Artery Flap Research Articles

Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer.

Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established. Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures. This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes. The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

The use of the posterior interosseous artery flap and anterolateral thigh flap for post-traumatic soft tissue reconstruction of the hand.

The purpose of this study was to examine the differences between the use of a posterior interosseous artery (PIA) flap and an anterolateral thigh (ALT) flap for post-traumatic, medium-sized soft tissue reconstruction of the hand based on flap characteristics, postoperative complications, and aesthetic outcomes.From October, 2010 to March, 2016, 62 patients undergoing soft tissue reconstruction of the hand with 30 PIA flaps and 32 ALT flaps were included in this study. The 62 patients were divided into the PIA flap group and the ALT flap group. The differences between the 2 groups were analyzed.The 62 patients included 52 males and 10 females, and the mean age at the time of surgery was 41 years. The flap failure rate was 13.3% (4/30) in the PIA flap group and 9.4% (3/32) in the ALT flap group. No significant differences in flap failure rate, recipient site complication rate, or donor site complication rate were observed between the 2 groups. However, the operative time (136 min vs 229 min) and aesthetic outcomes (flap bulk swelling, 0 cases vs 31 cases) were statistically significantly different.Both the pedicled PIA flap and the free ALT flap were comparable for the reconstruction of post-traumatic, medium-sized soft tissue defects of the hand according to the evaluated outcomes of postoperative complications. Based on the surgical characteristics of the flap and the evaluation of aesthetic outcomes, the pedicled PIA flap was significantly superior to the free ALT flap.

A Practical Tip for Intraoperative Perforator Vessel Selection

In planning of free-style free perforator flaps, relying on defined anatomical landmarks and preoperative imaging technologies is difficult to locate the perforating arteries. Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle. In these situations, the ideal perforator has to be selected mostly by clinical inspection. We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera, which may be a reliable intraoperative adjunct. An index digit soft-tissue reconstruction was planned with a free posterior interosseous artery flap. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber (<0.8 mm) and pulsation. A cold challenge test was applied to flap and a continuous video record with thermal camera was taken for 1 min. Video record shows that the dominant perforator is the distal one. Thus, the flap was raised based on distal perforator. Postoperative follow-up was uneventful. The portable thermal imaging is a low cost and readily accessible intraoperative adjunct for selecting the dominant perforator in free-style perforator free flaps.

A 3D visualization layered anatomy for acromial arterial rete and flap design.

The acromial arterial rete (AAR) is the junction between the skin blood supply of the cervical side and that of the upper arm, and it is the only site crossed by the trans-regional blood supply of the cervico-humeral flap (CHF). The aim of this study was to explore the structures of AAR to optimizing flap design. A body arteriography and spiral CT scan were performed on 33 whole adult corpses. The 3D reconstruction was used to perform continuous digital layered anatomy of the shoulder and upper chest; the acromion and acromioclavicular joint were used as the center to observe the source, route and distribution characteristics of a perforating branch and their anastomosis. The perforating branches were separated from an acromial branch of the transverse cervical artery (97%), posterior humeral circumflex artery (95%), a deltoid branch of the thoracoacromial artery (95%), and the acromial branch of the thoracoacromial artery (93%). The diameter of the acromial branch of the transverse cervical artery at its initial location was 1.18 ± 0.37mm; the trunk length was 12.53 ± 3.83cm, and it was anastomosed with other blood vessels in three forms. Deep fascia should be included in the flap design. Three kinds of pedicled transfer flaps can be designed with the acromial branch of transverse carotid artery as the vascular pedicle. Free flaps can be designed with the acromial branch of thoracoacromial artery as the vascular pedicle.

A new surgical strategy for reconstruction of claw nail deformity

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Three-dimensional Printing Technology for Deep Circumflex Iliac Artery Flap: From Recipient to Donor Sites.

SummaryThe deep circumflex iliac artery (DCIA) flap is one of the most commonly used vascularized free flaps for jaw reconstruction; however, its clinical application is limited by donor site complications. We aimed to describe a new technique of using 3-dimensionally (3D) printed patient-specific devices for mandibular reconstruction with DCIA flap and simultaneous dental implants, and for donor site restoration after harvesting the DCIA flap. One patient with mandible ameloblastoma underwent mandibular reconstruction using a DCIA flap with the “jaw-in-a-day” approach. The 3D-printed patient-specific devices included mandibular cutting guides, DCIA harvesting and dental implant guide, surgical plate, and iliac prosthesis. The postoperative 1-month accuracy measurement showed the mean distance deviations of the mandible, transferred bone grafts, dental implants and iliac prosthesis were 1.8 mm, 2.1 mm, 0.9 mm, and 1.2 mm, respectively. Three-dimensionally printed iliac prosthesis satisfactorily restored the contour of the iliac crest after DCIA flap harvesting. No complication of donor site was recorded during the follow-up of 12 months. We successfully used 3D-printed patient-specific implants in both donor and recipient sites for DCIA flap jaw reconstruction. Further studies with a larger sample size and long-term follow-up are needed.

