Neurocutaneous Flap Research Articles

The reverse sural artery neurocutaneous flap under combined sciatic and femoral nerve block for lower limb defects: a series of ten cases

The case of reverse sural artery neurocutaneous flap done for lower leg defects under combined sciatic and femoral nerve block is presented. Doing the flap using this method of anesthesia makes the positioning changes necessary during surgery easy. All flaps survived. Nine out of the ten blocks acted satisfactorily. The technique of giving the combined block is described in brief. The mean time of onset of action was 16.62 min, and the mean duration of action was 6.26 h using 1% Lidocaine with 1 in 200,000 adrenaline.

Distally based sural neurocutaneous pedicle flap

The distally based sural neurocutaneous flap is technically simple and characterised by limited morbidity. It is one of the therapeutic alternatives for the coverage of small ormiddle-sized soft-tissue loss in the distal third of the leg, at the level of the ankle and of the heel. This flap is based on a retrograde flux originating from the superficial sural artery. It depends on the perforating arteries originating from the peroneal artery. It can be harvested as a skin paddle or as an island flap. It will not lead to major artery sacrifice. It is a reliable flap, which can be performed on diabetic as well as arteritic patients. Its best indication is for the coverage of heel decubitus ulcer. Finally, it can be used for management of soft-tissue defects, especially related to osteomylitis with the filling of bone cavities.

Lateral Retromalleolar Perforator???Based Flap: Anatomical Study and Preliminary Clinical Report for Heel Coverage

Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point. This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap. The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications. The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.

The coverage of skin defects over the foot and ankle using the distally based sural neurocutaneous flaps: Experience of 21 cases

Skin defects over the foot and ankle remain a challenge to plastic surgeons. The distally based sural neurocutaneous flap is a reliable and effective procedure. The authors have performed 21 cases (22 flaps) since 2000. Twenty-one flaps survived uneventfully. The recipient range included the dorsum of the foot, heel and forefoot. The texture, thickness and colour were satisfactory although pressure ulcers occurred on flaps over the weight-bearing region, such as sole. The factors that influence the survival of the flap are the width of the pedicle, ligation of the lesser saphenous vein and complete vascular network around the ankle.

Clinical application of different neurocutaneous vascular flaps

目的 观察不同皮神经营养血管皮瓣的临床效果. 方法 根据病例骨外露或肌腱外露的创面,选择应用皮瓣种类:腓肠神经营养血管逆行皮瓣96例,隐神经营养血管逆行皮瓣35例,拇指尺背侧皮神经营养血管逆行岛状皮瓣35例,手背皮神经营养血管逆行岛状皮瓣2例,前臂外侧皮神经逆行皮瓣15例,股中间神经营养血管逆行皮瓣5例,肋间皮神经营养血管皮瓣3例,股后侧皮神经逆行皮瓣6例,足背内侧皮神经营养血管皮瓣6例,足背中间皮神经营养血管皮瓣10例,足背外侧皮神经营养血管皮瓣3例.其中皮瓣面积最大32cm×10cm,最小2cm×3cm.皮神经血管蒂最长18cm,最短2cm,蒂最宽4cm,最窄1cm.旋转度最大180°,最小90°. 结果 临床应用216例,其中201例皮瓣全部成活,15例皮瓣远端部分坏死,经换药、植皮后愈合. 结论 皮神经营养血管皮瓣血供可靠,切取简单,适用于四肢及躯干损伤创面的修复。

Expansion of Surviving Skin Paddle of Neurocutaneous Island Flaps in Rats by VEGF

The purpose of this study was to investigate whether vascular endothelial growth factor (VEGF) can enlarge the skin paddles of neurocutaneous flaps in rats. Wistar albino rats were used in four groups: Group 1, (n = 10): neurocutaneous island flap; Group 2, (n = 10): neurocutaneous island flap, surgical delay; Group 3, (n = 10): neurocutaneous island flap, VEGF; Group 4, (n = 10): graft. A 3 x 3-cm, neurocutaneous island flap was elevated on the anterolateral skin of the thigh of the rats. The surviving flap areas were 29.7 +/- 1.43 percent in Group 1, 41.3 +/- 3.24 percent in Group 2, 94.2 +/- 1.46 percent in Group 3. There were no surviving areas in Group 4. The vascular networks of Group 3 animals were more intensive and diffused on microangiography and the histopathologic findings were better in this group. The surviving flap areas in Group 3 animals were enlarged approximately three times over the original size.

