other five had left hand injuries. Hot-pressing machine injuries and crushing injuries were the most common cause (n 5 6), and one patient suffered a rolling belt injury. All of the patients presented with soft tissue defects on palmar or dorsal sides involving at least 2 digits. According to the Chen classification, our arterialized venous flaps were generally type III artery-vein-vein (AV-V) except one patient (A-V-A).21 All of the arterialized venous flaps in our series had an antegrade flow, along the valve pattern. Arterialized venous flaps measuring from 2 cm 3 4 cm to 5 cm 3 6 cm were utilized in seven cases. The venous flap technique was initially performed for three of our patients immediately after the injury, while the other four patients received surgery on the 3rd, 7th, 20th, and 22nd days. Surgical Technique
For all of our patients, the palmar forearm was used for the donor site to match the vessel diameter of digital
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vascular system. We tried to select the areas with the greatest venous plexus intensity when harvesting the flap. Regarding subdermal plexus, we add forearm fascia to the flap as well. The major large size veins were not included in any flaps. For palmar and dorsal defects that involved at least 2 digits, at least one afferent artery and two efferent veins were selected for the anastomosis. Flaps were designed always little wider than defect. For wider flap coverage, especially for three finger’s defect, the numbers of efferent anastomosis were increased. Therefore, the number of afferent and efferent anastomosis was increased in the rectangular, transversely located flaps. Hence the vessels entered to the skin island always clamped little longer than needed in order to increase available number of vessel for anastomosis. Those flaps usually contained “Y or H” pattern venous network. Generally, the vessels located on two opposite polar sides of the flap were chosen as afferents and efferents. While centering the flap skin island over the maximum vein containing area, flap margins were not determined strictly. Horizontal flap margins of the presumed skin island were incised first to detect maximum number of afferent and efferent veins. During elevation, flap skin island sometimes has been moved toward both side (ulnar/radial) to capture that diffuse territory. We dissected loose fatty tissue in neighboring of flap area to find out nearby vessels which could be contributed to the flap venous network. Thus the vessels located on the boundaries of the flap without any contribution to flap territory were not included into the flap and not used for anastamosis. During flap dissection, skin island was closely inspected and finally turned upside down in order to identify venous territory before any suitable anastomosis. The circulating blood within the flap was tried to enrich by this manner. Arterialized venous flaps along the valve pattern (orthodromic flow) were used for all cases. Therefore afferent veins are relatively smaller than efferents. An adequate length of afferent and efferent veins, to enable a healthy anastomosis outside of the injury zone, was also a major consideration. The length of afferent vessel was generally long enough to reach healthy digital arterial system which means further than web spaces proximally. The afferent vessel was anastamosed to the digital artery with the largest possible diameter or to the common digital artery to maximize flow. The efferent veins were anastamosed to dorsal veins. When the flap was used for a palmar defect, the efferent vessel was connected to the dorsal side of the hand either using a small incision or subcutaneous tunnels (Fig. 1). Antegrade venous flow drainage was achieved using commissural veins for the defects located near the web space. We routinely controlled the patency, filling characteristics of vessels under microscope peroperatively. After Microsurgery DOI 10.1002/micr
Figure 1. Illustration of flap inset for volar side defect. Afferent veins were coloured red and efferent veins blue. Efferent vessels were anastomesed to dorsal veins. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
completion of all anastomosis, flaps were observed in the first moments of their revascularization. If there was arterial insufficiency in their afferent phase, an extra anastomosis was added. After deflation of tourniquet and finishing afferent anastomosis, efferent’s outflow were checked under microscopic magnification. Close observation of flap circulation was undertaken without closure of skin in that early period. Donor sites closures were performed by primary closure or skin grafts with respect to narrow widths of the flaps in our series. In case of compound flap necessities, donor area closure was performed by using adjacent muscle bellies carefully without leaving any tendinous bare area. Post-operative flap monitoring was performed by the nurses every half hour for the first 6 hours and then hourly for the following 18 hours. Our post-operative protocol involves continuous elevation and immobilization. We didn’t use compression wrapping in the early post-operative period. Bulky dressings and short arm cast applied for immobilization. Patients were not allowed to mobilize for five days post-operatively for continuous elevation. Post-operative antibiotics and anticoagulation were given for the first 5 days. At the end of this period, if no complications were present, the patients were
Satisfactory Satisfactory 2 7 Same day 22th day
Satisfactory Satisfactory Satisfactory Satisfactory 6 6 48 11 7th day 3rd day Same day 20th day
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28 24 6 7
A: artery, V: vein, PIP: proximal interphalangeal joint. A-V-A: afferent arterial anastomosis–venous flap–Efferent arterial anastomosis. A-V-V: afferent arterial anastomosis–venous flap–Efferent venous anastamosis.