Surgical repair of discontinuous right pulmonary artery utilising an autologous main pulmonary artery flap: a case report and literature review

This is a case of an infant with unilateral discontinuous right pulmonary artery. Cardiac catheterisation with pulmonary wedge injection diagnosed the anomaly and aided in surgical planning. The patient underwent semi-autologous surgical repair utilising an autologous main pulmonary artery flap. One month following discharge, he underwent successful balloon dilation of the residual stenosis and was discharged the same day.

Reconstruction of soft tissue penile defects due to trauma using inguinal flaps

Background: We present a case of using the external pudendal artery (EPA) flap to cover the soft tissue defects of the penis following multiple trauma with penis shrinkage, corpus spongiosum and urethral injuries. Case report: A 54-year-old male patient was admitted to the hospital with multiple injuries: complex trauma with extensive scrotal and perineal skin loss, soft tissue defects of the penis with corpus spongiosum and urethral injuries, complex and open forearm fracture. The patient underwent emergency surgery to remove scrotal skin, Burry the testis in the subcutaneous pouches in the thigh, Foley sonde was placed over the bladder above the pubic bone and amputate the right hand.After that, the patient was operated on using foreskin flaps to cover corpus spongiosum defects and reconstruct the urethra. However, after about 10 days, the foreskin flap was infected and then necrotic resulting in the soft tissue defects of the penis exposing the urethral.Therefore we decided to perform surgery using the external pudendal artery (EPA) flap to solve that problem. We put sonde foley to shallow urethra and let urine pass out. The cosmetic and functional results of this foreskin-flap have been good. There was no infection, the length of the penis was maintained. The urinary stream has been normal with no urine leakage after surgery. Conclusion: The external pudendal artery flap is a good option for the treatment of patients with penile soft tissue defects. Due to its simplicity, short operation time, easy dissection, good aesthetic outcome. Therefore the external pudendal artery flap is an optimal choice for the treatment of cases of genital soft tissue defects (scrota and penis).

Distal Arterialized Venous Supercharging Improves Perfusion and Survival in an Extended Dorsal Three-Perforasome Perforator Flap Rat Model.

Perforator flaps are commonly applied for a variety of skin defects. Many strategies (e.g., hyperbaric oxygen and preconditioning) have been investigated to improve flap survival, but a postoperative 2.03 to 18.2 percent flap necrosis frequency remains a major complication. The authors hypothesized that a distal arterialized venous supercharged (DAVS) flap procedure might improve perfusion and survival in an extended three-perforasome perforator flap rat model and rescue flap ischemia intraoperatively. One hundred twenty male Sprague-Dawley rats (200 to 300 g) were divided into the thoracodorsal artery (TDA) flap group and the DAVS flap group (n = 60 per group). An approximately 11 × 2.5-cm2 flap based on the TDA perforasome was designed in the TDA flap. A DAVS flap was designed based on the TDA flap and supercharged by anastomosing the rat caudal artery with the deep circumflex iliac vein. At postoperative times 1, 3, 6, and 12 hours and 1, 3, 5, and 7 days, perfusion and angiography were compared. On day 7, flap viability and angiogenesis were assessed using histology and Western blotting. The DAVS flap showed a higher survival rate compared with the TDA flap (100 percent versus 81.93 ± 5.38 percent; p < 0.001). All blood flow ratios of deep circumflex iliac artery to TDA perforasome and of choke zone II to choke zone I were higher in the DAVS flap (all p < 0.05). Angiography qualitatively revealed that choke vessels in choke zone II dilated earlier and extensively in the DAVS flap group. CD34+ vessels (68.66 ± 12.53/mm2 versus 36.82 ± 8.99/mm2; p < 0.001) and vascular endothelial growth factor protein level (0.22 ± 0.03 versus 0.11 ± 0.03; p < 0.001) were significantly increased in the DAVS flap group. The DAVS procedure improves three-perforasome perforator flap survival and can be used for rescuing flap ischemia intraoperatively. Further study is needed before possible clinical adoption for reconstructive operations.

Abdominal-based free flaps in head and neck reconstruction.