The Tibial Second Toe Vascularized Neurocutaneous Free Flap for Major Digital Nerve Defects

Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period. From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe. All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5. The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common. Therapeutic IV.

Distally based dorsal digital neurocutaneous flap for finger-pulp reconstruction

目的 介绍应用指背皮神经营养血管皮瓣修复指腹创伤缺损的临床经验,并探讨改善静脉回流的方法.方法 自2004年3月至2005年10月,共急诊应用远端蒂指背皮神经营养血管皮瓣,修复指腹创面大于2 cm者18例.旋转轴点在近侧指间关节(PIP)平面以近0.5 cm,皮瓣面积2 cm×2 cm～3 cm×4 cm,皮神经筋膜蒂长2～3 cm.均将指背皮神经与指固有神经吻接,并在旋转点远侧1 cm处结扎指背浅静脉.结果 术后皮瓣均有不同程度的静脉淤血肿胀,8例皮瓣出现张力水泡.13例随访超过6个月,皮瓣恢复保护性感觉.结论 指背皮神经营养血管皮瓣修复指腹创伤缺损,方法简单,成活可靠.在蒂部远侧结扎指背浅静脉干阻断倒灌和在末端旷置敞开,均能改善静脉回流,减轻皮瓣肿胀。

Sensate dorsal thumb neurocutaneous flap for coverage of thumb pulp defect

目的 介绍吻合神经的拇指背侧皮神经营养血管皮瓣修复拇指腹缺损的方法.方法 对17例单侧拇指腹缺损的患者,应用吻合神经的拇指背侧皮神经营养血管皮瓣进行修复,其中采用拇指桡侧指背皮神经营养血管皮瓣7例,尺侧皮瓣10例.指腹缺损面积为1.5 cm×2.0 cm～2.5 cm×3.0 cm,皮神经与指神经缝合.结果 17例皮瓣全部存活,供区创面Ⅰ期愈合.术后随访6～12个月,拇指外形、功能满意,皮瓣质地、色泽与正常指相近,皮瓣不臃肿,两点分辨觉为10～15 mm.结论 拇指背侧皮神经营养血管皮瓣,皮瓣供区靠近创面,操作方便,患者容易接受,术后皮瓣外形满意,可恢复感觉,是修复拇指腹缺损较理想的手术方法。

Neurocutaneous Soft Tissue Reconstruction in the Fingers: Tibial Neurocataneous Second Toe Free Flap

Most digital nerve defects can be reconstructed by means of non-vascularized nerve grafts, artificial tubes, or the like. However, when the bed is poor, the defect is long, or there is a concomitant soft tissue loss, a vascularized nerve graft may be the best indication. The authors presented their experience in reconstructing major neurocuatenous defects in the fingers by means of a vascularized neurocutaneous flap from the toe.

Angiosome Territories of the Nerves of the Upper Limbs

The use of free vascularized nerve grafts requires intimate knowledge of the blood supply of peripheral nerves. The authors aimed to demonstrate radiographically the topography of the upper limb nerves with their blood supply, and to examine them as an application of the angiosome concept. An angiosome is a three-dimensional block of composite tissue supplied by a single source artery. This anatomical study involved the meticulous dissection of four fresh upper limb specimens injected intraarterially with a gelatin-lead oxide mixture. The nerves were tagged circumferentially with copper wire and radiographs were taken of the nerves with their arterial blood supply. The median, ulnar, radial, musculocutaneous, and axillary nerves were examined. The authors showed that the nerves of the upper limb were supplied segmentally by source vessels, which reinforced the angiosome concept. The suitability of each nerve for harvest in free vascularized nerve transfer was assessed according to its pattern of blood supply. The authors' work has a wide range of clinical applications and provides an anatomical basis for neurovascular and neurocutaneous flaps and free vascularized nerve grafting.

