Neurovascular Island Flap Research Articles

Transfer of digital neurovascular island flap from dorso-ulnar side of the same digit for repair of pulp loss in the thumb

目的 探讨拇指指腹缺损的显微修复方法.方法对9例拇指指腹缺损的患者,采用同指带指神经血管拇背尺侧岛状皮瓣移位修复.皮瓣缺损面积为2.0cm×1.5cm～3.0cm×3.0cm.结果 9例皮瓣全部成活,术后随访3～6个月,皮瓣外形满意,质地柔软,弹性好,两点分辨觉达6mm～10mm,拇指屈伸活动良好.结论同指带指神经血管蒂拇背尺侧岛状皮瓣移位,手术方法简单,术后功能、外形满意,是一种修复拇指指腹缺损较理想的术式选择。

RACKED-SHAPED KITE FLAP

Traumatic tissue loss of pulp on the first finger, represents a common problem which requires serious reconstructive operations. The final cosmetic appearance and the sensorial sufficiency for an optimum thumb function are important limitations of wound closure during the thumb reconstruction. Generally, these defects are closed by regional flaps as: Palmar advancement flap (Moberg), cross finger flap, neurovascular island flap (Littler) and the first dorsal metacarpal artery flap (Kite) (1,2).

Restoration of Function and Sensitivity Utilizing a homodigital Neurovascular Island Flap after Amputation Injuries of the Fingertip

Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two-point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries.

The pedicled intercostal neurovascular island skin flap for lumbosacral trunk reconstruction

The pedicled intercostal neurovascular island flap is a useful flap due to its pedicle length, skin pedicle size and possibility for sensation. We present our experience of using this flap for lumbosacral trunk reconstruction in four patients.

Four V–Y islanded flap reconstruction of full thickness defect of chin and labial sulcus

Few techniques are described specifically for reconstruction of full thickness defects involving the chin. We present a new method of reconstruction of a large full thickness defect over the chin and lower labial sulcus with four V–Y island flaps. Two of these were mental neurovascular island flaps. The other two were islanded musculomucosal flap. The mental flaps, previously described for reconstruction of the lower lip, were cosmetically more suitable for reconstruction of tissue defects of the chin. The principle of covering the tissue defect of chin with local tissue to provide good matching and function is achieved.

Composite Osteocutaneous Groin Flap Combined With Neurovascular Island Flap For Thumb Reconstruction

Three amputated thumbs were reconstructed with a composite osteocutaneous groin flap and a neurovascular island flap. The average age at the time of surgery was 28 (range 25–35) years. The level of the amputation was distal to metacarpophalangeal joint in two cases and proximal in one case. The injury mechanism was avulsion in all cases. The postoperative follow-up periods ranged from 27 to 30 months. There were no cases of skin necrosis, bone resorption or infection. Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients. This surgical procedure is reliable and simple and the functional results are satisfying. We reserve this technique for the treatment of thumb amputations which cannot be replanted, particularly as it does not result in bone resorption.

Digital artery flaps for closure of soft tissue defects of the forefoot

Reconstruction of recalcitrant soft tissue defects in the weightbearing surface of the forefoot can be achieved by using a neurovascular island flap. Island flaps, based on a pedicle from either the proper digital artery or the common digital artery, were used to provide supple and durable coverage. A retrospective analysis was performed on 12 patients who underwent a total of 15 digital artery flaps. There were 7 patients with neuropathic ulcers, 7 with a dysfunctional scar, and 1 with an ischemic ulcer after lower-extremity bypass. There was a failure rate of 13%; 2 flaps fully necrosed, necessitating a revisional digital artery flap. Minor complications were reported in 73% of cases; average time to complete healing was 71 days. All healed flaps have remained viable and durable at an average follow-up of 22.5 months from the date of surgery (range, 3 to 61 months). (The Journal of Foot & Ankle Surgery 42(4):208-214, 2003)

Heterodigital arterialized flaps for large finger wounds: results and indications.

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.

Vascular basis of dorsal digital and metacarpal skin flaps.

We studied the vascular anatomy of dorsal digital skin flaps and the vascular anastomoses between the dorsal cutaneous branch of the palmar digital artery (PDA) and the dorsal digital branches (the terminal branches) of the dorsal metacarpal artery (DMA) at the level of the proximal phalanx. Eight fresh cadavers (16 hands) were injected with a lead oxide-gelatin mixture. Our radiographic assessment revealed that there were 2 sources of the arterial supply to the dorsum of the digit, the dorsal digital branches of the DMA, and the dorsal cutaneous branches of the PDA. These branches anastomose with each other. A flap including the territory of the dorsal cutaneous branches of the PDA and a part of the territory of the DMA can be harvested on the dorsal aspect of the proximal and middle phalanges. The extended neurovascular island flap, based on the PDA and the dorsal branch of digital nerve, can be transposed to the volar surface of an adjacent finger resurfacing the entire length of the digit.

