Free Neurovascular Flap Research Articles

Salvage Procedures for Facial Reanimation With Neurovascular Flaps When Previous Surgeries Failed: Is Homolateral Vessel or Nerve Depletion a Contraindication?

Facial paralysis reconstruction can be difficult in extensive defects after complex facial or cranial base tumor resection and radiotherapy or when primary smile reanimation attempt has failed. The surgical challenge is more complicated when defects are associated with recipient vessels or nerves depletion. This scenario has not been well described in the literature, and the present article will address the alternatives that plastic surgeons may use in these circumstances. Seventy-five patients operated in the Hospital Gregorio Marañon between 2008 and 2020, for dynamic reconstruction of facial paralysis, were retrospectively evaluated, collecting data about previous facial nerve surgeries, radiotherapy, chemotherapy, recipient nerve for motor restoration and vessels used for free flaps, type of neurovascular free flap (NVFF), and functional score before and after the facial reanimation surgery. Patients presenting recipient vessel and/or nerve depletion after several facial surgeries requiring a variation from the common NVFF surgical protocol were included in this study. Six cases (8%) with facial paralysis and absent recipient homolateral vessels or nerves after severe cranial base surgery, parotid malignancies, or schwannoma surgery were included. Two patients had an immediate functional reconstruction during the oncologic resection surgery, and 4 patients had a delayed reconstruction. Three patients had previous reconstruction with free flaps, and the vascular pedicles of previous flaps were used for the new NVFF. In the other 3 cases, interposition vein grafts to the contralateral recipient vessels were required to perform NVFF. Masseteric nerve in 4 cases, hypoglossal nerve and posterior branch of the deep temporal nerve in 1 case each, were used as recipient nerves. House-Brackmann score improved in all patients after surgery. Neurovascular free flap can be successfully performed to restore facial motion after depletion of homolateral recipient vessels or nerves after previous facial or cranial base surgeries. In these cases, interposition vascular grafts or the pedicle of previous flaps are essential to provide vascularization as well as an optimal orientation of flaps, to reach recipient nerves in a 1-step procedure.

RECONSTRUCTION OF UPPER LIMB SOFT TISSUE INJURIES, EXCEPT FOR FINGERTIPS LESIONS.

ABSTRACTObjective: The main purpose of this work was to evaluate the advantages and disadvantages of reconstructive procedures applied in upper limb soft tissue injuries according to their location. Methods: The study involved 94 male and 22 female patients (116 total) operated between April 2001 and November 2017 due to traumatic injuries in a upper limb. Individuals were evaluated considering their age, sex, etiology, reconstruction area , applied methodology and complications. The finger injuries were excluded. Results: The performed reconstruction procedures include 29 skin grafts; six advancement flaps; seven rotation flaps; 33 pedicled fasciocutaneous flaps, 9 free fasciocutaneous flaps; 5 pedicled muscle flaps; 12 free muscle flaps, three pedicled musculocutaneous flaps; one free musculocutaneous flap; 11 neurovascular free flaps. Conclusion: Reconstructive procedures in the upper limbs are diverse, varying from skin grafting to free flaps. The indication of the best option depends on the type of injurie and the surgeon. The final goal is to reach the best functional result combined with the lowest possible morbidity. Level of Evidence IV, Case series.

The free neurovascular transverse wrist crease flap for repairing soft tissue defects of the fingers: clinical outcomes of multiple centers

BackgroundFlap transplantation is often needed for soft tissue defects of the fingers that cannot be closed directly. Sensory reconstruction of the fingers is important for patients to recover feelings. In this study, we report clinical outcomes of using free neurovascular transverse wrist crease flap for repairing finger defects from multiple centers.MethodsThis case series includes 72 consecutive patients with finger defects between June 2013 and June 2016 from multiple centers. A neurovascular transverse free radial artery superficial palmar branch flap, named transverse wrist crease flap, was designed to reconstruct soft tissue defects of the fingers with microvascular anastomosis. When there were soft tissue defects of the fingers with digital nerve defect, end-to-end neurorrhaphy between the median palmar cutaneous branch and the digital nerves was also performed. The donor incision was sutured directly. All the patients were followed-up for more than 24 months.ResultsThe soft tissue defects of the fingers were all completely covered with this free neurovascular transverse wrist crease flap, and the flaps in 71 patients survived completely without ischemia. Vascular crisis appeared in one case, and the wound healed gradually after changing wound dressing for nearly 1 month. Slight infections of wounds appeared in eight cases. There were no complications in the donor site, like infection and poor wound healing. At the last follow-up, the mean static two-point discrimination was 9.6 ± 2.4 mm on the injured finger and 4.5 ± 0.8 on the contralateral corresponding finger. The motion range of the distal interphalangeal joint and proximal interphalangeal joint on the injured finger were 72.5 ± 23.3% and 78.7 ± 32.5% of the contralateral corresponding finger, respectively. Patient self-evaluations were good in 53 cases and fair in 19 cases.ConclusionsThe results indicate that the free neurovascular transverse wrist crease flap is a good choice for repairing soft tissue defects of the fingers.Level of evidenceTherapeutic IV