A-V-V A-V-V 5 cm 3 6 cm 3 cm 3 8 cm Dredge machine Falling pipe Dorsal Dorsal
38 41 2 25 2 3 4 5
4,5 2,3,4
Dorsal Dorsal Palmar Palmar
35 1
2,3 3,4 2,3,4,5 2,3,4,5
1 afferent-2 efferent 2 afferent-2 efferent
Survived/No complication Survived/No complication Survived/Lost of 3rd fingertip Survived/PIP flexion contracture Survived/No complication Survived/No complication efferent efferent efferent efferent afferent-2 afferent-2 afferent-2 afferent-2 1 1 3 1 A-V-V A-V-V A-V-A A-V-V 5 cm 3 4 cm 4.5 cm 3 4 cm 4 cm 3 2 cm 2 cm 3 5 cm
4 Same day Survived/No complication 1 afferent-1 efferent A-V-V 6 cm 3 4 cm
Leather dredge machine Hot-press Pressing in machine Rolling belt Press Palmar
Age No.
2,3,4,5
Vessel anastamosis Etiologic factor
Defect size
Venous flap type
Case 1: A 2-year-old female patient was referred to us following a rolling belt injury. She had friction injury on the palmar side of fingers which created 2 cm 3 4 cm soft tissue defect involving neurovascular bundles and tendons (Figs. 2A and 2B). Distal amputated parts were examined under microscopic magnification and considered suitable for replantation. We performed a type III A-V-A flow-through flap for this patient. The 3rd and 4th fingers were replanted using a venous flap. Therefore, the 2nd to 4th digit palmar defects were able to be closed through syndactylizing, placing the flap obliquely on the palmar side at the same time (Fig. 2C). Although the distal part of the 3rd finger was lost later, there was minimal bone shortening because of survival of the flap. The PIP was preserved which would have been able to use for further toe transfer in order to get better result. But patient family didn’t accept this intervention. The flap adaptation for that patient at the 4-year follow-up was determined to be very good (Figs. 2D and 2E). Case 2: A 24-year old male patient was referred to us with a crush injury on the 2nd, 3rd, and 4th fingers, resulting from an iron pipe falling on his hand (Fig. 3A). This patient had a large damage zone, including the PIP
Defect location
Case Reports
Injured fingers
Neither cyanosis nor venous congestion was observed in any of the flaps post-operatively. Anastomotic revision was not recorded. The mean follow-up period was 12 months (minimum 2 months, maximum 48 months). None of our patients suffered a flap loss (Table 1). Congestion and swelling, which are the most common early post-operative complications of arterialized venous flaps, were not observed. Proximal interphalangeal joint (PIP) flexion contracture developed as a late complication in one patient. This complication was corrected via arthrolysis and pulley reconstruction. A further flap-thinning operation was suggested after the 6th month; however, this proposal was rejected because the patient was satisfied with the cushioning effect. With reference to the Semmes Weinstein monofilament test, all of the flaps were rated to have a general level of protective sensation of approximately 4.31.22
Table 1. Demographic Data, Characteristics of Injuries, and Flaps
RESULTS
Survival/Complications
Timing of Venous Flap
Total follow-up (months)
Outcomes
discharged from the hospital with outpatient clinic follow-up. The wound dressings were changed every 2 to 3 days, using interdigital gauze, to prevent maceration and infection. After waiting for the recipient site to adapt and flap monitoring for viability, interdigital flap separations were performed in the 4th week by longitudinal incisions.
