Femoral Flap Research Articles

Microsurgery in 46 cases with total hand degloving injury

To summarize the characteristics of total hand degloving injury and investigate the curative effect of microsurgery. A total of 46 patients with total hand degloving injury were enrolled in this study. The injury classification and treatment methods were as follows: Type I (11 cases), treated by replantation of the gloved skin; Type II (6 cases), treated by reconstruction using thumb wrap-around flap and second toe; Type III (4 cases), treated by reconstruction using bilateral second toe with dorsal foot flap; Type IV (9 cases), treated by replantation in situ or reconstruction; Type V (16 cases), treated by replantation or abdominal flap reconstruction. Of the patients who received Type I treatment, five completely survived, whereas eight had finger necrosis. In Type II, both the reconstructed fingers and hand flaps survived. For four patients who received Type III treatment, eight reconstructed fingers survived. In Type IV, two patients with reconstructed fingers survived, whereas the six with replantation in situ had necrosis of the partial palmar or hand dorsum skin. In Type V, nine patients with reconstructed fingers survived, and five cases with abdominal skin flap reconstruction and one case with anterolateral femoral flap survived. The restoration of hand appearance and function was the best in patients who received replantation. For reconstruction cases, however, the hand function was recovered to the basic self-care level. In cases with abdominal flap reconstruction, the hand function showed poor recovery. Total hand degloving injury can be classified into different types according to the injury degree. The appropriate microsurgical treatment based on these types can produce better curative effect.

Femur–fibula–fillet of leg chimeric free flap for sacral-pelvic reconstruction

We describe the first case of a femur free flap in which we utilized the femur to restore pelvic ring continuity following a combined external hemipelvectomy-sacrectomy for cancer. We feel that the femur flap can be an important reconstructive tool for load-bearing bony reconstruction of the pelvis and spine when lower extremity amputation is required. We also utilized a fibula flap to stabilize the spine and a fillet of leg flap to provide soft tissue coverage as part of a chimeric femur-fibula-fillet of leg free flap from the same limb, allowing us to reconstruct a large, complex defect with "spare parts" from the discarded lower extremity, thereby totally eliminating any donor site morbidity.

A New Flap Design

We hypothesized that an osseous tissue can be prefabricated with a peripheral nerve by vascular induction, and by using a rat model, we tested this hypothesis.Twenty Wistar rats were used in the prefabricated neuro-osseous flap study. Bilateral sciatic nerves were placed linearly within the medullary cavities of the femurs. Left femurs were accepted as the experimental group. The right femurs of all the rats were used as internal control where the sciatic nerves were ligated at the bony entrance of the flap.After 6 weeks, all experimental femur flaps were viable. Radioactivity counts and metabolic activity studies showed viable and functional bone tissue in experimental group compared with control group (P = 0.001). On microangiographic evaluation, significant dilatation of the perineural vasculature was observed in experimental group. Histologic investigations showed viable bone tissue only in the experimental group flaps.Due to its easy applicability, reproducibility, and robust circulation, the prefabricated neuro-osseous flap would be an option in reconstructive surgery.

The Microvascular Corticocancellous Femur Flap for Reconstruction of the Anterior Maxilla in Adult Cleft Lip, Palate, and Alveolus Patients

Free nonvascularized alveolar bone grafting in severe defects of the cleft region often results in poor implant bed conditions. Here an alternative augmentation technique using a new technique of vascularized bone transfer is described. In five patients with clefts of the lip, palate, and alveolus (four unilateral, one bilateral) there was a severe defect of the anterior maxillary alveolar ridge after tooth loss. The patients previously had augmentative surgery one to three times without success. The defect was covered using a microvascular corticocancellous transplant from the medial distal femur. The defects to be corrected measured 2.5 to 4.0 cm long, 1.0 to 1.5 cm wide, and 1 to 1.5 cm high. The microvascular pedicle of the femur bone flap was 3 to 7 cm long. The descending genicular artery was anastomosed to the facial or labial superior artery and the accompanying veins accordingly. In every case, the anastomoses were performed via an intraoral transmucosal approach. There were no serious complications and no flap loss. In all patients the defect was covered by a flap of the correct size and design. All patients were treated with dental implants (13 total) 6 months after successful reconstruction of the ridge. The implants were loaded 4 to 6 months after placement with fixed superstructures. There were good peri-implant conditions and no implant loss. The microvascular osteoperiosteal femur flap can be used successfully in individual reconstruction of segmental defects of the alveolar ridge in adult cleft patients.