Reversed Saphenous Neurocutaneous Flap in Lower Leg Reconstruction

Traumatic wounds over lower leg are difficult to be reconstructed. Those wounds are sometimes surrounded by vascular compromised tissue, which make the local flap, such as the tibialis muscle turnover flap, inaccessible. Besides these local compromised wound conditions, those traumatic patients are sometimes associated with life threatening injuries, such as liver laceration and intracranial hemorrhage. In these situations, life-saving procedures, such as repairing the liver laceration or craniotomy make time-consuming limb salvage procedure, such as free flap, impossible. From 2000 to 2005, we have used the reversed saphenous neurocutaneous flap to cover traumatic wounds over lower leg in 10 cases. Two of them were associated with trauma-associated life threatening injuries. The mean operation time of the harvest of reversed saphenous neurocutaneous flap and coverage of the defect was 126 minutes. All flaps survived well, except one superficial loss of the flap over the distal leg. This flap healed by dressing without further reconstruction procedure. The reversed saphenous neurocutaneous flap is reliable, and timesaving procedure, which is really useful in lower leg salvage in traumatic patients. It could be chosen as a first priority flap in lower leg reconstruction in trauma patients.

Anatomical study and primary clinical application of the medial dorsal neurocutaneous flap on foot

目的 为足背内侧皮神经营养血管皮瓣设计提供解剖学依据,并报道其临床应用效果.方法32侧乳胶灌注的成人下肢标本,对足背内侧皮神经及其营养血管进行解剖,观察其起始、直径、走行、分支及分布情况.在此基础上设计足背内侧皮神经营养血管皮瓣应用于临床修复足前端创面3例.结果足背内侧皮神经均续于腓浅神经,行于踝间线时位于中点内侧(0.7±4.3)mm,直径为(2.59±0.54)mm,主干于踝间线远端(3.0±1.5)cm处发出1～3条分支.足背内侧皮神经营养血管平均每侧6.9支,最为恒定的分支穿深筋膜时分别位于踝间线近端(4.1±0.5)cm,直径为(0.81±0.13)mm;第一跖趾关节内侧近端(1.4±0.2)cm,直径(0.48±0.08)mm;第二趾蹼尖近端(1.5±0.3)cm,直径(0.46±0.08)mm.临床应用3例皮瓣均完全成活.结论足背内侧皮神经营养血管皮瓣血供可靠,逆行皮瓣转移是一种理想的修复足前端创面的手术方法。

Expérience clinique et adaptations techniques du lambeau neurocutané sural à pédicule distal. À propos de 60 cas

The distally based sural neurocutaneous flap (Masquelet et al. , 1992) has proved to be a useful technique for lower limb skin defect reconstruction. We report our experience in a 60 case series for the coverage of foot, ankle, and distal third of the leg with success in 58 cases and 2 failures. For one of these, a total necrosis occurred after a technical problem when harvesting the pedicle, while the second failure was due to a severe inferior limb vascular disability. In 14 cases, a partial venous congestion with a slight epidermolysis or a marginal necrosis was observed but it resolved without sequel. Seventeen patients presented with distal vascular impairment and/or neuropathies (i.e. diabetes mellitus, arteriosclerosis, vascular lesions) of the inferior limb and our experience favour a larger pedicle trimming than in normal cases to avoid venous congestion of the skin paddle. In 18 cases, when undermining of skin between the pivot-point and the defect site to be covered was too hazardous, we used an external pedicle either temporary and severed a few weeks after or skin grafted. This is a helpful mean when local condition of the skin to be undermined for pedicle tunnelling may interfere with the final issue. This one-stage simple technique, without major vascular sacrifice and with minor consequences at the donor site, is reliable for the distal third of the inferior limb, ankle, and dorsal foot aspect reconstruction, the heel-bearing zone excepted.

