Sensate Flap Research Articles

Toe-to-Hand Transfer from a Cross-Foot Replantation in a Traumatic Four-Extremity Amputation

Treatment of mutilating hand injuries often requires multiple innovative procedures. This report describes a case of multi-limbed amputations from a train injury and the extraordinary microsurgical approaches for a two-hand reconstruction. The first stage of the procedure was a cross replantation of the left foot to the right leg. The second stage was a combined second and third toe transfer from the cross replantation of the left foot to the right hand, and a sensate fibular osteocutaneous flap transfer for left hand reconstruction. Satisfactory function was restored, including good protective sensation. These kinds of extraordinary microsurgical approaches are useful salvage procedures for hand reconstruction, when presented with a case of multi-limb amputation.

The compound thoracodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot

Nine cases of massive soft-tissue loss of the foot were reconstructed by means of a compound (chimera) thoracodorsal artery perforator (TAP) flap, which reconstituted the different functional units (dorsum, heel, instep, weight-bearing surface). In each case, the flap consisted of a skin component isolated on its perforator in combination with a portion of latissimus dorsi muscle and/or serratus fascia, all pedicled on the thoracodorsal vessels. The pedicle length allows up to 4-6 cm of independent mobility of the skin island. The mobility of the various flap components allows the various functional units of the foot to be reconstructed without relying on multiple flaps or anastomoses. The pedicle length was sufficient to be able to perform the anastomosis out of the zone of injury. In some cases the skin island was harvested along with intercostal nerve branches, this gave us the potential to develop a sensate flap. The indications and advantages of this reconstructive method are discussed.

Total reconstruction of the upper lip after resection of a malignant melanoma

The upper lip was totally reconstructed with a radial forearm sensory flap and vermilionplasty using medical tattooing after resection of a malignant melanoma. Three courses of chemotherapy (dacarbazine, nimustine, and vincristine) were given postoperatively. The reconstructed lip had good contour, colour, and sensory recovery.

Anterolateral Thigh Flap Technique in Hand and Upper Extremity Reconstruction

The anterolateral thigh flap is an extremely versatile flap first described in 1984. The flap is based on either a septocutaneous or musculocutaneous perforator of the descending branch of the lateral circumflex femoral system. It can be designed as a skin and subcutaneous flap, fasciocutaneous, or musculocutaneous flap. Furthermore, it can be harvested as a sensate flap by taking the lateral cutaneous nerve of the thigh. Technique for harvesting the flap is described in detail. Complications include flap failure and donor site morbidity. Due to its versatility, the anterolateral thigh flap is particularly useful for upper extremity reconstruction.

Combined Free Fibular Osteocutaneous–Lateral Calcaneal Fasciocutaneous Flap for Reconstruction of Composite Oromandibular Defects

The free fibular osteocutaneous flap is often used in the reconstruction of composite oromandibular defects. In contrast, the lateral calcaneal flap has never been used in oromandibular reconstruction. On the basis of their anatomic continuity, the authors combined the free fibular osteocutaneous flap with the lateral calcaneal skin paddle to obtain 2 adjoining flaps in different anatomic areas with the same vascular axis. The authors report their experience in 3 patients with composite oromandibular defects. In 1 patient without an outer skin defect, only a sensory lateral calcaneal skin paddle with a fibular osseus flap was harvested. The lateral calcaneal flap carried the sural nerve as a sensory flap in 2 patients, and the result was passable. Only 1 patient encountered superficial flap tip necrosis at the lateral calcaneal skin paddle, and recovered well after wound care. In conclusion, a flap with many specific features is a feasible choice for reconstruction of composite oromandibular defects.

Surgical treatment of pressure ulcers

Although a pressure ulcer is a potentially serious condition that always calls for treatment, only a small percentage of patients with pressure ulcers are candidates for surgery. The choice between conservative treatment and surgery for a pressure ulcer depends on a thorough evaluation of the ulcer, as well as the patient's physical and mental states. In general, superficial pressure ulcers (stages I and II) are likely to benefit from conservative treatment. Deep pressure ulcers (stages III and IV, often resulting from spinal cord injury) often require surgical intervention. The surgical techniques described in this essay include direct closure (which is rarely indicated), local and sensate flaps, and skin grafting. Skin transplantation and cutaneous and other thin flaps have more limited indications in pressure ulcer surgery. Thorough debridement before reconstruction, patient compliance, control of concomitant disease, professional postoperative support, and sufficient pressure relief are imperative for treatment success.

Radial forearm flaps for reconstruction in hand surgery.