Lateral-dorsal neurovascular island flaps for pulp reconstruction.

Finger pulp loss is often observed in daily practice. When the lateral and dorsal surfaces of the injured digit remain intact, a neurovascular island flap can be designed and raised from that part of the finger for pulp reconstruction. Two types of homodigital lateral-dorsal neurovascular island flaps were used in 17 patients (13 type I and 4 type II) for reconstruction of traumatic pulp loss on an emergent basis. The type I flap was used for the pulp defect less than 2.5 cm in length; the type II flap was designed for extensive pulp loss. The size of the pulp defect varied from 1.7 x 1.2 cm to 3.8 x 1.7 cm. All flaps survived completely without any partial loss. The mean follow-up was 17.7 months. The mean static two-point discrimination was 5.2 mm in type I flaps and 9.3 mm in type II flaps. All patients except five had full range of motion of the interphalangeal joint. These five patients (3 type I and 2 type II) had 10 to 20 deg reduction in flexion of the distal interphalangeal joints. The homodigital lateral-dorsal neurovascular island flap offers a durable, well-vascularized, sensate skin flap for one-stage pulp reconstruction in select patients. This technique is relatively simple, allows early postoperative mobilization, and has an acceptable surgical outcome.

Reconstruction of an elbow destroyed in gas explosion with total elbow replacement: a case report

A 25-year-old man severely injured his left elbow and lost his right hand in a gas explosion. The left forearm fracture was plated, the elbow debrided, an external fixator was applied, and the skin defect closed using local flaps and a split skin graft. Six months later the elbow was immobile due to an intra-articular fibrosis; a fully constrained hinged elbow replacement (Protetim) was implanted. Five weeks later there was a wound breakdown due to infection; the prosthesis became exposed. To salvage the limb, a latissimus dorsi myocutaneous neurovascular island flap was used to cover the soft tissue defect. Postoperative progress was uneventful and 30–100° of elbow flexion was achieved. One year later, the elbow replacement loosened without evidence of infection and it was replaced with a semiconstrained Coonrad-Morrey joint (Zimmer). In addition, the enlarged medullary canal of the humerus and ulna was packed with a morsalized homologous bone graft. One year after the revision and 3 years after the initial injury, the elbow is fully stable and pain-free with 5–120° of flexion and 40° of rotation. The patient works as a tradesman and is satisfied with the preserved function of his left hand.

Fingertip Reconstruction Using Two Variations of Direct-Flow Homodigital Neurovascular Island Flaps

The fingertip is an extremely intricate area of digital sensibility that plays an important role in fine perception and hand function. Thus, sensate fingertip reconstruction is essential to the recovery of most hand functions. The authors used two methods of direct-flow homodigital neurovascular island flap coverage to reconstruct distal finger amputations-namely, the triangular-advancement flap technique and the step-advancement flap method. The authors present their experience with these two variations of direct-flow homodigital neurovascular island flaps and their use in reconstructing 18 fingertips and 7 proximal amputation stumps. They did not observe flap failure, and they achieved stable, well-vascularized, appropriate-thickness skin coverage with good sensory properties in all patients. However, they found that the triangular-advancement flap technique was easier to plan and perform than the step-advancement method.

Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap.

In the past 60 years, several different procedures have attempted to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Recently, with improvements in free tissue transfer and microvascular technique, many free flap procedures have been developed with the goal of an aesthetically acceptable neophallus of adequate bulk that enables urination in a standing position and sexual intercourse, with minimal functional and aesthetic donor-site defects. Most authors currently agree that the method of choice for penile reconstruction is microsurgical free tissue transfer, although it does not always fulfill all of the aforementioned goals in a predictable manner. In fact, complete urethroplasty, penile rigidity, and donor-site disfigurement remain challenges, thus making this operation one of the most difficult in plastic surgery. The vascular anatomy of the lateral circumflex femoral artery, which we studied in 1991 with the anatomic dissection of 27 cadavers, gave us the idea to use a long tensor fasciae latae neurovascular island flap as a donor source for neophalloplasty. Grounds for the procedure and its surgical planning have been carefully evaluated with 10 additional fresh cadaver dissections. Since 1991, we have performed five neophalloplasties using this procedure; all patients were female-to-male transsexuals. In four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. The island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.