The distally based sural fasciomusculocutaneous flap for foot reconstruction

Finding appropriate soft-tissue to cover a wound located over the middle or distal portion of the foot can be challenging. A distally based sural fasciomusculocutaneous flap including the sural nerve and a midline cuff of the gastrocnemius muscle can be used for this purpose. This flap is designed on the proximal third of the posterior calf and is nourished in a retrograde manner by the lower peroneal septocutaneous perforators, through the vascular axis of the sural nerve to the musculocutaneous perforators of the gastrocnemius muscle. Between October of 2002 and January of 2004, this flap was applied in nine individuals, including four diabetic patients. The skin defects all resulted from trauma, osteomyelitis or chronic ulcer, and combined with bone or tendon exposure. One flap developed distal necrosis. The other flaps survived fully and provided good contour. In our series, diabetes mellitus seemed not to compromise the vascularity of the flap. The distally based sural fasciomusculocutaneous flap is very useful for lower limb reconstruction, particularly for the foot, because of its long vascular pedicle and the availability of the skin portion of the proximal calf based on direct branches between the musculocutaneous perforators and the neurovascular axis of the sural nerve. This is an important variant of the sural neurocutaneous flap and it appears to be a good alternative to free flaps for resurfacing the foot.

The Reverse Sural Neurocutaneous Flap for Hindfoot and Ankle Coverage: Experience and Review of the Literature

Soft-tissue defects about the ankle are common in orthopedic surgery. The wounds usually involve exposed bone or hardware, making skin grafting a poor option. Free tissue transfer remains a mainstay of treatment. Recently, the reverse sural neurocutaneous flap has gained popularity. At our institution, 11 fasciocutaneous flaps have been performed for defects averaging 53cm2. All flaps achieved stable coverage. One patient required repeat skin grafting. Given its reliability, easy dissection, and outpatient capability, this flap should be considered for coverage in this region.

Reparation of thumb soft tissue defect with dorsal thumb neurocutaneous vasotrophic island flap

目的 探讨带拇背侧桡、尺侧皮神经营养血管蒂的岛状皮瓣修复拇指软组织缺损的可行性及临床效果.方法从1997年10月至2004年2月,利用拇背侧皮神经营养血管皮瓣修复拇指软组织缺损,并将皮瓣内皮神经与受区内指神经行外膜吻合,重建受区感觉.结果临床应用101例皮瓣,其中97例皮瓣均成活,1例皮瓣坏死,3例皮瓣部分坏死,经吻合神经后皮瓣能恢复部分感觉.结论该皮神经皮瓣手术操作简单,皮瓣外形好,部分皮瓣能恢复感觉,是修复拇指软组织缺损的较为理想方法。

Sensorial donor site morbidity after saphenous neurocutaneous flap

Neurocutaneous flaps based on the arterial network around the superficial sensory nerves are popular in soft tissue coverage of the lower extremities, and are usually preferred in reconstruction of the lower leg and foot. Although sacrifice of sensory cutaneous nerves is mentioned as one of their major disadvantages to our knowledge the morbidity in the foot and at the donor site has not been properly investigated. We investigated sensorial morbidity in the foot and at the donor site caused by raising a saphenous neurocutaneous flap in 14 patients by using static two-point discrimination test, Semmes-Weinstein monofilament test, vibration test, and by measuring somatosensory evoked potentials in the twelfth postoperative month. Our results suggest that sensory recovery is good and protective sensation is gained in most patients.