Thirty-seven patients were treated using distally-based island radial forearm flaps. There were 31 men and six women. Reconstructed sites involved the dorsum of the hand (n = 17), the thumb (n = 11), the fingers (n = 5), the first web (n = 3), and the palm (n = 1). Sensory flaps were transferred in 15 cases, osteocutaneous flaps in six, and tendocutaneous flaps in eight. All the flaps survived. There were five donor-site complications, but no functional disturbances. Three patients had symptoms of cold intolerance. There were no radial fractures. In the six cases with osteocutaneous flaps, a mean of 2.6 months (range 2-3) was needed to obtain bony union. Among the eight cases with tendocutaneous flaps, postoperative tenolysis was required in two cases, and finally seven achieved a satisfactory outcome. The mean moving 2-point discrimination of the sensory flaps was 13 mm.

Advances in head and neck reconstruction.

There are numerous advances that have taken place over the last several years in head and neck reconstruction. In this article, the author has outlined three exciting developments. The first is in the area of palatomaxillary reconstruction using free tissue transfer. In select cases, depending on the nature of the defect, soft tissue flaps have been highly successful. However, in more extensive defects, the author chooses to transfer vascularized bone composite flaps to achieve successful dental restoration as well as closure of the palatal defect. Sensory restoration through the use of sensate flaps has been a topic of considerable controversy. The author presents his experience with three patients who underwent a unique reconstruction of the laryngopharynx that has demonstrated conclusively that targeted sensory restoration can be achieved through neural anastomoses. By anastomosing the sensory nerve to the superior laryngeal nerve, there are implicit physiologic implications with respect to the feedback that is achieved and its role in achieving glottic closure during deglutition. Extensive laryngeal reconstruction with subglottic involvement can be a very challenging problem. The author describes a new technique using vascularized tracheal autografts with the thyroid gland as a carrier. This provides the necessary ingredients for transferring a cartilaginous infrastructure within a thin layer of vascularized mucosa to restore the framework and the lining to the laryngotracheal region. Three patients have been restored who had extensive glottic and subglottic stenoses that have since been decannulated and are successfully eating as well as speaking. In addition, the author feels that this is a very promising technique for the management of chondrosarcomas, in which a significant portion of the cricoid arch requires reconstruction.

Long-term results with the proximally-based neurovascular lateral calcaneal flap.

From 1995 to 1997, the proximally-based neurovascular lateral calcaneal flap was used in eight patients to cover defects in the Achilles tendon area or the lateral malleolar region. The mean postoperative follow-up was 40 months (range 29-51). The outcome of the operation was investigated both clinically and using a questionnaire sent to patients. All flaps healed uneventfully within a mean of 33 days. Revisional operations were required in two cases because of pain at the donor site. No flaps had broken down up to the follow-up, which was between three and five years. Two of the patients operated on were paraplegic, and the other six patients had sensate flaps. Five of the six patients with sensate flaps were able to wear normal shoes and one patient needed a shoe elevated by about 7.5 cm because of a disease independent of the flap. All but two patients were satisfied with the functional and aesthetic results. The proximally-based neurovascular lateral calcaneal flap proved to be safe and can be recommended as a good option to cover tissue defects in the Achilles tendon area or the lateral malleolar region.

Mixed Nerve Suture Facilitated by Enzyme-Staining Techniques

Identification of motor and sensory fascicles to correctly match the motor and sensory fascicles helps surgeons to correctly align nerve stumps. Motor fibers, with their high cholinesterase activity, can be differentiated from sensory fibers. I developed a new modification that requires less than 1 hour and shows clearer differentiation compared with other histochemical techniques. In my clinical research, proximal stumps can be stained as long as 16 months after injury, however, distal stumps cannot be stained after 5 days. After 5 days, this staining could provide useful proximal information and distal fascicles may be identified by anatomic or topographical knowledge. I think this staining is especially useful in proximal nerve lesions and nerve injuries that require nerve graft within 4 days after injury. Also, this technique is useful in functioning muscle transfer to find motor fascicles and, in a sensate flap, to identify the sensory fascicle.

Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect

Soft-tissue reconstruction of the foot frequently requires flap coverage to preserve exposed tissues such as bones, joints, tendons, and weight bearing areas. Recently, reconstruction of skin defects in the heel has been greatly improved by use of the medial plantar sensory flap. However, forefoot coverage remains a challenge, since the alternatives for flap coverage are very limited. A case report is presented of a 52-year-old man with a chronic forefoot ulcer, successfully covered with a plantar marginal septum cutaneous island flap. This recently reported technique, which utilizes a reversed-flow flap based on the superficial branch of the medial division of the medial plantar artery, is relatively easy and disadvantages to the donor site are minimal.

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.

The recurrent neurotrophic buttock ulcer in the meningomyelocele paraplegic: a sensate flap solution.

A large percentage of meningomyelocele paraplegic patients have a distal zone of sensation-bearing skin on their thighs. This sensate skin can be used as a fasciocutaneous flap to resurface a recidivistic ulcer after excision. In this study, because the transposition distance was significant, the flap length-width ratio was greater than normal and, therefore, required a 3-week elevation delay. This also permitted appraisal of the sensate flap after the first stage. The wound-healing was excellent after both stages. This reconstructive procedure was completed in four patients, with an average follow-up period of 13 years. These patients remain chronic sitters in administrative jobs and have been pressure sore-free after flap repair.