Satisfactory
Syndactylizing Venous Flaps
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Figure 2. A 2-year-old girl was presented with third and fourth finger amputation and pulp defect in second finger after a rolling belt injury (A). Dorsal view after the injury (B). Replantations and pulp defect reconstruction were performed with a flow-through venous flap (C). Volar view after 4 years (D). Dorsal view after 4 years (E). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
and distal interphalangeal (DIP) joints, with volar and dorsal injuries (Fig. 3B). The wound had been contaminated by soil. Therefore debridement and irrigation was undertaken before any bony fixation (Fig. 3C). We decided to perform a staged procedure like long bone open fracture treatment accepting bony gaps and bone graft necessity later (Fig. 3D). The flexor mechanism had been severely lacerated, and the integrity of the extensor tendons was compromised. Because of the joint damage, we performed PIP arthrodesis and flexor tendon/extensor tendon repairs during the first operation (Figs. 3E and 3F). We didn’t make extra dissection of vascular bundles not to disturb existing good circulatory status. The wounds were loosely closed using the local skin flaps. Then, we waited, performed wound care and gave antibiotics until the 22nd day. In the second evaluation, some skin margin necrosis developed due to crush injury as expected. Second debridement made skin closure more difficult. Measured defect was 3 cm 3 8 cm. Thus we decided to cover it with a venous flap (Fig. 4). Flap was harvested from the Microsurgery DOI 10.1002/micr
same forearm (Fig. 5A). A healthy well nourished tissue would also have affected bone graft incorporation and infection control positively (Fig. 5B). Bone grafting and venous flap coverage was undertaken at the same time (Figs. 5C and 5D). At the final follow-up examination, patient was satisfied with his hand and he was able to return his job (Fig. 5E). He had stable PIP on account of PIP arthrodesis and full metacarpophalangeal joint mobility (Fig. 5F). His follow-up duration was 7 months. DISCUSSION
Multi-finger injuries occur as a result of various accidents. They can present as crushing injuries that completely disrupt the finger circulation or as injuries that do not disrupt finger circulation but rather are visible as a pronounced tissue defect. Crushing injuries generally cause segmental loss of tissue viability in all of the fingers that are affected in transverse or oblique patterns. The preferable approach in these types of complex soft tissue injuries is to repair all of the damaged tissue in a one-stage procedure. When an injury involves more than
Syndactylizing Venous Flaps
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Figure 3. A 24-year-old male patient was presented with a crush injury on the 2nd, 3rd, and 4th fingers, resulting from an iron pipe falling on his hand (A). Volar view of crush injuries to the 2nd, 3rd, and 4th fingers. There was no arterial injury that compromises circulation (B). There were severe PIP damage and segmental bone fragmentation. Debridement and bone and tendon repairs were performed in the first operation (C, D). Volar and dorsal views of the hand prior to bone grafting and flap application on the 22nd day (E, F). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
one finger on the palmar side, providing circulation by vein grafts, reconstructing the soft tissue for each finger individually at the same time generally require a more complex, time-consuming reconstructive procedure, which is sometimes not feasible. The complex nature of this procedure is often the cause of additional complications and potentially unsuccessful results. For some multi-finger injuries with only soft tissue defects, the distal circulation is preserved. A local flap is intended to cover the open areas of a finger’s vital tissues, such as the tendons, nerves, and bones, but the traditional local flaps commonly used for single finger injuries may not be an option. These convenient flaps include direct-flow homodigital neurovascular flaps; reverse-flow, homodigital, dorsal, proximal phalanx skin flaps; and homo/heterodigital middle phalanx island flaps.14,23 Unfortunately, often in multi-finger injuries, using any of the aforementioned flaps is not possible because of damaged donor areas. The defects with the dimensions and location that require venous flap coverage are also generally larger than the classic
limits for these flaps. Other potential harvesting sites include the dorsal hand, thenar/hypothenar area, and forearm.22,24–26
Figure 4. Illustration of flap inset for dorsal side defect. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Figure 5. A flap was harvested from the forearm. Note the length of the afferent and efferent vessels (A,B). Post-operative view of the syndactylizing flap (C). Post-operative view of the hand after finger separation (D).Views of the donor area and the hand (E, F). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Using arterialized venous flaps by syndactylizing fingers for multi-finger injuries is possible. In previous studies, while successful venous flap reconstruction for the revascularization and reconstruction of single finger defects has been noted, there are limited publications available on syndactylizing venous flaps for soft tissue reconstruction of multiple finger defects.16–18,20 Recently, it has become possible to use venous flaps on larger, multi-digit, asymmetric defects because of an increased understanding of venous flap perfusion dynamics and advances in preparation.4,8,15,16,20 Yan et al. reported their use of arterialized sensate/ insensate flaps for every single pulp defect without syndactylizing. Both along the valve pattern and against the valve pattern flaps have been preferred in their study. Their results showed that comparable functional and aesthetic outcomes can be obtained by using venous flap in pulp defect of more than 2.5 cm.22 Lin et al. reported 100% flap survival in their 15 cases by using shunt restricted arterialized venous flaps. There was only one syndactylizing flap application in their series. They found higher rate of congestion especially “I” pattern venous Microsurgery DOI 10.1002/micr