Vascularized Femur Flap for Stabilization after Combined Total Sacrectomy and External Hemipelvectomy

Vascularized Femur Flap for Stabilization after Combined Total Sacrectomy and External Hemipelvectomy

Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap—first clinical results

This study describes a new microvascular flap combination from the medial femur and ear to reconstruct the nose after subtotal resection and presents the first clinical results. In four patients a squamous cell carcinoma of the nose was registered. In three patients this was diagnosed for the first time while in the fourth patient it was the second relapse after two resections and local flap surgery. In every case, tumour resection ended up in an extended defect of the nose, cheek and upper lip region. For skeletal reconstruction and the inner lining of the nose, a microvascular osteocutaneous femur flap was used. After reconstructing the nasal skeleton, the remaining defect was covered by a microvascular composite flap from the left ear and preauricular region. Both flap pedicles were anastomosed to the facial vein and artery. In every case, the flaps healed without complications. There was no tumour relapse. 12 months after reconstruction, minor surgical corrections were made. The patients showed a satisfying functional and aesthetic result. The combination of a microvascular osteocutaneous femur flap and a microvascular ear flap can be used successfully for reconstructing the nose after subtotal resection.

Surgical management for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma

To investigate the surgical managements for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma. Seventy-eight cases of neck masses (39 cases for unilateral residual diseases, 9 for bilateral residual diseases and 30 for recurrent diseases) after radiotherapy in nasopharyngeal carcinoma who were treated surgically between January 1990 and December 2005 were retrospectively analyzed. There were 56 males and 22 females. Their ages ranged from 28 to 65 years (median 41 years). There were 27 patients with skin involvement. After preoperative imaging assessment, 17 patients whose common carotid arteries or internal carotid arteries were difficult to separate routinely attained the carotid balloon occlusion test which confirmed that 15 cases of cerebral arterial circle open to compensation, however, two cases of poor compensation. Surgical procedures included expanded neck mass resection (21 cases), unilateral radical neck dissection (49 cases) and bilateral radical neck dissection (8 cases). Of them 5 patients were with unilateral internal carotid artery resection. Neck defects were repaired with pectoralis major muscle flaps (15 cases), free anterolateral femoral skin flaps (9 cases) and trapezius muscle flaps (3 cases). Of the 78 patients, 13 with microscopic positive diseases and 2 with residual diseases in internal carotid artery walls underwent postoperative radiotherapy, with the doses of 45 to 50 Gy. All patients were closely followed-up more than 5 years. Three- and five-year survival rates were 46.2% and 28.3% respectively. Neck defects were successfully repaired with skin flaps immediately after resecting diseases in 27 cases, only one patient with delayed healing. Of 51 patients without skin flap repair, neck wounds healed successfully in 45 patients and with delayed healing in 6 patients. Pathological positive rates of lymph nodes located in the level I, II, III, IV and V were 10.5%, 61.4%, 10.5%, 1.8% and 28.1% respectively. Preoperative balloon occlusion test is required to assess the function of Willis' ring before determining ligation or resection of internal carotid artery. Residual or recurrent diseases commonly exist in level II, VA and III, which should be included in neck dissection. Pectoralis major muscle flap and free anterolateral femoral skin flap are recommended for the repair of neck defect.

Tunneled superficial inferior epigastric artery (SIEA) myocutaneous/vascularized femur chimeric flaps: A model to study the role of vascularized bone marrow in composite allografts