The head and neck reconstructive surgeon is intimately familiar with the anterolateral thigh, radial forearm, and parascapular flaps. This review serves to describe the major abdominal-based free tissue transfers in head and neck reconstruction that can be used as alternatives to these traditional workhorse flaps. Abdominal-based free flaps, while not traditionally used in head and neck reconstruction, are great alternatives or second-line flaps. For example, the deep circumflex iliac artery flap is an excellent alternative to the fibular free flap due to its bone height and greater overall quality of life. This review article serves to review the major abdominal-based free tissue transfers in head and neck reconstruction in order to expand the toolbox of the head and neck surgeon.

Islanded supraclavicular artery flap: A versatile flap for oral reconstruction

There is a paucity of information on listener perceptions of Individuals with a Laryngectomy (IWL) based on different modes of speech, in particular, speech following Supracricoid Laryngectomy (SCL).

Reverse Dorsal Metacarpal Artery Flaps to Repair Distal Hand and Dorsal Finger Defects After Mohs Micrographic Surgery.

Reverse Dorsal Metacarpal Artery Flaps to Repair Distal Hand and Dorsal Finger Defects After Mohs Micrographic Surgery.

An extended distally based reverse posterior interosseous artery flap reconstruction for the thumb and distal defects of the fingers.

The reverse posterior interosseous artery flap is useful for covering hand defects. However, its major drawback is the short pedicle that limits the reach of the flap up to the metacarpophalangeal level. The authors performed a new modification extending the distal reach of the flap by including the recurrent branch of the posterior interosseous artery and they aimed to present the results of reconstruction with this technique. Seven patients with a mean age of 35.2 years (range 17-64 years) underwent extended RPIAF surgery. Six patients were admitted to the emergency department with isolated hand trauma. One patient was present in elective settings with chronic osteomyelitis and skin loss of the thumb related to previous trauma. The defects were located on the distal metacarpophalangeal level (thumb and other fingers). PIA perforators and the recurrent branch were included into the pedicle (Type A) in five cases, whereas the flap was harvested based solely on the recurrent branch (Type B) in two cases. The type B flaps had longer pedicle lengths due to discarding the forearm skin. The donor sites were covered with skin grafts in six patients. The average size of the extended RPIAF was 3 × 3.5 cm to 10 × 6 cm (mean 8.28 × 4.14 cm). All of the flaps completely survived, and no complications were encountered during the postoperative period. Functional recovery of the operated hands were observed during the follow up period 13.5 months (8-24 months). Both the patient and our satisfactory levels were high and all of the patients returned to their works. Quick DASH score was used in the final functional evaluation retrospectively. Due to the pandemic, the evaluation could be made with a telephone. Two patients could not be reached in the evaluation. The mean quick DASH score of five patients was 28.64. The extended RPIAF is a reliable choice in distally located thumb and finger defects if the recurrent branch of the posterior interosseous artery is included in the pedicle.

Long Term Outcomes of Nasoseptal Perforation Repair With an Anterior Ethmoidal Artery Flap.

Nasoseptal perforation repair is a challenging condition with no standard technique for repair recognized. A case series of consecutive patients who underwent nasoseptal perforation repair with an anterior ethmoidal artery flap was conducted. Demographic data, preoperative features of the perforation and postoperative outcomes were analyzed. Closure rate, complications and persistence of nasal symptoms were documented. Thirty-two patients were included in the study. The average perforation diameter was 1.48 cm (range: 0.4-3 cm). Iatrogenic trauma was the most common cause (56% of patients). Nine cases ended up being idiopathic. The overall closure rate was 81%, but 87.5% when perforation had a 2-cm diameter or less. Of the six failures, 2 were due to flap necrosis and 4 to a residual anterior perforation. Despite the persistence, 2 patients solved their symptoms. One patient underwent revision surgery. The anterior ethmoidal artery flap is a reliable and minimal invasive technique for closure of symptomatic perforations. For defects larger than 2 cm, a lower success rate and additional reconstructive measures should be considered. Objective questionnaires are needed in order to evaluate functional outcomes.

