Reverse Island Research Articles

Reverse island fascio-cutaneous flaps with distally based sural nerve for distal foot reconstruction

目的 报道应用带腓肠神经营养血管逆行岛状筋膜皮瓣及髂骨植骨重建足远端部分缺损的方法,探讨皮瓣转位范围.方法 2002年3月～2006年2月,应用腓肠神经筋膜皮瓣及髂骨植骨修复32例足远端1/3外侧软组织和骨缺损患者.其中男23例,女9例;年龄17～58岁,平均35.2岁.本组32侧肢体,共32块皮瓣,其中12例患者进行髂骨植骨.开放创面27例,其中感染创面8例;无菌创面5例.创面面积为4.0 cm×7.0 cm～7.0 cm×16.0 cm.髂骨移植长度为4.0～7.0 cm,平均5.0 cm.手术先根据跖骨骨缺损大小切取髂骨,接着处理受区创面,然后将切取的髂骨植入跖骨骨缺损处,在电视透视下用克氏针固定,建立足外侧骨支架,最后利用腓肠神经逆行岛状筋膜皮瓣覆盖创面.结果 32例患者获5～27个月(平均12.7个月)随访.皮瓣一期存活30例;皮瓣远端部分表皮坏死2例,经换药后愈合.髂骨移植一期骨愈合11例,愈合时间为3～14个月,平均5.7个月;骨不愈合1例,经再次植骨后愈合.皮瓣外形良好28例,皮瓣臃肿4例.供区创面一期愈合,无功能障碍.术后患足功能根据Maryland足部评分系统评价:优19例,良10例,可3例,优良率为90.6%.结论 腓肠神经逆行岛状筋膜皮瓣结合髂骨植骨是重建足远端部分缺损较理想的方法。

Repair of pulp defect with reverse digital artery island flap including the palmar cutaneous branch of proper digital nerve

目的 报道应用吻合指固有神经掌皮支的指动脉逆行岛状皮瓣修复指腹缺损的临床效果.方法对15例16指末节指腹缺损的患者,应用吻合指固有神经掌皮支的指动脉逆行岛状皮瓣修复,皮瓣切取面积为1.8cm×2.1cm～3.1cm×3.6cm.结果 15例皮瓣全部成活,术后随访6个月～2年,伤指外形与正常指相近,指腹饱满而不臃肿,质地柔软,有排汗功能,两点分辨觉在5～7mm以内.结论应用吻合指固有神经掌皮支的指动脉逆行岛状皮瓣,术后效果好,供区损伤小,是修复末节指腹缺损较理想的手术方法。

Antebrachial Reverse Island Flap With Pedicle of Posterior Interosseous Artery: A Report of 90 Cases

Antebrachial Reverse Island Flap With Pedicle of Posterior Interosseous Artery: A Report of 90 Cases

Innervated Reverse Island Flap Based on the End Dorsal Branch of the Digital Artery: Surgical Technique

Fingertip or pulp loss of the fingers is observed frequently in unskilled workers. To reconstruct a sensate fingertip or pulp we designed the innervated reverse island flap based on the end dorsal branch of the digital artery, which was harvested from the dorsum of the middle phalanx. The sensation of the fingertip or pulp was re-established through coaptation of the proper branches of the digital dorsal nerves to the digital nerves. Three fingertip or pulp defects were reconstructed with this technique. All patients achieved satisfactory functional and cosmetic results. The mean follow-up time was 7.7 months. The average size of the flaps was 1.6 x 1.8 cm. The average static 2-point discrimination and moving 2-point discrimination of the flaps were 4.6 mm and 3.0 mm, respectively. The technique we applied seems to be an excellent option for 1-stage reconstruction of fingertip or pulp defects.

Unusual Merkel cell carcinoma in a renal transplant recipient: case report and review of the literature

Merkel cell carcinoma (MCC) is an uncommon and aggressive neuroendocrine primary skin cancer known for its high propensity for local recurrence and distant metastases. There is no consensus regarding the optimal therapeutic approach, and the relative roles of surgery, radiotherapy and chemotherapy are still controversial. MCC generally affects elderly patients in areas of actinically damaged skin. Several studies suggest that a more aggressive course is observed in immunocompromised patients such as organ transplant recipients. Clinically, MCC usually appears as a rapidly growing, dome-shaped and solitary nodule. More than half of these tumours occur in the head and neck, and can become a challenge for the plastic and reconstructive surgeon. An unusual case of this cutaneous malignancy is presented in a renal transplant recipient. The tumour was located in the medial canthus of the eye. Tumour resection was performed and a reverse flow pre-auricular island flap and a forehead flap were used for reconstruction.

Homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients

Diabetic ulcers located in the plantar surface of the great toe resist conservative treatment modalities including skin grafts and usually require flap coverage for a stable reconstruction. Free tissue transfer is not feasible in these patients, because these defects are closely associated with peripheral vascular disease and local flap alternatives are extremely limited in this region. Reported here is the use of homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients with encouraging results.

Anatomical basis for a vascular pedicled island flap from the dorsal area op the wrist

We explored the cutaneous vascularity of the dorsal wrist area to examine the possibility of using reverse island flaps from this area for reconstruction of the hands and fingers. Four dominant arterial branches including the dorsal branches of the ulnar and radial arteries and terminal branches of the anterior and posterior interosseous arteries, which supplied the dorsal skin over the extensor retinaculum, were explored. The location, number, and diameter of skin perforators from these arteries were examined. The dorsal branches of the radial and ulnar arteries that passed along the dorsal cutaneous nerves gave off 2-4 skin perforators (diameter 0.1-0.2 mm) at the level of the carpal bone and always connected distally to perforating arteries from the palmar arterial system at the metacarpal head. Skin perforators from the anterior and posterior interosseous arteries were found passing through the extensor retinaculum in the second and third and fifth and sixth intercompartmental areas. The terminal branches of the anterior and posterior interosseous arteries always continued to the dorsal carpal arch, and lay over the distal carpal row. It may be anatomically possible to raise two different island flaps from the dorsum of the wrist.

Innervated reverse island flap based on the dorsal cutaneous branch at distal interphalangeal joint of the digital artery

目的 介绍用指动脉远侧指间关节背侧皮支逆行岛状皮瓣修复指端及指腹缺损,并同时重建感觉的一种新的术式. 方法根据指背皮肤血供及神经支配的特点,应用指动脉远侧指间关节背侧皮支为血管蒂的中节指背皮瓣,逆行转移修复指端及指腹缺损,同时应用指背部神经的分支重建指端及指腹感觉3例. 结果术后皮瓣全部存活,随访3～6个月,外形满意,质地柔软,耐磨,无触痛,耐寒冷,动态及静态两点辨别觉分别为2～4 mm及4～6 mm,指间关节活动范围减少在10°以内. 结论该术式不需牺牲主要血管及神经,采用中节指背非功能面的皮肤为供区,并能重建良好的感觉,不需2次手术,是修复指端及指腹缺损可选用的皮瓣之一。

Antebrachial reverse island flap with pedicle of posterior interosseous artery: a report of 90 cases

We report our experiences of 90 cases of the reverse antebrachial flap based on the posterior interosseous artery. In 1985, we found a consistent anastomosis (96%) between the posterior interosseous artery and the anterior interosseous artery at the dorsal side of the ulnar head in an anatomical study. From 1985 to 2000, we used this antebrachial flap to repair soft tissue defects of the hands or wrists, the first web space, or to reconstruct thumbs in 90 cases. Only one case suffered flap necrosis. The reverse antebrachial flap on the posterior interosseous artery pedicle has the advantages of good texture and colour, and appropriate thickness compared to the hand. The anastomotic arch which determines the point of rotation is consistent, and the pedicle is long. This flap is reliable for repairing soft tissue defects with or without defects of the nerve, tendon and bone, and also for reconstruction of the first web and thumb. Donor site morbidity is acceptable.

Beyond-Mean-Field Treatments of Island Formation during Submonolayer Deposition: Island Size Distributions for Large Critical Sizes

ABSTRACTKinetic Monte Carlo (KMC) simulation of atomistic models reveals the failure of mean-field treatments of the island size distribution (ISD) for islands formed by homogeneous nucleation during submonolayer deposition on perfect surfaces. KMC also facilitates analysis of scaling properties of the ISD, although here some misperceptions persist which we attempt to clarify. However, KMC becomes inefficient for highly reversible island formation (e.g., for large values of a critical size, i, above which islands are stable) due to the high density of diffusing adatoms on the surface. This reduced efficiency is quantified here with results for CPU time versus i. This feature has motivated development of alternative beyond-mean-field coarse-grained approaches which should be more efficient for large i. We provide results for the ISD for a range of i = 1, 2, 3, and 6 using one such approach, a stochastic geometry-based simulation (GBS) strategy.