New Buccinator Myomucosal Island Flap: Anatomic Study and Clinical Application

The authors studied the vascular anatomy of the buccinator muscle by dissecting fresh cadavers. The anatomy of the buccal branches of the facial artery consistently confirmed the existence of a posterior buccal branch, a few inferior buccal branches, and anterior buccal branches to the posterior, inferior, and anterior portions of the buccinator. The buccal artery and posterior buccal branch anastomose to each other and ramify over the muscle. Several veins originate from the lateral aspect of the muscle, converge into the buccal venous plexus, and drain into the facial vein (from two to four tributaries) or into the pterygoid plexus and the internal maxillary vein (from the buccal vein). These vessels and nerves enter the posterior half of the buccinator posterolaterally. The facial artery and vein are located at variable distances from each other around the oral commissure and the nasal base. Two patterns of buccinator musculomucosal island flaps supplied by these buccal arterial branches are proposed in this article. The buccal musculomucosal neurovascular island flap (posteriorly based), supplied by the buccal artery, its posterior buccal branch, and the long buccal nerve, can be passed through a tunnel under the pterygomandibular ligament for closure of mucosal defects in the palate, pharyngeal sites, the alveolus, and the floor of the mouth. The buccal musculomucosal reversed-flow arterial island flap (superiorly based), supplied by the distal portion of the facial artery through the anterior buccal branches, can be used to close mucosal defects in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum, lip, and orbit. The authors have used the flaps in 12 patients. There has been no flap necrosis, and results have been satisfactory, both aesthetically and functionally.

Intraocular and Intraorbital Compartment Pressure Changes following Orbital Bone Grafting: A Clinical and Laboratory Study

Visual loss is an uncommon but catastrophic complication after intraorbital bone grafting for the reconstruction of acute traumatic defects or long-standing enophthalmos. Increased intraocular or intraorbital compartment pressure may be pathogenic in this setting. A two-part study was designed to test the null hypothesis that intraocular and intraorbital compartment pressure values remain constant despite orbital volume reduction with graft material. Laboratory study: Intraocular and intraorbital compartment pressures were measured during sequential orbital volume reduction in New Zealand White rabbits that had been randomized to one of three groups: intact orbits (n = 10), acute orbital wall defects (n = 8), and chronic (3 months) orbital wall defects (n = 11). Intraocular pressure was significantly (p<0.05) elevated in all three groups of orbits undergoing orbital volume reduction compared with control, nonoperated orbits. Intraorbital compartment pressure values did not change significantly from control levels throughout the grafting sequence. Although no significant differences existed between groups in the maximum levels of intraocular pressure attained, the chronic group demonstrated a greater rate of rise and slower rate of decline. Clinical study: Using applanation tonometry, intraocular pressure was measured before and serially after orbital floor exploration and intraorbital placement of split calvarial bone grafts in 19 patients who presented with orbital-zygomatic complex fractures that required surgery. A separate group of 16 patients with orbital-zygomatic complex fractures that required exploration of the orbital floor but not bone grafting was used for comparison. A significant (p<0.05) elevation of intraocular pressure was observed immediately after bone grafting compared with nongrafted orbits, but values returned to normal within 30 minutes and remained stable through the third postoperative day. There were no cases of visual impairment in any patients in either group as the result of surgical treatment. These data indicate that orbital volume reduction with graft material results in significant, temporary elevation of intraocular pressure. No significant elevations of intraorbital compartment pressure were detected in the rabbit orbits. Data from this study may have direct relevance in defining guidelines for "tolerable" changes in orbital tissue and globe pressures after surgery.

NECROSIS OF THE INDEX, MIDDLE AND RING FINGER PULPS AFTER TRANSFER OF A HETERODIGITAL NEUROVASCULAR ISLAND FLAP

The heterodigital neurovascular island flap is indicated for the resurfacing of significant defects of the thumb pulp. It provides excellent soft tissue cover and sensibility.1 The complications reported have been mostly neurological and include poor sensation, hyperaesthesia, failure of cortical integration and cold intolerance.2–4 Loss of the flap from vascular insufficiency has also been reported.2,5 We report the loss of the index, middle and ring finger pulps in a patient after transfer of a heterodigital neurovascular island flap from the middle finger to the thumb.

