Reverse-flow Flap Research Articles

Hand Reconstruction with Posterior Interosseous Flap. A Review

For the greatest functional outcome, hand reconstruction with soft tissue abnormalities requires an early, single-stage, well-vascularized cover. Since important tissues including tendons, bones, and joints are exposed, a full thickness graft is typically needed, and subsequent repair is frequently necessary. Reverse flow flaps in the posterior interosseous artery provide a flexible and dependable means of covering intricate soft tissue abnormalities in the hand in full thickness.

Bilateral reconstruction of palmar soft tissues defects of the hands after thermal injury

Introduction Thermal injury to the palmar surface of the hand is usually complicated by flexion desmogenic contracture of the finger joints. This condition is more complicated with significant wound areas and depths of soft tissue destruction. Conventional surgical methods and soft tissue reconstructions may fail to provide full restoration of the hand function.The objective was to present the optimal treatment strategy for patients with scar flexion contractures of the fingers after thermal injury to the palmar surface of both hands using a pediatric case report.Material and methods A child aged 2 years and 4 months underwent surgical treatment to include excision of scars, skin grafting of both hands with a vascularized fasciocutaneous flap raised with the radial artery.Result The patient could regain all types of hand grip on both sides 12 years after surgical treatment. Both hands were aesthetically acceptable.Discussion Treatment of patients with thermal injury and substantial soft tissue damage is a complex disease process. Conservative treatment and surgical procedures using non-vascularized skin flaps are normally used for the condition. These approaches are associated with cicatricial and arthrogenic flexion contracture of the finger joints. The radical treatment includes thorough wound debridement and early flap coverage and wound closure using a flap with an axial-pattern blood supply, free flaps and reverse-flow flaps. The surgical approach helps to avoid flexion contracture of the fingers initiating early restoration of professional, social stereotypes and stereotypes in everyday life.Conclusion The clinical observation has shown the possibility of one-stage organ-preserving surgical treatment using flaps with an axial blood supply.

The Reversed Flow Hemisoleus Propeller Muscle Flap.

Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet. The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap. A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects. All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity. The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.

Comparison of reading man flap and skin grafting for closure of resultant donor defects in homodigital reverse flow flaps

The reading man procedure is a valuable treatment option for circular defects of different parts of the body. The aim of this study was to compare reading man procedure and skin grafting for coverage of resultant donor defects in homodigital reverse flow flaps. From January 2018 to October 2020, 38 patients underwent fingertip reconstruction using homodigital reverse flow flaps. The donor sites were resurfaced with full-thickness skin grafts in 20 patients and with reading man flaps in 18 patients. Flap survival, postoperative complications, operative time for closure of donor site, return work time, range of motion of the injured fingers, static two-point discrimination, and aesthetic results were evaluated. All the outcomes, including flap survival, postoperative complications, operative time for closure of donor site, return work time, range of motion of the injured fingers, static two-point discrimination, and aesthetic results, were similar between the two groups. No patients complained of cold intolerance or hypersensitivity. The reading man flap is useful and reliable for covering resultant donor defects in homodigital reverse flow flaps. The functional and aesthetic outcomes in both groups are similar.

Propeller Flap: Surgical Option after Resection of Lower Limb Melanoma

Objective: To describe a series of cases of lower limb reconstruction using an axial reverse flow flap (propeller flap) after melanoma excision. Patients and methods: From August 2014 to December 2016, at the Plastic Surgery Service at UNIFESP, five patients with defects in the lower limbs after melanoma resection were reconstructed using propeller flap. In all cases, the perforating vessels were previously mapped using Doppler ultrasound. Results: The size of the defect ranged from 4 cm × 3 cm to 8 cm × 4.5 cm. One case had a 180º rotation. In all the others, a 90° rotation was sufficient. All patients had good aesthetic results. Conclusion: The propeller flap is a simple and low cost technique. It is indicated for reconstruction of the distal third of small and/or medium-sized lower limb. The aesthetic result is satisfactory with the thickness and color of the flap very similar to the excised area.