Reverse dorsal digital and intercommissural flaps used for digital reconstruction

Reverse dorsal digital and intercommissural flaps offer a simple and versatile option for skin cover of distal finger defects, especially when other local flaps are not available. Twenty-one reverse dorsal digital flaps were used, on an outpatient basis, to cover dorsal soft tissue defects over or beyond the PIP joint. All the flaps were transposed as reverse island flaps. The average size of the defects was 2.5 cm 2 and they were all used to cover exposed tendon, bone, joint or a combination. Twenty flaps survived completely and did not present any feature of circulatory difficulty. Marginal necrosis of one flap was noticed, while two patients complained of swollen finger 6 months later. No morbidity was reported and the patients maintained good range of motion. Various other types of flaps that have been used to reconstruct distal digital skin defects are reviewed and compared with the reverse dorsal digital and metacarpal flaps.

Geometry-based simulation (GBS) algorithms for island nucleation and growth during sub-monolayer deposition

Versatile geometry-based simulation (GBS) algorithms are developed to describe the formation of two-dimensional islands during sub-monolayer film growth. These GBS algorithms avoid an explicit treatment of the diffusion of deposited atoms across terraces, the process which mediates both island nucleation and growth. Treatment of terrace diffusion is a computationally expensive component of either conventional atomistic kinetic Monte Carlo (KMC) simulations, or of coarse-grained continuum formulations of island edge evolution. Our GBS approach characterizes island growth in terms of simply constructed “capture zones” surrounding each island, an old concept which was recently refined and made quantitatively precise. However, in addition, GBS implements simple but realistic geometric rules to incorporate crucial spatial aspects of the island nucleation process, specifically nucleation nearby capture zone boundaries. By detailed comparison of predictions of results from GBS with conventional atomistic KMC simulations, we show that this approach correctly predicts island size distributions as well as subtle spatial correlations in island locations. Perhaps, just as importantly, refinement of the prescription of island nucleation is readily achieved in GBS, thus elucidating the effects of this prescription on the resulting island distribution. Finally, we emphasize that GBS is particularly effective for highly reversible island formation where atomistic KMC simulation becomes inefficient.

Geometry-based simulation of submonolayer film growth

A geometry-based simulation (GBS) strategy is developed for modeling film growth, which avoids explicit treatment of the terrace diffusion of adatoms and their aggregation with islands---a computationally expensive component of either atomistic simulation or continuum analysis. GBS characterizes island growth in terms of capture zones (CZ's), and implements simple but realistic geometric rules to incorporate crucial spatial aspects of the island nucleation process, i.e., nucleation nearby CZ boundaries. This approach reliably predicts island size distributions and spatial correlations, and is especially efficient for highly reversible island formation.

Venous drainage in retrograde pedicle flaps: experimental study in rats

This study was performed to investigate the venous drainage in reverse island groin flaps in a rat model. Two groups of 10 rats were studied. All rats of group A had a groin reverse flap with a complete pedicle (artery and venae comitantes). In rats of group B, an arterial groin reverse flap (artery without venae comitantes) was performed. For the two groups, the perivascular tissue was excised. Nine flaps in the group A and seven flaps in the group B, survived without partial or complete necrosis. Microscopic examination showed venous dilatation in the two groups. There was no significant difference between the two groups. These results confirm that venous drainage of the arterial reverse flow flap without venae comitantes is performed by venae arteriosa. However, venae comitantes probably ensure venous drainage when they are respected.

Reverse-flow island flap from the thenar area of the hand.

A reverse-flow island flap from the thenar eminence of the hand was applied in six patients to treat palmar skin defects, and amputation injuries of the thumb. There was one female and five males, and the patients' ages at the time of surgery averaged 48 years. A 3 x 2 to 5 x 3.5-cm fasciocutaneous flap from the radial aspect of the thenar eminence, located over the abductor pollicis brevis muscle, was designed and transferred in a retrograde fashion, to cover skin and soft-tissue defects of the thumb. The flap was based on the superficial palmar branch of the radial artery and, in three patients, was made sensate by the palmar branch of the superficial radial nerve. Follow-up periods averaged 61 months. The postoperative course was uneventful, and all the flaps survived without significant complications. The donor site was primarily closed in five patients, and one patient required flap coverage. A reverse island flap from the thenar area is easily elevated, contains durable fasciocutaneous structures, and has good color and texture, matching to the finger pulp. This flap offers a good alternative for reconstruction of palmar skin and soft-tissue defects of the thumb in selected patients.

Anatomical consideration of reverse-flow island flap transfers from the midpalm for finger reconstruction.