The role of vascularized bone marrow in promoting composite allograft survival can be assessed by intrinsically chimeric flaps. In this study, we introduce a significant modification to a previously described rat model of combined superficial inferior epigastric artery (SIEA) myocutaneous/vascularized femur transplantation. We previously noted autocannibalization in orthotopic myocutaneous SIEA allotransplants, which complicated clinical and histologic evaluation of rejection. We therefore designed syngeneic experiments in eight Lewis (RTl(1) ) rat pairs to explore the feasibility of tunneling the SIEA component of chimeric SIEA myocutaneous/vascularized femur flaps to the recipient dorsum. Vascularized SIEA myocutaneous/femur transplants survived in their entirety to POD 63 study endpoint with patent anastomoses in seven of eight (87.5%) transplants as confirmed clinically, histologically, and via near-infrared fluorescent angiography. Tunneling of the SIEA component of SIEA myocutaneous/vascularized femur flaps to the recipient dorsum can be achieved with high success rate and acceptable operative times, and is a technically easy method to study the role of vascularized bone marrow in composite allografts. This modification facilitates SIEA component monitoring, removes it from constant contact with cage bedding, and places it in a location where autocannibalization is unlikely.

Repair of the soft tissue defects at legs with free tissue flap anastomosed with descendant branch of lateral femoral circumflex artery

To investigate the therapeutic effect of free tissue flap anastomosed with reverse descendant branch of lateral femoral circumflex artery for severe soft tissue defect at leg. The severe soft tissue defect at leg, without any vessels for anastomosis of free tissue flap, was reconstructed with free tissue flap, which was anastomosed with proximal end of descendant branch of lateral femoral circumflex artery and great saphenous vein. From Oct. 2004 to Dec. 2009, 36 cases were treated with 15 cases of latissimus dorsi musculocutaneous flaps, 12 cases of anterolateral femoral flaps, and 9 cases of thoracoumbilicus flaps. All the 36 free flaps survived completely. The patients were followed up for 6 months to 2.5 years with good cosmetic results. It is effective and practical to repair the severe soft tissue defects at legs with the reverse descendant branch of lateral femoral circumflex artery to carry the free flaps.

Vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral nonunions

Vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral nonunions

Comparative study of the osseointegration of dental implants after different bone augmentation techniques: vascularized femur flap, non-vascularized femur graft and mandibular bone graft

The purpose of this study was to evaluate the osseointegration of the dental implants placed into the mandible augmented with different techniques in pigs. Four adult domestic pigs were used. Horizontal augmentation of the mandible was performed in animals by using vascularized femur flap (VFF), non-vascularized femur graft (NVFG) and monocortical mandibular block graft (MG). After 5 months of healing 10 dental implants were placed into each augmented site. The pigs were sacrificed after 3 months of healing. Undecalcified sections were prepared for histomorphometric analysis. Mean bone-implant contact (BIC) values for implants placed into MG, NVFG and VFF were 57.38 ± 11.97%, 76.5 ± 7.88%, 76.53 ± 8.15%, respectively. The BIC values of NVFG and VFF group were significantly greater than MG group (P<0.001). On the other hand, there was not statistically significant difference between NVFG group and VFF group (P=0.999). NVFG as well as VFF can be considered as a promising method for augmentation of alveolar defects and the placement of the implants. The selection of non-vascularized graft or vascularized flap depends on the condition of the recipient site.

Femur Flap for Tibial Reconstruction: Percent Circumference Required to Convey a Mechanical Advantage over the Fibula

The fibula flap is commonly used to reconstruct the tibia. This has risk of postoperative fracture despite long-term non-weight bearing. A flap using noncircumferential distal femur is proposed. This study is to determine the circumference of femur required to produce greater strength than the fibular flap. Femurs and fibulas were harvested from eight cadavers. The structural strength of fibula and femur flaps was assessed using three-point bend. Compression testing was performed on osteotomized and whole femurs to assess donor site morbidity. The 35% flap (mean maximum force at fracture 869 N) was not significantly stronger than the fibula flap (626 N; P > 0.05). The 40% flap (1225 N) was significantly stronger than the fibula flap ( P < 0.01). There was no significant difference between forces at fracture for whole femurs (3978 N), femurs with 35% osteotomies (3604 N), and femurs with 40% osteotomies (3493 N; P = 0.87). Change occurred in the fracture pattern of femurs following osteotomies. Whole femurs consistently fractured at the femoral neck, and osteotomized femurs consistently fractured obliquely from the osteotomy. A flap consisting of 40% of the circumference of the distal femur exceeds the structural strength of the fibular flap. Taking such a flap changes the femur's structural integrity; fixation may be prudent following harvest.