Clinical Evaluation of Peroneous Brevis Muscle Flap as a Reconstructive Tool for Defects Around the Ankle

Background: Soft tissue defects of the distal lower extremityare notoriously difficult wounds to treat. This is dueto the paucity of soft tissue in this area and the thin integumentas well as the relatively superficial tendons. Those defectsoften require local rotation flaps, the reverse flow flap or freetissue transfer. The success of local tissue rotation flaps canbe improved with supercharging techniques; however, just aswith free tissue transfers, these techniques require specialsurgical skills. One excellent alternative within the reconstructivespectrum of the lower leg is the distally based peroneusbrevis muscle flap. This muscle flap is a viable option inproperly selected patients for coverage of wounds about theankle.Patients and Methods: In this study, we used the distallybased peroneous brevis muscle flap to reconstruct 20 casesof defects around the ankle. Cases presented to Plastic SurgeryDepartment, Minia University Hospital in period betweenJanuary to October 2017. Surgical procedure was performedunder spinal anaesthesia in all cases. We followed cases for6 months postoperatively.Results: The mean age was 35 years old, 16 patientswere males and 4 were female. 55% of patients had completeflap viability, 15% of cases had partial graft loss and 20%with partial flap necrosis and 10% of cases had completeflap loss.Conclusion: We can suggest that the peroneus brevismuscle flap is an additional valuable option for reconstructionof defects around the ankle because of its adjacent location,reliability, and the relative simplicity of technique. The surgicaltechnique is relatively easy, safe, and suitable for reconstructionof soft-tissue defects in a single stage.

Lower Leg Reconstruction With Free Tissue Transfer Using Reverse Flow Recipient Vein: A Case Report.

Since the introduction of distally based flap, the concept of reverse flow flap was expanded to free tissue transfers. For recipient vessels, retrograde arterial inflow is considered a safe option for anastomosis. However, the reliability of a retrograde recipient vein remains controversial. This report presents a case of successful lower leg reconstruction with free flap using a retrograde recipient vein. A 43-year-old woman had a mass lesion in the lateral side of the right calf, which was diagnosed as a malignant granular cell tumor. During wide excision of the tumor, the anterior tibial artery (ATA) and veins were ligated and resected at the bifurcation point from the popliteal artery and veins because the tumor abutted on the ATA near the bifurcation. The skin defect measured 17 × 7 cm with the proximal part of the tibia and lateral condyle exposed. A 19 × 7.5 cm anterolateral thigh flap was elevated, and anastomoses were performed using the distal end of the ATA and anterior tibial vein as retrograde recipient vessels. The flap was well perfused, and no signs of venous insufficiency were observed. Complete survival with no postoperative complications was achieved. In free tissue transfers of the lower leg, retrograde venous flow can be considered as a recipient vein when an antegrade vein is not available or has risks of venous insufficiency.

Reverse-Flow Versus Perforator Propeller Lateral Arm Flap for Elbow Reconstruction.

The lateral arm flap (LAF) represents an attractive option for elbow reconstruction, due to low donor site morbidity and a consistent surgical anatomy. It has been described as reverse-flow and as perforator propeller flap (radial collateral artery perforator [RCAP]). We compared the 2 techniques in terms of immediate- and long-term outcomes, together with functional and aesthetic evaluation. We retrospectively reviewed 15 patients, 9 males and 6 females, according to the department prospectively maintained database. Ethiology of the defects and patient comorbidities were listed together with flap and clinical data (operative time, time to healing, hospital stay, etc). Functional outcomes were measured according to Quick Disability of Arm Shoulder and Hand score at the time of the last follow-up. Seven LAF flaps were raised in a reverse-flow fashion, whereas 8 were RCAP flaps. No patients described any major elbow functional limitations, and they were generally satisfied with the aesthetic appearance. When comparing the 2 groups of reconstruction, harvest of RCAP flap resulted significantly faster and patients needed less hospitalization days (*P < 0.05). Aesthetic scores were lower where a cutaneous bridge was left intact during rotation (leading to a dogear), which was always the case in reverse-flow flap. Among complications, a partial RCAP flap necrosis occurred in a highly comorbid patient and required a skin graft coverage, whereas 4 reverse-flow flaps presented distal venous congestion which, in 1 patient, led to a secondary flap procedure. In our practice, elbow reconstruction using the RCAP flap required less hospital stay and operative time. Being less prone to venous congestion, in presence of sizeable perforators, it should be preferred to the reverse-flow LAF flap.