Harvesting the Abductor Digiti Minimi as a Muscle Plug With the Lateral Calcaneal Artery Skin Flap

The abductor digiti minimi muscle flap and the lateral calcaneal artery skin flap were raised as one combined flap and were used to cover plantar heel wounds with chronic osteomyelitis of the calcaneus. The combined flap was used successfully in 4 patients. The muscle component of the flap obliterated the dead space and provided a vascularized muscle over the debrided calcaneus, and the skin component acted as a sensate flap in the plantar heel.

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

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

Dorsal branches of superficial radial nerve: an anatomic study with potential clinical applications

An anatomical study was performed to assess the course of the dorsal branches of superficial radial nerve and to investigate potential clinical applications in hand surgery. Eight upper extremities were dissected, using an operating microscope. All branching points of the superficial radial nerve were noted and the distances from the radial styloid process were recorded. Their proximity to neighboring vascular structures was noted. The superficial branches of the radial nerve can vascularize axial neurofasciocutaneous flaps via their paraneural arterial network. In addition, various reverse neurofasciocutaneous flaps may be harvested, based on dorsal branches of the superficial radial nerve. The nerve can be anastomosed with a suitable nerve in the recipient area. The dorsal branches of the superficial radial nerve can easily be added to the reverse first dorsal metacarpal artery flap and other reverse dorsal metacarpal artery flaps, thus making it possible to form a sensate flap. These branches may be anastomosed with nerves in the recipient site, such as dorsal branches of digital nerve stump, without significant donor site morbidity. A free sensate first dorsal artery flap can be prepared with a combination of dorsal branches of the superficial radial nerve and used with the same indications as a free digital artery flap. It has some advantages over the free digital artery flap, because the main neurovascular structures of the finger are kept intact. Finally, a dorsal nerve branch which accompanies the first dorsal metacarpal artery may be harvested with this artery and a subcutaneous dorsal vein as vascularized nerve graft. It can be used to repair a digital nerve defect in dense scar tissue.

Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects

The principle of the V-Y advancement flap has been used since its first description by Blasius (1848) for reconstruction of smaller defects. We wish to describe V-Y advancement flaps, the design of which includes distinct perforator or fascial feeder vessels, which may originate from periosteum, muscle, cutaneous nerve or from large tendon sheaths. These flaps are planned in an oblique manner when there is a defect over the anterior, antero-lateral or antero-medial aspect, and in a vertical manner when there is a defect over the posterior aspect of the leg. The main advantage of this design is the ability to close the secondary defect primarily, allowing adequate cover of the defect, particularly in the pre-tibial region, without the unsightly divot left by a split skin graft in this area. When the flap includes branches of the long saphenous nerve on the medial aspect, superficial peroneal nerve laterally or sural nerve posteriorly it results in a sensate flap, giving protection in this vulnerable area, which has previously not been possible. We describe 40 cases where perforator-based V-Y advancement flaps have been used to cover large defects of the lower leg following excision of malignant skin lesions and in selected trauma cases that do not involve degloving injuries. This technique allows adequate soft tissue cover in the pre-tibial area and around the ankle with excellent aesthetic results. The planning, operative technique and the results with case presentations have been described.

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.

Anatomical variations of the sensory nerves to the fibular osteocutaneous flap.

To describe the anatomical relationship of the sural sensory nerve complex to the posterior crural intermuscular septum (PS), the key anatomical structure for the osteoseptocutaneous fibula skin paddle. Anatomical study. Twenty-two legs from 11 cadavers (7 females and 4 males). The lateral sural cutaneous (LSC) nerve, present in 20 of 22 legs, divides into lateral and medial branches near the head of the fibula. The LSC nerve and its medial branch course away from the PS, whereas the lateral branch tends to course toward the PS. The lateral branch courses nearest to the PS at a median distance of between 4 cm proximally and 3 cm distally. The medial branch of the LSC nerve terminates approximately in the middle of the leg, and the lateral branch of the LSC nerve terminates within 7 cm below the head of the fibula. The peroneal communicating branch is thicker than the LSC nerves; however, it is further from the PS in the upper leg. The LSC nerve is the most consistent and accessible donor sensory nerve in the posterior leg for harvest with the osteoseptocutaneous fibula free flap. Results of this study will assist the surgeon in harvesting a sensory nerve with the osteoseptocutaneous fibula free flap, bringing this potentially sensate flap into more common use. Arch Facial Plast Surg. 2000;2:252-255

Sensate free flaps

Microvascular free flaps have greatly advanced the field of head and neck reconstruction. This allows the transfer of vascularized tissue from distant sites to reconstruct postextirpative defects. Adding to the refinement of these techniques is the introduction of sensate flaps. These are essential in restoring function in the upper aerodigestive tract. In this review, we present a discussion on the importance of sensation for proper swallowing function. We also describe the techniques used for sensate free flap reconstruction.