A novel step in the anterolateral thigh free flap harvest

The ALT is a versatile flap in head and neck reconstruction1. Classically this flap allows for suprafascial or subfascial identification of perforators. Subsequent retrograde dissection of the perforators through the intermuscular septum or muscle identifies the pedicle (descending branch of the lateral circumflex artery). This technique can be time consuming and risks injury to the delicate perforators. • Technique used in 75 consecutive patients undergoing ALT flap. • Approximate harvest time is 1 hour. • No change in infection or hematoma at donor site has been observed. • No neurovascular injury. • Complication: false loading GIA stapler (1) which required obtaining hemostasis with bipolar cautery. The Anterolateral thigh (ALT) flap, based on branches of the circumflex femoral artery, has increasingly become a popular flap in head and neck reconstruction because of its versatility1 י2. Classically described as a perforator flap, the ALT flap can be harvested to include skin only, skin and muscle and as a chimeric flap with separately perfused skin paddles2 י3. As with all free tissue transfer procedures in the head and neck, efficiency in technique is paramount in reducing the overall surgical duration. We describe the technique of retrograde pedicle dissection and the adapted use of a GIA 80 stapler in harvesting ALT flaps. This technical modification has been implemented in 75 consecutive patients with an approximate harvest time of one hour. 1.Song YG, Chen GZ, Song YL. The free thigh flap: A new flap concept based on the septocutaneous artery. Br J Plast Surg 37:149-159, 1984. 2. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: A musculocutaneous flap in disguise I head and neck reconstruction. Br J Plast Surg53:30-36, 2000 3.Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 82:305-310,1988. 4. Koshima I, yamamoto H, Hosoda M et al. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions:An introduction to the chimeric flap principle. Plast Reconstr Surg 92: 411-427, 1993. Technique Step 1: The ALT is exposed and a flap is designed based upon the perforators. Step 2: The medial edge of the flap is incised down to fascia. The septum between the rectus femoris vastus lateralis muscles is identified and separated. Step 3: The descending branch of the circumflex femoris artery is identified as it courses on or through the vastus lateralis muscle. Step 4: The perforators to the flap are then clearly identified and outlined. Step 5: The lateral margin of the skin flap is incised down to fascia. Step 6: While protecting the perforators and the main pedicle, the GIA staple is applied to divide a cuff of the vastus lateralis muscle above and below the most superior and inferior perforators. Step 7: The descending branch of the lateral circumflex femoral artery is then traced in a retrograde manner till adequate pedicle length and vessel caliber is achieved. Step 8: The flap may be thinned down, when desirable, by carefully debulking muscle and subcutaneous fat from the flap periphery. For very thin flaps, antegrade dissection of the perforators through the vastus lateralis muscle may be necessary. • Safe technical modification. • Efficiency in a time consuming procedure. • GIA stapler beneficial to the pedicle No thermal energy for hemostasis In single maneuver keeps protective cuff of muscle to protect pedicle. The flap is harvested in typical fashion with the exception of a novel technical modification . We outline the technique used at our institution for ALT flap harvest: Results

Clinical application of free super-thin anterolateral femoral perforator flap

Objective To explore clinical effect of repairing soft tissue defect in forearm, hand and foot with free super-thin anterolateral thigh perforator flaps. Methods At first the site of perforator vessels were determined by Doppler, then the flaps were designed and harvested with the site as center; the fascia lata and subcutaneous fat were removed by sandhill-likely only the 4.0 cm × 3.0 cm - 3.0 cm×2.5 cm disc-like fascia lata and dermis layer were reserved. 15 traumatic soft tissue defects including forearm, hand and foot were repaired with the ree super-thin antemlateral thigh perforator flaps. Results No vascular crisis happened and all skin grafts survived in donor sites. 2.0 cm×1.2 cm of the distal of flap was necrosis in 1 case and it was healed by dress changing. 15 cases were followed up 3 months-2 years and the average is 6 months. The contour and texture of all flaps were good and two point discrimination (2-PD) was about 8-10 mm of. Conclusions The contour and texture of free super-thin anterolateral thigh perforator flap are good, the feeling of recipient site recovered well, it's less injury for donor site and there is no reshaping for flap. It is a fineness donor site for repairing soft tissue defects in hand and foot. Key words: Anterolateral femoral flap; Perforator flap; Microsurgery