Comparison of Innervated Digital Artery Perforator Flap Versus Homodigital Reverse Flow Flap Techniques for Fingertip Reconstruction

The aim of this study was to investigate and compare outcomes of 2 different flap techniques for fingertip reconstruction: innervated digital artery perforator (IDAP) flap and homodigital reverse-flow flap. Medical records of 33 patients who underwent fingertip reconstruction either with an IDAP flap (15 patients) or with a homodigital reverse-flow flap (18 patients), between 2014 and 2016, were evaluated retrospectively. In both study groups, full-thickness skin grafts harvested from the proximal/volar side of the forearm were used to cover the flap donor site. Flap survival, venous congestion, cold intolerance, static 2-point discrimination, flap size, duration of surgery, time to return to work, proximal and distal interphalangeal joint range of motion, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time were evaluated. All the major outcomes, including flap survival, cold intolerance, static 2-point discrimination, flap size, time to return to work, range of motion values for proximal and distal interphalangeal joints, Disability of the Arm, Shoulder, and Hand questionnaire scores, and follow-up time, were similar between the 2 flap methods. Mean duration of surgery was shorter in the IDAP flap group. Marginal flap necrosis occurred in 1 IDAP flap, and there was complete survival of the remainder of the flap after debridement. Temporary venous congestion was seen in 3 IDAP flaps, all of which resolved with nonsurgical measures. Similar success rates and satisfactory outcomes were achieved with IDAP flap and reverse-flow flap techniques used for fingertip reconstruction. Therapeutic IV.

Functional and cosmetic outcomes of posterior interosseous artery flap in reconstructing hand defects

Objective The objective of this study was to evaluate the fu ncti onal and cosmetic results of reversed-flow posterior interosseous artery (PIA) flap for reconstruction of hand defects and to assess them by follow-up and physiotherapy. Background Reconstruction of soft-tissue defects in the hand needs a single-stage procedure that can provide well-vascularized graft coverage at the earliest to give the best functional result. Patients and methods This follow-up study that included 20 patients (16 male and four female) was carried out in Menoufia University, Plastic and Reconstructive Surgery Department, from March 2015 to January 2017, with assessment by a follow-up period of 12 months and physiotherapy. All our patients had PIA flap for coverage of the defects. The defects were due to post-traumatic raw areas in 15 cases, postburn deformities in two cases, postcongenital hand deformity surgeries in one case, and post-tumor ablation in two cases. The first webspace defect occurred most often and the largest flap was 10 × 12 cm2. The donor site was covered by split skin graft in 14 cases, and in six cases the donor site was directly closed. Results Regarding flap course and survival, 15 (75%) flaps passed uneventfully, four (20%) flaps suffered from venous congestion, and one (5%) flap showed ischemia. Three flaps (the ischemic flap and two congested flaps) suffered total loss. Two congested flaps survived without loss, and thus we had 17 (85%) survived flaps. All cases were satisfied with cosmetic outcome. Conclusion The reverse-flow flap based on PIA is a reliable and versatile source for coverage of complex soft-tissue defects in the hand.

Evaluating Venous Drainage in Reverse Flow Pedicles: Available Evidence and Mechanisms.