Primary soft-tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area. In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar arch and common palmar digital artery was examined. The cutaneous perforating arteries and nerve branches supplying the midpalmar area were dissected, and the number, location, and arterial diameter of these branches were measured. In six other specimens, the common palmar digital artery was injected to determine the skin territory supplied by the artery. The superficial palmar arch contained the three common palmar digital arteries and its terminal branch coursed along the radial margin of the index metacarpus. This terminal branch had three to six cutaneous perforators (diameter range, 0.1 to 0.5 mm) and supplied the radial aspect of the midpalmar area located over the ulnar half of the adductor pollicis muscles. The midpalmar area was divided into two regions-the proximal and distal-according to the vascular distributions. The proximal region contained dense aponeurosis and thin subcutaneous tissue, and the cutaneous perforators were rather sparse (between three and nine) and had a small diameter (0.1 to 0.3 mm). The distal region, which had loose aponeurosis and abundant subcutaneous tissue, had a rich vascular supply from the common and proper digital artery. Perforating arteries of this region coursed frequently in an oblique fashion and the number of perforators (between eight and 15) and their arterial diameters (diameter range, 0.1 to 0.5 mm) were higher than those of the proximal region. The area of skin perfused by the common palmar digital artery was 5 x 3 cm at the distal midpalmar region. There were three to five cutaneous nerve branches from the palmar digital nerve supplying the midpalmar area. From this study, two different reverse flaps were proposed. First, a 5 x 2 cm flap from the distal midpalmar region was elevated on the basis of the common and proper palmar digital artery. Measurement of the rotation arc revealed that the pivot point of this flap was located at the proximal interphalangeal joint level and could cover the finger pulp of the digits. The second flap candidate was that from the radial aspect of the midpalm, which was supplied by the terminal branch of the superficial palmar arch. In studies with cadaver hands, connection of this artery with the deep arterial system enabled this flap to reach the thumb pulp. These flaps may be a useful reconstruction option for significant palmar soft-tissue loss of the fingers.

Reverse Digital Artery Island Sensory Flap With Bilateral Neurorrhaphy For Fingertip Reconstruction

Reverse Digital Artery Island Sensory Flap With Bilateral Neurorrhaphy For Fingertip Reconstruction

Knowledge of flap complications in finger pulp surgery and patient education--ethical implications

The two highest French courts have recently decided that not to fully inform a patient constitutes negligence, and that doctors should be able to prove that the information has been given. The medical community is now debating as to how to protect physicians without harming the doctor-patient relationship. Following this study we put forward the hypothesis that although information might not be available to surgeons nevertheless this should not prevent them taking the ethical steps necessary to redress the situation. We conducted a telephone interview to discover what surgeons knew about the complications of finger flaps used for the reconstruction of pulp defects. Four flaps were studied: the VY flap described by Atasoy, the island finger flap known as Ventataswami's, the reverse island flap and the thenar flap. Surgeons were asked to give the percentage of necrosis, infection, sensory disturbances, digital stiffness and exclusion, as well as the time off work, the time of healing and the sensory discrimination of the flap. The results obtained were compared to those obtained by a literature review. Twenty one qualified hand surgeons answered the questionnaire. Many answers were absent or only fragmentary when sought in the literature. Where complication rates were available, there was a huge variation among series. A large variety of answers was also found in our study. The direct island flap was the best known flap. Complications of the reverse island flap and the thenar flap were overestimated in the group interviewed. There is no true answer, either in the literature or from the study group. There is a gulf between the jurists' demand and the possibilities of knowledge by surgeons. We are still waiting for clinical studies that will answer the questions asked by patients regarding the complications of surgery. However, even if absolute knowledge is not available, it is the ethical duty of surgeons to give the patient information that is as close as possible as the "truth", and that will be helpful to them.

The Boomerang Flap in Digital Reconstruction

The anatomic and clinical bases for the reliable and versatile boomerang flap in reconstruction of complex distal finger injuries are presented. This one-step procedure, utilizing the dorsolateral skin of the proximal phalanx of an adjacent digit as a reverse island flap, has proved valuable in the salvage of severely injured digits. The boomerang flap was applied in ten cases with distal phalanx injuries. Soft tissue defects in all patients were combined with bone, joint, or tendon exposure. The flaps were transferred as a neurovascular flap for sensory resurfacing of the major pulp loss. This flap preserves the proper palmar digital artery to the fingertip and provides an extended and innervated skin paddle to cover finger soft tissue defect as well as to improve flap sensibility in the distal pulp.

The Surgical Treatment of Dupuytren Contracture with the Reverse Flow Dorsal Metacarpal Island Flap

The Surgical Treatment of Dupuytren Contracture with the Reverse Flow Dorsal Metacarpal Island Flap