Early single-stage surgical revascularization of pulmonary artery in unilateral absence of a pulmonary artery

BackgroundThis research aims to summarize the findings of the early single-stage revascularization of remnant pulmonary artery in unilateral absent intrapericardial pulmonary artery.MethodsWe retrospectively analyzed the medical records of 10 patients with unilateral absent pulmonary artery, in which 7 were right and 3 were left, the median age and mean weight at surgery was 4 months and 5.6 kg, respectively. The patients received operation from January 2009 to June 2020.ResultsTen patients, 1 case associated with atrial septal defect, 2 cases with tetralogy of Fallot, and 1 case with aortopulmonary window. The mean diameter of the affected hilar pulmonary artery remnants was 3.14 ± 1.09 mm (1.6-5 mm), and the Z value was − 3.66 ± 1.86 (range, − 6.7 to − 1.75). All the patients received single-stage revascularization: tube graft interposition in 3 patients, autologous pericardial roll in 4, direct anastomosis in one, and main pulmonary artery flap angioplasty in the rest 3. No hospital deaths occurred. Mean follow-up in this cohort was 3.3 ± 1.9 years One case underwent percutaneous balloon dilatation due to new pulmonary artery stenosis. Nonetheless, the results were encouraging, symptoms have improved in all patients. The median Z value of the latest ipsilateral pulmonary artery diameter was − 1.88 (range, − 4.52 to − 1.35), a significantly improvement when compared to the preoperative value. The Z value of that in patients who using Gore-Tex tube increased relatively small.ConclusionsSingle-stage pulmonary artery revascularization is effective at restoring normal antegrade flow to the affected lung, resulting in improved diameter of the PA, regression of pulmonary hypertension, and patient’s symptoms. Revascularization by using the autologous tissue or autologous pericardium may obtain a preferred result. The new pulmonary artery stenosis certainly will need to be addressed in the long-term follow-up.

Reconstruction of the weight-bearing heel with nonsensate reverse sural artery flaps

BackgroundThe reverse sural artery flap (RSAF) is widely used to reconstruct foot and ankle defects. Although it is commonly used in a nonsensate type, there has been controversy as to whether it provides sufficient stability and durability when applied to weight-bearing heels. The aim of this study was to evaluate patient outcomes after weight-bearing heel coverage using a nonsensate RSAF. MethodsTwenty-three patients who underwent reconstruction surgery of the weight-bearing heel with RSAF from 2004 to 2018 in a tertiary hospital were retrospectively reviewed. All surgeries were performed without a sensate procedure. The patients’ experience of pressure sore on the flap area and the ability to use normal footwear were investigated. Light touch, Semmes-Weinstein test (SWT), and two-point discrimination tests were assessed, along with postoperative wound complications. ResultsHeel damage etiologies included malignant tumors in 14 (61%), trauma-related in 7 (30%) and diabetic ulcers in 2 (9%) patients. Patient mean age was 58 years (range, 18–93 years) and the mean follow-up period was 57 months (range, 12–185 months). The mean size of the flap was 64.1 cm2 (range, 20–169 cm2). All flaps healed without major complications. All returned to daily living activities and 20 (86%) patients were able to use normal footwear. Of the 11 patients who had available measurement records, 8 (73%) showed a light touch sense. The mean SWT value was 4.31 (range, 3.61– 4.56). Two-point discrimination was not observed in any of the patients. Two patients had experienced superficial ulcers on the flap within a one-year postoperative period, which spontaneously healed and did not recur. No full-thickness ulcers were observed during the follow-up period. ConclusionsThe results of this study suggest that patients who underwent nonsensate RSAF for the reconstruction of the heel could expect to maintain the property for stable weight-bearing without pressure sore.

Versatility of Reverse Sural Artery Flap (RSAF) in management of lower limb defects: Our experience

Background: Wounds around the lower 1/3rd of leg and foot are difficult to manage. Treatment options like skin grafting, healing by secondary intention can result in an unstable scar. Free tissue transfers and Regional flaps has its own disadvantages. To circumvent these difficulties a fasciocutaneous flap harvested from sural angiosome was proposed. In this study, we have made an attempt to find out different scenarios in which this flap can be used as a management option and ways to minimize the complications associated with this flap. Methods: A retrospective observational study was conducted over 2 years. 30 patients were studied. Patient details was obtained from the case record, operative notes and postoperative follow-up.Results: Patients between the age of 10 years to 65 years were studied. RSA flap with adipofascial pedicle and fasciocutaneous pedicle was done in 21 and 9 patients respectively. Delaying of flap was done in 9 patients, with most common indication as distal defect. Common site of defect which were reconstructed was on the Tendoachilles region, Heel region. Various complications were loss of graft used to cover adipofascial pedicle, Venous congestion, hematoma formation and partial skin necrosis of the flap. None of the patients complained of any effect on routine activity during postoperative follow up.Conclusion: It is a versatile flap and different scenario can be managed with customization in plan. With proper selection of patients, it can be judiciously used to manage different leg defects.