The anatomy and physiology of venous drainage in the reversed flow vascular pedicle is controversial and there have been few well-designed, controlled studies to effectively evaluate the physiology. We evaluated the available evidence for venous drainage to synthesize the conclusions of these studies, and to identify areas in need of further research. Electronic databases were searched for articles published from January 1, 1950 to November 1, 2017. A total of 316 citations were screened for inclusion. Fifty articles met inclusion criteria and underwent review, yielding 12 articles for final data analysis. Three principal study types were found: human cadaveric (7), animal (3), human clinical (1), and mixed (1). We identified two main theories regarding the mechanism of venous drainage in reverse flow flaps. The "avalvular bypass" theory is based on the findings of intact valves of the venae comitantes, and venous outflow through the crossover pattern of the communicating branches and bypass pattern of the collateral branches. Alternatively, the "valvular incompetence" theory implies that pedicle dissection, proximal ligation, and insetting of the flap cause physiologic changes, such as increased venous pressure, denervation, and simultaneous proximal and distal filling, which together result in valvular insufficiency. The mechanism by which retrograde venous outflow occurs in reverse flow flaps remains controversial. Nonetheless, a few well-designed studies have contributed to the understanding of venous anatomy and outflow. Most likely, the true mechanism is based on venous outflow that occurs via the "avalvular bypass" route initially and the "valvular incompetence" route later.

Reverse-Flow Intrinsic Fasciocutaneous Island Flaps in Foot Reconstruction.

Reconstruction of soft tissue defects in the foot remains a challenge due to its specialized tissue for weightbearing and ambulation. Considering the principle of replacing "like with like," adjacent soft tissues would be a best option for a donor site. Although several kinds of reverse-flow island flaps for the lower leg have been well described, intrinsic foot reverse flow flaps have been rarely reported. We describe 3 kinds of reverse-flow intrinsic fasciocutaneous flaps (RIFFs) for foot reconstruction. From September 2012 to August 2015, a retrospective study was done on case notes of all patients who had a RIFF for coverage of soft tissue defects within the foot following trauma or tumor ablation. A total of 7 patients were included in this study, with an average of 5 × 3.5 cm sized defects in the forefoot, second and third web space, and sole, which were reconstructed with RIFF. All flaps were well perfused and recovered excellent function of the foot with satisfactory aesthetics and minimal limitations in range of motion. However, one case showed a complication of venous congestion, due to remnant scar tissues, which resolved after medical leech application. Donor defects healed completely with split thickness skin grafting in all cases. Soft tissue defects within the foot were repaired successfully by RIFF. In spite of its technical challenges, it is a reliable one-stage procedure requiring no microsurgical anastomosis. Precise vascular evaluation of the reverse inflow has to be preceded for satisfactory outcome of RIFF.

Modified reversed superficial peroneal artery flap in the reconstruction of ankle and foot defects following severe burns or trauma

ObjectiveChallenges persist in the reconstruction of the ankle and the foot with exposed tendons, joints, and bones as a result of severe burns and trauma. In flap elevation involving the sensitive superficial nerve, the local nerve was always sacrificed to obtain an anesthetic donor site; however, such a procedure introduced the possibility of painful neuromas. In this study, we present a desired clinical application of a modified reversed superficial peroneal artery flap, in which the superficial peroneal nerve is preserved. MethodsFrom 2008 to 2015, 12 patients with ankle or foot defects were treated with the modified reversed superficial peroneal artery flap. The defects of the patients were caused by hot liquid scald (one patient), electrical injury (five patients), and trauma (six patients). The flap was utilized for covering defects on the ankle (seven patients) and the foot (five patients). The size of the flaps ranged from 4.0cm×6.0cm to 18.0cm×10.0cm. The superficial peroneal artery was involved in the flap, whereas the superficial peroneal nerve was spared by dedicate dissection. The reverse-flow flap was nourished by the superficial peroneal artery through the terminal peroneal artery perforator. ResultsThe obtained outcomes were satisfactory functionally and aesthetically. The flaps in 11 patients survived completely without complications, whereas partial necrosis occurred in a 78-year-old patient when the flap survived a week later during follow up. CT angiography revealed the stenosis of the popliteal artery. The wound healed after interventional treatment involving placing a stent and changing the dressings. Basic functions and configurations were salvaged in all cases. All patients were completely satisfied with the proposed flap and suffered no paresthesia in their lower leg. ConclusionExhibiting beneficial characteristics such as reliable blood supply, favorable thickness, wide rotating arc, and retention of major vessels and the superficial peroneal nerve, the modified reversed superficial peroneal artery flap is useful in the reconstruction of ankle and foot defects that would not cause any hypoesthesia of the foot.

