Vascular Island Research Articles

New Technique for the Proximal Leg Reconstruction: Medial Sural Artery-Based Cross-leg Flap.

Reconstruction of the lower extremity, especially the proximal lower leg, is known to be a challenge for reconstructive surgeons. When there is extensive vascular damage, the use of local flaps and microsurgical methods will be limited, so there are few reconstructive options available. We want to define the use of medial sural artery-based cross-leg flap for the reconstruction of the proximal lower leg. A 51-year-old male had a soft tissue defect on the proximal leg region because of a gun-shot injury. We observed that there was no chance of a local flap as a result of CT angiography. We considered free flap to be risky because of extensive vascular damage and medial sural artery-based cross-leg flap was planned. 12*20-cm-sized medial sural artery-based cross-leg flap was elevated from the contralateral leg and adapted to the defect without tension. Medial sural artery-based flap is mostly used as a vascular island for the reconstruction of knee defects. However, its use as a cross-leg flap has not been found in the literature. We believe that it is a safe option to consider in challenging cases such as after flap failure or patients not suitable for a free flap.

Thirty-year experience of utility of island groin flap for scrotal defect single-stage reconstruction

For the last 32years, we have been using island groin flap successfully to cover the scrotal defects in a single stage with good results. This flap utility for single-stage urethral fistula repair was first reported by the senior author in 1987 and was published in Br J Urol.1We have performed single-stage repair of scrotal defects of medium and moderate size with this flap in 25 cases of Fournier's gangrene and in 4 cases of scrotal avulsion injuries due to road traffic accidents. All had good aesthetic results. More than 50% scrotal size defects were treated by a single groin flap alone. In cases with total loss of the scrotum, the groin flap was used along with two superior medial pedicle thigh flaps. Here, we have included cases of single-stage reconstruction of scrotal reconstruction by island groin flap alone. All our patients were operated under spinal anaesthesia. The results were satisfactory for the patients. We conclude from our 30 years of experience of utilizing this vascular island groin flap for a single-stage repair of scrotal defects of moderate size to be a procedure of better choice.

Using Dorsal Metacarpal Artery Perforator Flap in the Soft Tissue Reconstruction of Traumatic Finger Defects: A Single-Center Study.

The reconstruction of soft tissue defects of fingers is a challenge due to the limitations of local tissue availability. The dorsal metacarpal artery perforator (DMAP) flap is a vascular island flap raised on the dorsum of the hand, and it is a good option for finger reconstruction by replacing similar-for-similar in a single operation. In this study, we would like to share our experience of using the DMAP flap in cases of various traumatic finger defects. From November 2016 to May 2019, patients who had traumatic finger injuries and had undergone DMAP flap for soft tissue reconstruction were examined. The patients' demographic data, injury and flap characteristics, wound healing status, and complications were collected and studied. The functional and aesthetic outcomes were evaluated using the Michigan Hand Outcomes Questionnaire. There was a total of 10 patients included in this study, of which 9 were male and 1 was female. The average age was 43 years (17-66 years). Seven patients were administered general anesthesia, and 3 others wide-awake local anesthesia. The average flap size was 4.9 × 2.0 cm, and all the donor sites were primarily closed. Nearly half of the patients had temporary venous congestion, but most of the flaps survived well ultimately. Only 1 patient had a partial flap necrosis, which required an additional skin graft. The DMAP flap offers a thin and pliable skin to reconstruct finger defects within 1-stage surgery. It is easy to harvest with reliable and constant circulation. With adequate design, the DMAP flap can be used to resurface both volar and dorsal finger defects and also can reach the tip of the little finger. The DMAP flap is the ideal flap for reconstruction of traumatic finger defect with either local or general anesthesia.

Flap Related Complications Requiring Secondary Surgery in a Series of 851 Local Flaps Used for Fingertip Reconstruction.

Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues. 851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis. 31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis. Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

Lambeau de scalp pédiculé sur l’artère auriculaire postérieure. Étude anatomique et application clinique

Management of scalps defect is a common subject for reconstructive surgery. The use of local flap is better because of the hairy skin. The auricular posterior artery is often described as an accessory blood supply for the scalp. We present an original case of 16×6cm scalp flap harvested almost in "vascular island" on the right retro-auricular pedicle to cover an occipital wound. We have obtained an effective healing in 20days. Despite its considerable length, no distal necrosis has occurred. Rarely reported in the surgical literature, the posterior auricular vessels are a good blood supply to harvest scalp flap. This procedure adds to overall techniques of reconstructive surgery for scalps defects that plastic surgeons can use.

Vascular islands increase during microvascular network regression and proliferate during angiogenesis

Angiogenesis is commonly associated with capillary sprouting and intussusception. Recent work implicates vascular island incorporation as another endothelial cell dynamic. The objective of this study was to characterize the presence of vascular islands temporally correlated with vascular regression. Mesenteric tissues were harvested from adult male Wistar rats according to the following groups: unstimulated, 10 days post compound 48/80 mast cell degranulation stimulation, 70 days post stimulation, 70 days post stimulation + 3 days re‐stimulation, and 70 days post stimulation +10 days re‐stimulation (n= 16 tissues per group). Tissues were labeled for PECAM, NG2, and Collagen IV. Vascular length density increased at day 10 post stimulation and decreased by day 70. Compared to day 10 networks, the number of vascular islands, defined as disconnected endothelial cell segments, was dramatically increased at day 70. Vascular islands associated with regressing networks at day 70 contained NG2 positive pericytes and were typically bridged to nearby networks by both pericytes and collagen IV labeling. By day 3 post re‐stimulation proliferating endothelial cells were observed along islands, and by day 10 post re‐stimulation the number of vascular islands again decreased. The results from this study suggest that vascular islands associated with regression contribute to microvascular network re‐growth.

Anatomic assessment and clinical application of the lateral sural nerve-lesser saphenous vein vascular plexus island flap

Objective To investigate the practical anatomy and clinical applications of the lateral sural nerve-lesser saphenous vein vascular plexus island flap with median sural nerve preserved.Methods Ten lower limbs injected with color red latex and 20 fresh limbs were observed.Based on anatomical studies,the island flap pedicled with the vascular axis of lateral sural nerve and lesser saphenous vein was designed for clinical application in 63 cases.In procedure,the median sural nerve were preserved in donor site and the distal end of the lesser saphenous vein were not ligated.Results The accompanying arteries formed a favourable vascular plexus around the nerve and the vein,lied along the lateral sural nerve and the lesser saphenous vein and nourished the skin through cutaneous branches.The distance of the lateral ankle to the confluent of lateral and median sural nerve was (8.5± 0.8) cm.63 patients with soft tissue defects in the distal leg and foot were repaired.Their appearance and function were satisfaction without feeling lose in the heel and lateral side of the foot.Conclusions The lateral sural nerve-lesser saphenous vein vascular island flap is a reliable source of soft tissue to cover defects in the lower leg and foot.This flap has sufficient blood supply and high survival rate without the sacrifice of the median sural nerve. Key words: Lateral sural nerve; Lesser saphenous vein; Median sural nerve; Flap; Tissue defect

Vascular islands during microvascular regression and regrowth in adult networks

Objective: Angiogenesis is the growth of new vessels from pre-existing vessels and commonly associated with two modes: capillary sprouting and capillary splitting. Previous work by our laboratory suggests vascular island incorporation might be another endothelial cell dynamic involved in microvascular remodeling. Vascular islands are defined as endothelial cell segments disconnected from nearby networks, but their origin remains unclear. The objective of this study was to determine whether vascular islands associated with microvascular regression are involved in network regrowth.Methods: Mesenteric tissues were harvested from adult male Wistar rats according to the experimental groups: unstimulated, post stimulation (10 and 70 days), and 70 days post stimulation + restimulation (3 and 10 days). Stimulation was induced by mast cell degranulation via intraperitoneal injections of compound 48/80. Tissues were immunolabeled for PECAM (endothelial cells), neuron-glial antigen 2 (NG2) (pericytes), collagen IV (basement membrane), and BrdU (proliferation).Results: Percent vascular area per tissue area and length density increased by day 10 post stimulation compared to the unstimulated group. At day 70, vascular area and length density were then decreased, indicating vascular regression compared to the day 10 levels. The number of vascular islands at day 10 post stimulation was dramatically reduced compared to the unstimulated group. During regression at day 70, the number of islands increased. The disconnected endothelial cells were commonly bridged to surrounding networks by collagen IV labeling. NG2-positive pericytes were observed both along the islands and the collagen IV tracks. At 3 days post restimulation, vascular islands contained BrdU-positive cells. By day 10 post restimulation, when vascular area and length density were again increased, and the number of vascular islands was dramatically reduced.Conclusion: The results suggest that vascular islands originating during microvascular regression are capable of undergoing proliferation and incorporation into nearby networks during network regrowth.