USING LOCAL FLAPS FOR FINGERTIP RECONSTRUCTION

Hand SurgeryVol. 03, No. 01, pp. 81-98 (1998) SYMPOSIUM: FINGER TIP INJURYNo AccessUSING LOCAL FLAPS FOR FINGERTIP RECONSTRUCTIONR. Elluru and Tsu-Min TsaiR. ElluruChristine M. Kleinert Institute for Hand and Micro Surgery, Louisville, Kentucky, USA and Tsu-Min TsaiDepartment of Orthopedics, University of Louisville School of Medicine, Louisville, Kentucky, USACorrespondence to: Dr Tsu-Min Tsai, Christine M. Kleinert Institute for Hand and Micro Surgery, One Medical Center Plaza, Suite 850, 225 Abraham Flexner Way, Louisville, Kentucky 40202.https://doi.org/10.1142/S021881049800012XCited by:0 PreviousNext AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsRecommend to Library ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetails Recommended Vol. 03, No. 01 Metrics History Received 28 December 1996 Accepted 14 May 1998 PDF download

The use of P31 magnetic resonance spectroscopy to evaluate the effect of ATP-MgCl2 perfusion on the metabolism of rat skin island flaps.

Depleted levels of adenosine triphosphate (ATP) are described as one of the important causes of skin flap failure. This study evaluated the beneficial effects of intra-arterial perfusion of ATP-magnesium chloride (MgCl2) in ischemic neurovascular skin island flaps in the rat and observed the changes of the highenergy phosphate metabolite using phosphorus 31-(P31) magnetic resonance spectroscopy (MRS). The changes of ATP, phosphocreatine (PCr), and inorganic phosphate (Pi) were observed from P31 MRS and the ratios of each metabolite were compared. The extent of skin flap survival was assessed 7 days after operation using an image analyzer. The PCr/Pi ratio of the experimental group (ATP-MgCl2) was significantly different from the control group (balanced salt solution; p < 0.05). Furthermore, the infusion of ATP-MgCl2 (40.3%) significantly improved the area of flap survival compared to the control group (14.2%; p < 0.05). The ratios of PCr/Pi PCr/(PCr + Pi) correlated with the extent of flap survival, and correlation coefficients were 0.59 and 0.60, respectively. In conclusion, ATP-MgCl2 improved skin flap survival. We were able to assess the metabolic state of the ATP-MgCl2-perfused skin flap and found that PCr/Pi ratios correlated with flap survival.

The neurovascular infrahyoid muscle flap: a new method for tongue reconstruction.

Description of a new neurovascular island flap derived from the infrahyoid muscles to reconstruct a total tongue or large defects of the tongue base. The surgical technique, anatomic findings, and the postoperative function tests with the patients' outcome are described. Eleven patients had tongue cancer, 5 at a T2 stage, 3 at a T3 stage, and 3 at a T4 stage. Four patients underwent total glossectomy, 3 patients underwent hemiglossectomy, and in 2 patients a half and in another 2 patients a quarter of the tongue base were resected. The tongue of the patients who underwent total glossectomy has been reconstructed with the infrahyoid myofascial neurovascular flap from both sides of the neck; in all the other patients this new flap has only been taken from one side of the neck. In one patient a glossectomy had to be combined with a laryngectomy. In 10 patients the tracheostoma could be closed in 4 weeks after the operation, and all patients could eat an oral diet. Electromyography showed voluntary innervation of the reconstructed tongues. With the neurovascular infrahyoid flap, defects of the tongue base can be reconstructed successfully after partial resections or total glossectomies. The main advantage is the voluntary innervation of this flap by means of the ansa cervicalis and the prevention of scarring and atrophy of the reconstructed tongue.

Resurfacing of thumb-pulp loss with a heterodigital neurovascular island flap using a nerve disconnection/reconnection technique.

The problems of late deterioration of sensation and a "double sensibility" phenomenon, either in the thumb or donor finger, are a known deficiency of the conventional heterodigital neurovascular island flap. This is probably related to unsatisfactory cortical reorientation following flap transfer. To obviate this problem, the authors have used a disconnection/reconnection technique for heterodigital island flaps in 17 patients, to resurface defects in the skin of the thumb. All patients were followed-up for 1 year, while 15 were followed-up for 2 years or more. There were no flap complications or failures, and the length of the thumb tip was preserved in all cases. The classic two-point discrimination was less than 6 mm in eight of these patients, and the remaining nine patients had two-point discrimination of between 6 and 8 mm. This technique was found to provide sensitive, supple, and well-vascularized skin with proper cortical representation, to replace the loss of the tactile pump of the thumb tip in one operative stage.