Supermicrosurgery-assisted venous supercharging of a reverse-flow angular artery perforator flap for nasal reconstruction

The centre ground in the world of flaps have over time, gradually shifted from tubed pedicled, random-pattern, axial-pattern, pedicled, free and currently, to free-styled flaps. These concepts are broadly based on the angiosome-perforasome concept. In this case report, we illustrate how the concept of venosome capture can be transposed onto reverse-flow flaps with the aid of venous supercharging. Moreover, if this is seen from the free-styled flap perspective, it requires supermicrosurgical expertise. This case report hence, serves as a fusion of all the above concepts.

Complex reconstruction of the upper and lower limbs by using reverse-flow flaps: a series of 32 cases

Complex reconstruction of the upper and lower limbs by using reverse-flow flaps: a series of 32 cases

The submental island flap: Pedicle elongation and indications in head and neck reconstruction

BackgroundThe submental island flap is an axial pattern skin flap first described by Martin et al. in 1993. When used to reconstruct skin defects it matches the recipient site in terms of colour, texture and thickness. One of the main limitations to its application is the arc of the pedicle allowing coverage of only the lower two thirds of the face. MethodsA retrospective review was performed of all patients who had had a submental island flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of the University Hospital of Parma, Italy, between 2001 and 2011.The Authors focused on the surgical technique adopted, the clinical indications and the results obtained. They analysed the different ways to elongate the pedicle and discuss their thoughts on the choice of reconstruction. A flowchart was created to help in the decisional process. ResultsBetween 2001 and 2011 the submental island flap was used to reconstruct head and neck defects in 22 patients. Thirteen patients had defects of the oral cavity; the remaining 9 patients had skin defects involving the pre-auricular region, the temporal area and the peri-nasal cheek skin.No major complications occurred and in one case a partial necrosis of the distal portion of the flap was observed. Five patients underwent surgical revision involving intraoral flap debulking 6–10 months after the primary procedure. Discussion and conclusionsThe techniques to elongate the pedicle used and described were: additional dissection of the pedicle, Y–V procedure, reverse flow flap, section of facial vein and microvascular anastomosis. Their choice is mainly conditioned by the site of the defect.

Effects of Verapamil, Nifedipine, and Daflon on the Viability of Reverse-Flow Island Flaps in Rats

Reverse-flow flaps are preferable in reconstructive surgery due to their several advantages. However, they may have venous insufficiency and poor blood flow. In this study, effects of various pharmacological agents on the viability of reverse-flow flaps were investigated. Forty Sprague-Dawley rats were used. Superficial epigastric artery- and superficial epigastric vein-based reverse-flow island flaps were preferred. The rats were divided into 4 groups. Group 1 was considered as the control group. Group 2 was given verapamil 0.3 mg/kg per day, group 3 nifedipine 0.5 mg/kg per day, and group 4 Daflon 80 mg/kg per day for 7 days. On day 7, viable flap areas were measured, angiography was performed, serum nitric oxide levels were evaluated, and histopathological examination was done.The mean flap viability rate was 67.59% (±13.12259) in group 1, 77.38% (±4.12506) in group 2, 74.57% (±3.44780) in group 3, and 85.39% (±4.36125) in group 4 (P = 0.001). The mean nitric oxide level was 31.66 μmol/dL (±2.42212) in group 1, 51.00 μmol/dL (±2.96648) in group 2, 34.00 μmol/dL (±2.96648) in group 3, and 47.66 μmol/dL (±2.80476) in group 4 (P = 0.001). On angiography, there were vessel dilations and convolutions in group 2; capillaries became noticeable, and anastomotic vessels extended toward the more distal part of the flaps in group 4. Histological examinations showed severe inflammation in group 3 and minimal inflammation and venous vasodilatation in group 2.Verapamil and Daflon in therapeutic doses significantly increased the viability of reverse-flow island flaps. However, nifedipine did not make a significant contribution to the flap viability. The results of this study will contribute to the literature about the hemodynamics of reverse-flow island flaps and guide further studies on the issue.