Ramified anterolateral femoral flaps pedicled with different musculocutaneous branches for soft-tissue defects at extremities

Objective To introduce ramified anterolateral femoral flaps pedicled with different musculocutaneous branches used for primary repair of soft-tissue defects at different regions of extremities. Methods From January 2008 to April 2009, 15 patients, 10 males and 5 females, were treated with an-terolateral thigh flaps for their soft-tissue defects at limbs which involved 4 hands, 6 feet and 5 legs and an-kles. Different shapes of anterolateral thigh flap were designed according to clinical anatomy and particular conditions of blood vessels and musculocutaneous branches in different cases. The flaps were ramified into 2 independent free flaps to repair 2 independent defects. The maximum distance between 2 defects was 8 cm. The area of defect ranged from 3.0 cm×3.5 cm to 8.0 cm×11.5 cm, and the flap area from 5.0 cm×5.0 cm to 9.0 cm×15.0 cm. Results According to clinical anatomy, the presence of sarco-cutaneous branches was 100%. The source blood vessel of the flaps was quadriceps artery of femur. The 15 patients were followed up from 3 to 8 months. The tissue grafts all survived and the flaps primarily healed at the recipient site. Revisions were done 3 weeks to 3 months after the primary operation to thin down the clumsy skin flaps in 6 cases, The shape and texture of the flaps were satisfactory. Conclusion Ramified anterolateral femoral flaps pedicled with different musculocutaneous branches provide an ideal way of repairing severe and complex soft-tissue defects at extremities. Key words: Surgical flaps; Tissue transplantation; Wounds and injuries; Microanrgery

Free anterolateral femoral skin flap addied radiotherapy and chems repair primarily the raw surface of malignant tumor cut on lower limbs

Objective To study the effect of free anterolateral femoral skin flap addied radiotherapy and chems primary repair the raw surface of malignant tumor cut on lower limbs.Methods Superficial malignant tumor were given radiotherapy 10～30 times with 3000～7000Gy,and large dose comprehensiveness chems must be given if osseous metastasis occurred.The raw surface of malignant tumor cut on lower limbs were repaired with free anterolateral femoral skin flap,after the operation,radiotherapy were given with 5000～6000Gy,and chems routly.Results All the raw surface of malignant were repaired successfully,most of the patients were retained with labour ability and full self-care.Survival rate of five years was reached to 92.2%.According to the survival quality evaluation criterion,68.6% of patients were gained good effect.Conclusion Free anterolateral femoral skin flap addied radiotherapy and chems could repair primary the raw surface of malignant tumor cut on lower limbs,the effect were good. Key words: Anterolateral femoral skin flap; Malignant tumor; Raw surface; Repair

An intraoral anastomosing technique for microvascular bone flaps in alveolar ridge reconstruction

The main indication for microvascular reconstruction of the face is to achieve the best possible functional and aesthetic outcome. In several cases of reconstruction of the alveolar ridges of the mandible or maxilla, extraoral scars might have been avoided if microvascular anastomoses had been performed without using the extraoral approach. In 9 patients with severe defects of the alveolar ridge of the mandible or maxilla caused by trauma, tumour resection, atrophy or partial loss of premaxilla, reconstruction was performed using six microvascular corticocancellous femur flaps, two iliac crest flaps and one osteoperiosteal fibula flap. In every case, an intraoral approach was used to prepare the transplant bed and the facial vessels. The anastomoses were carried out via this intraoral approach between the donor vessels and the facial vessels. The patients were followed up radiologically and clinically for 6-24 months postoperatively. There was no flap loss or severe complication postoperatively. All patients had good functional and aesthetic results, were treated successfully with dental implants 4-6 months after microvascular reconstruction, and were subsequently fitted with implant-retained prostheses. Intraoral anastomosing of microvascular bone flaps is a reliable technique for microvascular reconstruction of the alveolar ridge. Extraoral scars can be avoided.