Formation of a sensate forearm stump through neurovascular tissue transplantation

The use of neurovascular flaps can help to maximize limb length and gain sensory re-innervation in amputees. We describe the case of a 19-year-old patient who underwent an innovative reconstructive approach aimed at preserving viable limb length with sensory regeneration by using innervated tissue transfer after traumatic upper extremity amputation below the elbow. The forearm length was maximized by means of two neurovascular free flaps that formed a robust, functional, and versatile stump. The mechanism of this reconstruction originated from the practice of placing a double-innervated anterolateral thigh flap over a myocutaneous flap for covering protruding forearm bone shafts. This form of vascularized tissue transplantation helps to minimize the risk of necrosis of radial and ulnar bone shafts. In this patient, an upper arm prosthesis would have been necessary if lower arm bone shafts had been shortened for primary wound closure. Therefore, the newly formed stump enabled the patient to wear a forearm prosthetic instead of a less functional upper arm device. In addition, neurovascular tissue transfer facilitates sensory re-innervation, improvement of the healing process and serving a protective function over the covered area. Through co-adaptation of free nerve endings, neuroma formation can also be prevented. To ensure long-term success, it is vital that the patient be in good mental and physical health, as well as demonstrate the capacity for long-term rehabilitation therapy prior to performing such reconstructions. Level of Evidence: Level V, therapeutic study.

Repair of minor tissue defect in hand by transfer of free tissue flap from the toe.

To introduce our experience of using the free neurovascular flap from great and second toe. Thirteen patients (fifteen fingers) sought surgical treatment for soft tissue defects of the hand at our medical institution between March 2006 and September 2009. In two patients, fibular side skin-nail flaps of great toe were applied to cover the dorsal defect of distal thumb. In twelve, the treatment was carried out for the pulp defect of finger with fibular side flap of great toe or tibial side flap of second toe. In one, the treatment was carried out for the defect of distal middle with composite flap with distal digital bone of second toe. All flaps survived. The average subjective satisfaction score was 8.08 (range 4-10). Nine patients (69%) experienced cold intolerance, and 2 patients (15%) dysesthesia. The Semmes-Weinstein sensitivity score was between 3.47and 4.72 on the flap, and 0-4.18 on the donor site. The mean two-point discrimination was 6.8 mm (range 4-12). Grip strength was 10% less than in the unaffected hand. The proximal interphalangeal mobility loss was less than 15 degrees. Our results indicated that these free flaps from toe are useful for patients with a small soft-tissue defect in hand.

Weight-bearing plantar reconstruction using versatile medial plantar sensate flap

The medial plantar flap serves as an ideal tissue reserve for reconstructing the weight-bearing plantar areas as these areas require a sensate and glabrous skin. Furthermore, the flap provides tissue that is structurally similar to the plantar foot as it is also composed of thick glabrous plantar skin, shock-absorbing fibro-fatty subcutaneous tissue and plantar fascia. During the past 25 years, 20 patients (10 men, 10 women) with skin and soft-tissue defects over the weight-bearing plantar foot were treated. They ranged in age from 20 to 70 years (mean, 31.5 years). The causes of the defects were trauma (n=14) and malignant tumour (n=6); the defects were localised at the heel (n=16) and plantar forefoot (n=4). The medial plantar flap was transposed to the defects in three different ways: proximally pedicled sensorial island flaps (n =8), distally pedicled sensate island flaps based on the lateral plantar vessel (n =3) and neurovascular free flaps (n =9). Flap size varied from a width of 4-8cm and a length of 6-12cm. The mean size of the medial plantar flap was 49.5cm(2) (range, 28-96cm(2)). The follow-up period ranged from 6 to 80 months (mean, 19.9 months). Partial flap loss was observed in two proximally pedicled sensorial island flaps and one distally pedicled sensate island flap. Two free flaps restored normal sensation within 5 years of surgery. Minor skin graft loss at the donor site was observed in seven patients. However, no revision or re-grafting was performed. Hyperkeratosis was observed in one case. All patients achieved normal gait within 3 months after surgery and none noticed recurred ulceration. Durable, sensate coverage of the defects was achieved in all patients. We advocate variable sensate medial plantar flaps for the reconstruction of moderate-size defects of the weight-bearing plantar subunits.