A New Flap Design: Neural-Island Flap

This report introduces the "neural-island flap" concept, which represents a consistent and reliable skin flap design supplied only by the intrinsic vasculature of a cutaneous nerve. In this study, the lateral femoral cutaneous nerve was selected as the pedicle of the neural-island flap, and a standard skin flap, which is the territory of the accompanying vessels (i.e., iliac branches of the iliolumbar artery and vein), was elevated on the lower dorsal region of the rats. In a total of 92 Wistar rats, three experiments were performed. In part I (n = 24), the vascular anatomy of the lateral femoral cutaneous nerve was established by the methods of dissection, microangiography, nerve mapping, perfusion with colored latex and India ink, and histologic analysis. In part II (n = 46), the role of the cutaneous nerve in supporting an acutely elevated skin flap was explored by creating five flap groups as follows: group 1, conventional flap (artery, vein, and nerve intact); group 2, neural island flap (only the nerve intact); group 3, neurocutaneous flap (vein and nerve intact); group 4, denervated flap (artery and vein intact); and group 5, skin graft. In part III (n = 22), the role of a preliminary surgical delay procedure to augment the survival of the neural island flap was investigated. Results of the anatomic studies indicated a consistent perineural vasculature by the accompanying iliolumbar artery. Skin flaps survived totally in groups where the artery and vein were intact, whereas mean survival rates for the neural island flap and the neurocutaneous flap were 38.2 +/- 3.1 percent and 44.5 +/- 3.8 percent, respectively (p > 0.05). Results of part III of the experiment demonstrated a significantly higher survival for the delayed neural island flap (94.5 +/- 5.5 percent) compared with the acutely elevated neural island flap (p < 0.05). The perineural and intraneural vessels were found to be greatly dilated after a delay procedure, demonstrated by direct observation, microangiography, histologic analysis, dye injection study, and scanning electron microscopy. On the basis of this promising series of experiments, a clinical technique was developed using the sural neural-island flap. The flap was used to reconstruct lower extremity defects in four cases. A delay procedure was accomplished in the first stage by elevating a fasciocutaneous flap from the midcalf region based on a posterior skin bridge and the sural nerve. After a 2-week delay period, a sural neural-island flap was created based on the nerve and transposed to the defect. Flap survival was complete in all cases, with a satisfactory result. The authors conclude that this report proves for the first time that a robust and reliable skin flap can be created pedicled only by the intrinsic vasculature of a cutaneous nerve, after a proper surgical delay. The so-created neural-island flap design offers two novel advantages: (1) a very narrow pedicle and (2) a pedicle without any restriction to a specific pivot point, in addition to the previously described unique advantages of preservation of a major artery and avoidance of microvascular anastomoses.

Neurocutaneous Island Flap:

The rabbit ear has often been used as an experimental model; however, a neurocutaneous flap has never been described before. The authors examined the reliability of a skin cartilage flap with a pedicle composed only of a sensory nerve with its vascular network in a rabbit model: A 2 x 2-cm cutaneous cartilage flap was harvested on the dorsal side of the ear bilaterally. Vessels were tied and cut on the 4 sides of the flap, including the central auricular artery and vein. The nerve was cut at the distal side of the flap and was "skeletonized" to the extent of 1 cm on the proximal side, meticulously preserving its vascular network. Subsequently, the flap was elevated with the cartilage as a composite flap and was sutured back to its natural site. The authors elevated 28 skin cartilage flaps on the dorsal side of both the ears of 14 New Zealand White rabbits, centered on the central neurovascular axis. All 28 flaps survived. In the control group of 7 rabbits, the artery, vein, and nerve (pedicle) were severed, and the skin cartilage island was sutured back as a composite graft. None of these 14 grafts survived. In 4 additional rabbits, the authors performed a histologic examination 1 day, 3 days, 7 days, and 3 weeks postoperatively of the neurovascular axis after the same skin cartilage flap was harvested. They compared these results with the histologic examination of the nerve of the contralateral nonoperated ear, and noted a marked dilatation and multiplication of blood vessels in the operated ear beginning on day 1 postoperatively. The presence of this neurocutaneous vascularization should be considered when other kinds of flaps (venous flaps or others) are used as experimental models using the rabbit ear.