Comparison of Vascularized Osteoperiosteal Femur Flaps and Nonvascularized Femur Grafts for Reconstruction of Mandibular Defects: An Experimental Study

The aim of this study was to compare the vascularized osteoperiosteal femur flaps (VFFs) and the nonvascularized femur grafts (NVFGs) for reconstruction of the mandibular defects of pigs. Eight adult domestic pigs were used. The defects created in the mandibular angle were reconstructed with VFFs in 4 pigs (group 1) and NVFGs in the other 4 pigs (group 2). All the pigs were killed after 3 months of healing. Undecalcified and decalcified sections were prepared for histomorphometric analysis and histologic examination. Radiodensitometric absorptiometry was used to assess the differences in bone mineral density between the 2 groups. The bone volume to the total measured volume, trabecular thickness, and trabecular number were significantly greater in the VFF group than in the NVFG group (P < .05). However, the trabecular separation was significantly lower in the VFF group than the NVFG group (P = .029). Although the VFF group had a greater bone mineral density value than the NVFG group, the difference was not statistically significant (P = .057). In histologic examination, the viability of bone in the VFF group, enchondral bone healing, and lamellar bone formation in the NVFG group were apparent. The results of this study suggest that NVFGs have a greater bone resorption rate than do VFFs. Furthermore, the histomorphometric results imply that reconstruction of the mandibular defects with vascularized osteoperiosteal femur flaps will provide greater strength.

Clinical application of modified anterolateral femoral skin flaps

股前外侧皮瓣因其血管蒂长、解剖恒定、操作方便,被广泛运用于四肢皮肤软组织缺损伴有骨、肌腱外露创面的修复,但因手背、足背等非功能区运用皮瓣修复后外观臃肿,一定程度上影响了手术效果.因此,2000年以来,我们将股前外侧组织瓣改良设计成一半为筋膜瓣,另一半为皮瓣游离移植的新方法分别修复手、足软组织缺损创面的非功能区与功能区,术后受区在外形、功能上与游离股前外侧皮瓣移植、游离股前外侧筋膜瓣移植联合植皮修复手、足软组织缺损的方法比较,报告如下。

The clinical study of direct cutaneous artery flap of the upper thigh

Objective To study the anatomic basis of direct cutaneous artery flap of the upper thigh and review the clinical outcome of its application. Methods The direct cutaneous arteries of the upper thigh were dissected in 20 sides of the adult embalmed cadaverie specimens perfused with red relax. The arteries were perfused with Chinese ink in 2 fresh cadaver specimens to observe the distribution area. During surgical harvesting of anterolateral femoral skin flap in 50 cases, the occurrence rate, source artery, diameter and course of the direct cutaneous arteries of the upper thigh were noted. Forty-two cases of soft tissue defects were repaired with direct cutaneous artery skin flap of the upper thigh. Results Direct cutaneous arteries of the upper thigh oecurred in 15 of 20 sides of the adult embalmed cadaveric specimens perfused with red relax. The occurrence rate thereof was 75.0%. The size of the flaps dyed with Chinese ink was 11.0 cm × 18.0 cm. The occurrence rate of direct cutaneous arteries during dissection of the 50 cases of anterolateral femoral skin flap was 72.0% (36 arteries in 36 cases). Direct cutaneous artery of the upper thigh came from the lateral femoral circumflex artery ( 56.9%, 29 sides), the deep femoral artery( 15.7%, 8 sides) or the femoral artery ( 27.4%, 14 sides ). The mean diameter of origin site. of these direct cutaneous arteries was (2.7 ±0.2) mm. Among the 42 cases of direct cutaneous artery skin flap of the upper thigh, 3 flaps survived with partical necrosis and healed after changing dressing or skin graft. The others survived completely, the size of flaps ranged from 6.0 cm × 8.0 cm to 11.1cm×18.0cm(11 free skim flaps andm 31 pedicle flaPS), Conclusion The direct eutaneous artery skin flap of the upper thigh has good blood supply and is easy to harvest. It can be made into not only pedicled flap but also free transplantable flaps. It is possible to harvest the flap without any muscle. The lateral femoral cutaneous nerve can be harvested and anastomosed with a cutaneous nerve of the recopient site. Key words: Surgical flaps; Hand injuries; Mierosurgery; Direct eutaneousarteries of superior thigh