The relationship between the deep fibular nerve and the dorsalis pedis artery and its surgical importance

The aim of this study was to demonstrate the relationship between the deep fibular nerve and the dorsalis pedis artery to provide useful anatomical knowledge for safe surgical approaches in plastic surgery. The dissection of 30 cadaver lower limbs was undertaken to describe the relationship of the deep fibular nerve to the dorsalis pedis artery in the anterior tarsal tunnel and on the dorsum of the foot. The anterior tarsal tunnel is a flattened space between the inferior extensor retinaculum and the fascia overlying the talus and navicular. The deep fibular nerve and its branches pass longitudinally through this fibro-osseous tunnel, deep to the tendons of the extensor hallucis longus and extensor digitorum longus. Four distinct relationships of the deep fibular nerve to the dorsalis pedis artery were determined. The dorsalis pedis neurovascular island flap contains both the dorsalis pedis artery and the deep fibular nerve. Because the design of a neurovascular free flap requires detailed knowledge of the nerve and vascular supply, the data presented here are intended to help surgeons during surgical approaches to the foot and ankle.

The relationship between the deep fibular nerve and the dorsalis pedis artery and its surgical importance

ABSTRACTThe aim of this study was to demonstrate the relationship between the deep fibular nerve and the dorsalis pedis artery to provide useful anatomical knowledge for safe surgical approaches in plastic surgery. The dissection of 30 cadaver lower limbs was undertaken to describe the relationship of the deep fibular nerve to the dorsalis pedis artery in the anterior tarsal tunnel and on the dorsum of the foot. The anterior tarsal tunnel is a flattened space between the inferior extensor retinaculum and the fascia overlying the talus and navicular. The deep fibular nerve and its branches pass longitudinally through this fibro-osseous tunnel, deep to the tendons of the extensor hallucis longus and extensor digitorum longus. Four distinct relationships of the deep fibular nerve to the dorsalis pedis artery were determined. The dorsalis pedis neurovascular island flap contains both the dorsalis pedis artery and the deep fibular nerve. Because the design of a neurovascular free flap requires detailed knowledge of the nerve and vascular supply, the data presented here are intended to help surgeons during surgical approaches to the foot and ankle.

Transfer of free rural neurovascular flap based on perforating branches of the peroneal artery to repair soft tissue defects of the upper limbs

Objective To introduce the surgical techniques of transferring sural neurovascular flap based on peroneal artery distal perforators for coverage of soft tissue defects of the upper limbs.Methods From June 2006 to August 2007,sural neurovasculur flap based on peroneal artery distal perforators was transferred to repair upper limb soft tissue defects in 6 cases.In 4 cases cutaneous nerve of the recipient site was sutured to the sural nerve.Results All flaps survived completely.The patients were followed-up for 4 months to 1.5 years.The appearance and quality of the flaps,including color,thickness,texture and contour,are comparable with the recipient site.The flaps with cutaneous nerve coaptation recovered S2 and better sensation.The 2 cases without cutaneous nerve repair recovered protective sensation.Conclusion Free sural neurovaseular flap based on perforating branches of the peroneal artery is an effective method for treatment of soft tissue defect in upper limbs. Key words: Surgical flaps; Microsurgery; Arm injuries

The Clinical Importance of the Relationship between the Deep Peroneal Nerve and the Dorsalis Pedis Artery on the Dorsum of the Foot

The aim of this study was to describe the relationship between the deep peroneal nerve and the dorsalis pedis artery to help ensure a safer surgical approach in flap surgery. The dissection of 36 cadaver lower limbs was undertaken to describe the relationship of the deep peroneal nerve to the dorsalis pedis artery in the anterior tarsal tunnel and on the dorsum of the foot. Four distinct relationships of the deep peroneal nerve to the dorsalis pedis artery were determined. In type 1 (36.1 percent), the artery was medial to the deep peroneal nerve in the tunnel and medial to the medial terminal branch below the tunnel on the dorsum of the foot. In type 2 (25.0 percent), the artery was medial to the deep peroneal nerve in the tunnel and lateral to the medial terminal branch below the tunnel on the dorsum of the foot. In type 3 (30.6 percent), the deep peroneal nerve and the artery were crossing over each other at multiple levels. In type 4 (8.3 percent), no medial terminal branch was observed. The artery was medial to the lateral terminal branch. The dorsalis pedis neurovascular island flap contains both the dorsalis pedis artery and the deep peroneal nerve. Because the design of a neurovascular free flap requires detailed knowledge of the nerve and vascular supply, the data presented here will help surgeons during the surgical approaches to the foot and ankle.