The posterior interosseous artery flap versus the adipofascial radial artery perforator flap in reconstruction of firecracker and homemade bomb blast injuries of the hand

Background: The soft tissues of the radial aspect of the hand are predominantly affected in firecracker and homemade bomb blast injuries. In such cases, regional flap options are quite appealing for defect coverage. We have compared the outcomes of using two pedicled regional forearm flaps in these injuries, the posterior interosseous artery flap (PIAF) and the adipofascial radial artery perforator flap (ARAPF).Methods: 37 patients underwent reconstruction of the hand with PIAF (20 cases) and ARAPF (17 cases) between January 2014 and December 2019. They were compared with regards to patient demographics, reconstruction techniques, short-term and long-term functional and aesthetic outcomes using the disabilities of the arm, shoulder and hand (DASH) score and the subjective satisfaction score (SSS).Results: All our flaps survived without any major complications affecting long-term outcome. We found no statistically significant difference between the two flaps in terms of patient demographics, flap paddle size, duration of hospital stay, DASH score and SSS for recipient site. However, significant difference was noted in the duration of surgery, method of donor site closure and SSS for the donor site.Conclusions: Both the PIAF and ARAPF can be considered in cases of soft tissue defects of the hand from firecracker or bomb blast injuries. Both preserve the major arteries of the hand while still having reliable vascular pedicle.

Muscle Cuff in Distal Pedicled Adipofascial Sural Artery Flaps: A Retrospective Case Control Study.

Background:Amputation after open tibial fracture occurs in 3% of cases. The rate increases when flap reconstruction is required. The standard care involves microsurgical tissue transfer although the pedicled reverse sural artery adipofascial flap (PRSAF) is a local alternative in patients endangered by a prolonged operative time. Incorporation of a gastrocnemius muscle cuff in this flap can be used to fill dead space and increase healing potential. Literature shows superior survival rates for both PRSAF and inclusion of a muscle cuff in comparison with the cutaneous version. The aim of the study was to compare the outcome of the PRSAF and the musculoadipofascial version (PRSMAF). We hypothesize that the PRSMAF provides similar lap viability and flap-related complication rates as does the adipofascial version. The muscle component may reduce the long-term osteomyelitis rate.Methods:Patients were evaluated retrospectively after reconstruction with either PRSAF or PRSMAF. Preoperative osteomyelitis, flap survival, complications and osteomyelitis clearance were analyzed.Results:The study shows preliminary results supporting the potential use of the PRSMAF. We compare either 23 PRSMAF or 20 PRSAF flaps. We found no statistically significant differences in flap survival or in complication rate.Conclusions:Although the anatomical situation may sometimes dictate the use of a free flap, a technically less-complicated option may in some cases offer a viable alternative. This study shows that the PRSMAF can serve as an alternative for complex bone defects in the limb, though it does not provide statistical improvement to the PRSAF.

Application of superficial inferior epigastric artery flaps to repair oral and maxillofacial defects with the aid of digital three-dimensional reconstruction technique

Objective: To explore the application value of digital three-dimensional(3D) reconstruction technology in the repair of oral and maxillofacial defects with superficial inferior epigastric artery (SIEA) flap. Methods: Twelve cases of oral cancer patients, including 8 males and 4 females; aged (57.4±12.6) years, were selected from the Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Bengbu Medical College from January 2018 to October 2019 and were proposed to repair with SIEA flap. There were 10 cases of squamous cell carcinoma, one case of adenoid cystic carcinoma and 1 case of mucinous epidermal carcinoma. The data were imported into AW4.7 software for post-processing. The left or right dominant donor area was selected to clarify the origin, diameter, alignment, and location of penetration point of the flap blood supply, and digital 3D reconstruction technology was used to guide the flap preoperative design. Results: Eleven cases were repaired by SIEA flap in 12 patients, one case was repaired by superficial iliac artery flap because the source artery was undiscovered, one case had venous vascular crisis after surgery, and the rest of the flap survived. In 11 patients repaired with SIEA flap, there was no significant difference between the preoperative SIEA diameter measured by CTA [(1.0±0.3) mm] and the actual measured value [(1.1±0.3) mm] (P>0.05). The follow-up was 6 to 12 months, with an average of 10 months, and the donor-receiver areas were all healed in phase Ⅰ. No obvious complications occurred, and the abdominal scar was hidden. Conclusions: In the SIEA flap repair oral and maxillofacial defect reconstruction surgery, the use of digital 3D reconstruction technology can objectively reflect the diameter and the location of the superficial artery of the abdominal wall before surgery, effectively reduce the difficulty and risk of flap surgery.