Experimental Model of Degloving Injury in Rats

Degloving injuries may be a challenge when it comes to deciding the surgical approach to be used. Repositioning of the flap and suturing are faster and more straightforward, but often these procedures often lead to total or partial loss of the avulsed flap. Pharmacological agents with vascular properties that enhance the viability of the reattached flap could be beneficial to patients with degloving injuries. Experimental models with which to test this hypothesis are scarce. An experimental model reproducing a degloving injury of the hind limb of rats was developed in our department, and the effects of pentoxifylline (Ptx) and allopurinol (Alp) were assessed. In all, 3 groups of rats were studied (25 rats each). A hind limb degloving model was used in all groups, resulting in a reverse flow flap. The flap was then repositioned and sutured. The control (Ct) group received only saline solution, the Ptx group received pentoxifylline (25 mg/kg), and the Alp group received allopurinol (45 mg/kg). The rats were observed for 7 days, after which they were killed, and the flap was removed. The total area of the avulsed flap and the necrotic area were measured. The median total flap area (cm) was 5.6 for the Ct group, 5.5 for the Ptx group, and 5.8 for the Alp group (P = 0.9465). Thus, the flaps were similar. The median necrotic flap area (cm) was 3.3 for the Ct group, 2.3 for the Ptx group, and 1.9 for the Alp group (P = 0.0001). There was a statistical difference between the Ct and Ptx groups and the Ct and Alp groups (P < 0.05). The areas of necrosis observed in the degloved flaps of the rats' hind limbs were smaller in the pentoxifylline and allopurinol groups. Although allopurinol seems to be more efficient, the difference was not significant.

BIPEDICLED HOMODIGITAL NEUROVASCULAR ISLAND FLAP FOR RESURFACING DORSAL DIGITAL DEFECTS AMPUTATION

Critical defects distal to the proximal interphalangeal joint are usually treated by heterodigital or reverse-flow homodigital flaps. Drawbacks of the former are potential donor digit stiffness and scarring, while the latter might be complicated by flap congestion. A bipedicled neurovascular island transposition flap design that preserves both proximal and distal extent of digital nerve and artery was employed to treat critical dorsal skin defect in two patients with encouraging results. Technical details and cadaveric study concepts are presented.

跗外侧动脉岛状皮瓣逆行转移修复踇趾软组织缺损

目的：探讨足踇趾软组织缺损的修复方法。方法：在足背外侧设计以足背动脉为蒂的跗外侧动脉皮瓣逆行转移修复踇趾缺损，皮瓣供区取全厚皮片移植。结果：29例跗外侧动脉皮瓣及植皮全部成活，感觉及外形恢复良好。结论：足背动脉蒂跗外侧动脉岛状皮瓣逆行转移修复踇趾缺损，皮瓣有神经支配，解剖位置较恒定，皮瓣蒂部较长。 Objective: To investigate the clinical method of closing cutaneous defect on big toe injury. Methods: Lateral tarsal artery insular flap was designed as a reverse flow flap to close big toe defect in dorsal lateral foot while perforating branch of lateral tarsal artery as turning point. Donor site was covered by skin-grafting. Results: Nine cases survived satisfactorily good shape and regaining sensory. Conclusion: Lateral tarsal artery insular flap can be used in converaged of big toe defect; it was a flap with constant anatomy and to regain the sensory of big toe.