One-Stage Reanimation of the Paralyzed Face Using the Rectus Abdominis Neurovascular Free Flap

Functional free muscle transfer for the surgical correction of long-standing facial paralysis has gained validity over the past three decades. These traditionally multistep reconstructions often achieve clinical success, but at the cost of significant morbidity and lengthy recovery periods. To address this dilemma, the authors propose reconstruction using the rectus abdominis and accompanying intercostal nerve in a one-stage neurovascular free flap reanimation procedure. Between 1998 and 2001, five patients with long-standing unilateral facial paralysis at the University of Pittsburgh Facial Nerve Center underwent reanimation using the authors' protocol. Preoperative and postoperative assessments included clinical evaluation using the Facial Grading System and electromyography. The patients were followed for a mean of 16 months. At the final postoperative visit, all five patients demonstrated improved levator electromyographic potential, with a median 67 percent improvement. All five patients further demonstrated an increase in zygomaticus electromyographic potential, with a median 225 percent improvement. All five patients demonstrated increased Facial Grading System score at most recent follow-up. The one-step reanimation using free rectus abdominis neurovascular free flap demonstrated a consistent positive outcome in electromyographic and clinical assessments. The additional benefits of reduced recovery time and anatomical reliability of the flap render the authors' method preferable to other traditional methods of surgical reanimation of the paralyzed face.

Abstracts

Abstracts

Neurovascular musculocutaneous latissimus dorsi free-flap transfer for reconstruction of a major cheek defect with facial palsy in a 14-month-old child

This report deals with a female infant 14 months old at time of surgery. Three weeks before admission, she suffered a direct blow to the left cheek by hitting a table. Within 24 h, she developed a hematoma involving the whole cheek. Ten days later, she developed an eschar on the cheek and was referred to us. Three weeks after the initial trauma, the damaged tissues were debrided, including the skin, subcutaneous tissue, and muscle. The buccal mucosa remained intact. Facial palsy involving the territory of the buccal and mandibular branches was already evident at 3 weeks, as well as facial asymmetry. Consequently, a free musculocutaneous neurovascular latissimus dorsi free flap was proposed to restore the volume, shape, and function of the left half of the face. We present the surgical technique and the results 3.5 years later.

Does the removal of pectoralis minor impair the function of pectoralis major?

The treatment of long-standing unilateral facial palsy with cross-facial nerve graft and free pectoralis minor muscle flap to the face has been the elective choice for more than 300 patients during the last 20 years at Mount Vernon Hospital in Northwood, United Kingdom. In this study, the authors assessed the residual donor-site morbidity in the chest after the procedure. During the second stage of the operation, the medial and the lateral pectoral nerves are divided at a proximal level from the plexus. Due to the common innervation shared by the two pectoral muscles, a consequent change in pectoralis major muscle function can be expected, but so far no study has been carried out to find out whether or not this occurs. The authors have performed a subjective and an objective study on a voluntary sample of 38 patients previously operated on for facial palsy with pectoralis minor muscle transfer. Cosmetic and functional outcomes were recorded. The subjective evaluation was obtained through a questionnaire. The objective evaluation was obtained through physical examination (inspection and palpation). The following quantitative parameters were determined: thickness of the muscle, arm muscle circumference, power produced at contraction, and muscle fiber activity. Subjectively, six patients (15.8 percent) reported a reduction in the force of the muscle, and 10 patients (26.3 percent) noticed a change in muscular thickness at the site of the operation. Objectively, the results of the electromyogram were almost normal in all of the muscles sampled (17 patients). Occasionally, minor changes from the normal pattern were seen in the lower half of pectoralis major. The dynamometer adduction test showed a significant reduction in the force developed on the operated side when it was the dominant side (p = 0.02), whereas no difference was shown in the group of patients who underwent operations on the nondominant sides (p = 0.18). The pectoral fold and the arm muscle circumference did not show any difference between the side operated on and the nonoperated side. This clinical study confirms that the use of the pectoralis minor muscle as a neurovascular free flap for face reanimation is associated with a low morbidity at the donor site. The authors believe that the medial pectoral nerve has a marginal role in pectoralis major muscle innervation in contrast to the classic anatomic descriptions and some of the positions of the official surgical literature regarding the actual function of this nerve.