network. They concluded that shunt restriction can be a solution for flap peripheral perfusion.27 While covering the defect, especially for single digit palmar tissue loss, venous flaps are also a good vessel carrier for revascularization.19,28–30 Multi-finger soft tissue injuries occasionally present with a longitudinal loss of the rectangular shape only on the palmar or dorsal side. In these cases, finger length and function can be maximally protected by using a venous flap. The tendon can also be included in the flap for injuries involving extensor defects, especially on the finger dorsum.31,32 Preserving finger length is very important for stump closure following unsuccessful multi-finger replantations. In such cases, individual stump closure of each finger generally requires bone shortening. A venous flap can be used in such cases for the distal end of the finger/fingers, without the need for bone shortening, providing a net gain of preserved bone of 0.5–1 cm. In multi-finger injuries, venous flaps also have some disadvantages. The greatest disadvantage is that a circulation defect in a single finger can detrimentally affect the
Syndactylizing Venous Flaps
entire flap, especially if the flap is being used as a flowthrough flap. Unfortunately, this situation is also frequently difficult to monitor. As venous flaps do not involve perfusion like standard flaps, if they do develop venous congestion and arterial ischemia, the primary cause is very difficult to identify (i.e., checking all of the anastomoses and venous/arterial thrombosis). The use of dual venous outflows via separate venous networks may be useful for minimizing venous congestion in larger flaps but it would be technically demanding to separate venous network in smaller flaps.33 In smaller flaps, we think that increasing the number of efferent veins and rigid post-operative protocols involving continuous elevation and immobilization are the major factors preventing venous congestion and edema. Kakinoki et al. found that smaller flaps less than 763 mm2 have been more likely survived. We also thought that maximum vein containment and small flap size as Kakinoki pointed out may be the reasons of our high flap survival.34 Replantation was performed using a flow-through flap in only one patient in our series, who presented with a rolling belt injury. While the distal part of one finger could not be saved, the fact that the flap remained viable was crucial for the overall healing process. Flap survival rates and patients’ satisfaction outcomes were significantly high in our series. These results might be an unexpected condition with respect to previous reports. Unfortunately, the small number of our patient group could prevent us to make some precise determinations about the factors that might be effective in outcomes. Nevertheless in the light of our limited experience, high survival rates of arterialized venous flap may be related to the following factors: (1) diffuse venous network, (2) at least 2–3 efferent anastomosis, (3) peroperative early circulatory observation and if necessary additional anastomosis in afferent phase, (4) not to use parallel veins for anastomosis, (5) always use polar vein for anastomosis, (6) good quality maximum flow for arterial anastomosis, (7) small diameter afferent vessel, (8) small flap size. CONCLUSIONS
Using a single flap to close multiple defects on two or more fingers is slowly becoming a more attractive option. Achieving the same results using more than one flap greatly increases the complexity of the procedure, leading to increased risk. This report focuses on a technically demanding procedure in the treatment of complex hand injuries with high satisfactory outcomes as distinct from some previous reports. We believe that as the preparation and application of single arterialized venous flaps become more widely studied, these flaps may become an important salvage procedure for surgeons treating multifinger injuries.
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24. Iwasawa M, Ohtsuka Y, Kushima H, Kiyono M. Arterialized venous flaps from the thenar and hypothenar regions for repairing finger pulp tissue losses. Plast Reconstr Surg 1997;99:1765–1770. 25. Murata K, Inada Y, Fukui A, Tamai S, Takakura Y. Clinical application of the reversed pedicled venous flap containing perivenous areolar tissue and/or nerve in the hand. Br J Plast Surg 2001;54: 615–620. 26. Yan H, Fan C, Gao W, Chen Z, Li Z, Chi Z. Finger pulp reconstruction with free flaps from the upper extremity. Microsurgery 2012;32: 406–414. 27. Lin YT, Henry SL, Lin CH, Lee HY, Lin WN, Wei FC. The shuntrestricted arterialized venous flap for hand/digit reconstruction: Enhanced perfusion, decreased congestion, and improved reliability. J Trauma 2010;69:399–404. 28. Kong BS, Kim YJ, Suh YS, Jawa A, Nazzal A, Lee SG. Finger soft tissue reconstruction using arterialized venous free flaps having 2 parallel veins. J Hand Surg Am 2008;33:1802–1806. 29. Nakazawa H, Kikuchi Y, Honda T, Isago T, Morioka K, Itoh H. Use of an arterialised venous skin flap in the replantation of an
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amputated thumb. Scand J Plast Reconstr Surg Hand Surg 2004;38: 187–191. 30. Titley OG, Chester DL, Park AJ. A-a type, arterialized, venous, flow-through, free flap for simultaneous digital revascularization and soft tissue reconstruction-revisited. Ann Plast Surg 2004;53:185–191. 31. Chen CL, Chiu HY, Lee JW, Yang JT. Arterialized tendocutaneous venous flap for dorsal finger reconstruction. Microsurgery 1994;15: 886–890. 32. Cho BC, Byun JS, Baik BS. Dorsalis pedis tendocutaneous delayed arterialized venous flap in hand reconstruction. Plast Reconstr Surg 1999;104:2138–2144. 33. Rozen WM, Ting JW, Gilmour RF, Leong J. The arterialized saphenous venous flow-through flap with dual venous drainage. Microsurgery 2012;32:281–288. 34. Kakinoki R, Ikeguchi R, Nankaku M, Nakamua T. Factors affecting the success of arterialised venous flaps in the hand. Injury 2008;39 (Suppl 2):18–24.