Morphometric changes in free neurovascular latissimus dorsi flaps: an experimental study.

This study was designed to investigate regeneration of reinnervated, free transplanted muscles. We used a rat model, consisting of eight rats per group, in which the latissimus dorsi muscle was transplanted orthotopically and then harvested and evaluated after 2 and 12 weeks. Age-matched control animals were used to oppose non-operated muscles. At date of removal the patency of the vascular anastomoses was checked clinically and histologically. Electrophysiological measurements were also performed and conventional and enzyme histochemical histological slides manufactured. Two weeks after the free neurovascular flap transfer the muscle was not yet innervated, and histologically a dissolved pattern of type 1 and type IIA muscle fibres was found. The muscle fibres demonstrated a decrease of more than 50% cross-sectional area. After 12 weeks the muscles were reinnervated again; muscle contraction was positive with electrical stimulation and the cross-sectional area had regained 80% of the activity of normal muscle fibres. With enzyme histochemical staining the typical type grouping of reinnervated muscles could be demonstrated.

Free sensate secondary skin flaps: an experimental study on patterns of reinnervation and neovascularisation

The main purposes of the present study were: 1) to compare differences, if any, in the patterns of reinnervation between secondary skin flaps, created either from “innervated skin grafts” or from ordinary denervated skin grafts; 2) to examine the influence of time, and the possible roles of granulation tissue and fibrosis in reinnervation following implantation of a nerve trunk into a secondary skin flap at different stages; and 3) to compare neovascularisation before and after free transfer of these flaps. Neurovascular changes were studied in a rat model by microangiography and by immunohistochemical techniques, using antisera to protein gene product 9.5 (panneural marker), to calcitonin gene-related peptide (sensory neurones) and to von Willebrand Factor (endothelial cell marker). The results indicate a potential clinical role for secondary sensate skin flaps where conventional methods of reconstruction including free neurovascular flap transfers are not available.

Penis Reconstruction with Cutaneous, Myocutaneous and Free Neurovascular Flaps

Surgical techniques for the reconstruction of the penis are reported. Problems and difficulties still exist such as reconstruction of the neo-urethra and the possible occurrence of fistulas and/or stenosis; restoration of tactile and erogenous sensitivity; cosmetic and functional results; rejection of the functional endoprosthesis. Pros and cons connected with different techniques for the reconstruction of the penis, such as cutaneous, myocutaneous and free neurovascular flaps are examined. The use of skin-expanders for clitoris expansion gender transforming operations is considered and the results analysed.

Avulsed Index Finger Reconstruction with a Free Neurovascular Flap from the Big Toe

Avulsed Index Finger Reconstruction with a Free Neurovascular Flap from the Big Toe

Tissue transplants in primates for upper extremity reconstruction: A preliminary report

Recent advances in clinical transplantation surgery suggest that hand transplantation is no longer an unrealistic expectation. However, two questions must be answered. Can composite tissue transplants survive in a primate species? Does the required neural reinnervation occur under immunosuppression? Four hand transplants and seven neurovascular free flap transplants were done in baboons immunosuppressed with Cyclosporin A and steroids (methylprednisolone). Long-term survival occurred in nine. Electrophysiologic tests of sensory axons revealed reinnervation of transplanted skin as evidenced by well-defined, low threshold receptive fields in the donor tissue. Reinnervation of donor muscle was demonstrated by motor unit recruitment in stepwise fashion after electrical stimulation of the recipient's median and ulnar nerves. Afferent fibers serving the donor's joints and muscle spindles were also observed.

Reconstruction of the thumb by a free pedal neurovascular flap and composite phalanx-joint-tendon homograft: a preliminary report.

A one-stage procedure for reconstructing the thumb was used in 10 patients, using previously frozen bone-joint-tendon composite allograft and a neurovascular free skin flap from the foot. Levels of injury ranged from the greater multiangular bone to the middle of the first phalanx. Postoperative bony absorption and joint degeneration were minimized, and no cases of tissue rejection were encountered. Further advantages of the procedure are that subsequent nerve regeneration and cutaneous sensibility are improved, and that there are better functional and aesthetic results, compared to other techniques. Using this procedure, donor site dysfunction is also minimal.