Lambeau total du dos du nez basé sur l’artère alaire supérieure

The complete dorsal nasal aesthetic unit can be raised in a vascular island flap based on the superior alar artery, at the level of the nasalis muscle. This flap uses the vertical glabellar cutaneous laxity. It hides scars between the nasal aesthetics units and its distal rotation point allows a pure translation of the nasal skin without distortions encountered when using medial canthal rotation flaps. This local flap is reliable and had been successfully used for four patients without complications or secondary procedures. It allows large reconstructions for up to 25 mm defects leaving minimal scars. It represents an interesting alternative for the reconstruction of defects of the nasal tip or supra tip of the nose, and has also been used for alar reconstructions.

Cause investigation and management of necrosis in reversed island flap or distally-pedicled flap

Objective To propose the cause and management of necrosis in reversed island flap or distally-pedicled flap. Methods From June 2000 to June 2009, 120 cases with skin and soft tissue defect were repaired using reversed island flap or distally-pedicled flap. In 12 cases the flaps partial necrosis, to analysis the cause of necrosis. Results One hundred and eight cases survived completely in 120 patients,flap necrosis in 12 cases. 3 cases fully necrosis, in which venous disorders cause flap necrosis in 2 cases, arterial blood disorder caused necrosis of flap in 1 case. Partial necrosis in 9 cases, in which dorsal metacarpal artery reversed island flap in 1 case, digital artery reversed island flap in 1 case, posterior tibial artery reversed island flap ankle epithelial branch in 4 cases, medial leg perforating branches of reversed island flap in 1 case, superficial peroneal nerve vascular reversed island flap island flap in 1 case, distally-pedicled based sural neurocutaneous flap in 1 case, after debridement and dressing change subeschar healed in 7 cases, by the other flaps were cut close to rerepair necrotic wounds in 2 cases. Conclusion Blood circulation barrier is the main reason to flap necrosis, improper handling of pedicle is another important reason of flap necrosis,which cannot be ignored. Key words: Surgical flaps; Island flaps; Transplantation; Necrosis; Microsurgery

Use of Homodigital Reverse Island Flaps for Distal Digital Reconstruction

The homodigital reverse vascular island flap-a regional, axial-patterned skin flap elevated with a vascular pedicle from the proximal digit-is a one-step procedure used to replace skin and soft tissue loss or destruction in the distal finger. The purpose of this study was to evaluate the clinical outcome. From April 1993 to June 2005, 58 patients with a soft-tissue defect at the distal part of the finger were treated by homodigital island flaps for reconstruction. A "sensory" form island flap was used for defects in the pulps or fingertip, using reanastomosis of the terminal nerve end to the sensory nerve in the flap. We evaluated the active range of motion of the involved finger, hypersensitivity and cold intolerance, the patient's satisfaction with the appearance of the finger and the operation, and a two-point discrimination and pulp writing test, with at least 1 year of follow-up. Forty-five patients were followed up for at least 1 year after operation; 24 patients were treated with sensory-form reverse island flaps. The patients rarely complained of pain, anesthesia, or the cold intolerance of the flap. Both dynamic and static two-point discriminations were better in the sensory form than in the "arterial" form reverse vascular flap, with statistical difference. Seven patients aged older than 50 years were successfully treated and had a good functional outcome. The homodigital reverse island flap is an ideal surgical treatment for distal digital defects with a lower complication rate and good functional result, and the indication of age can be extended for older patients with a good preoperative evaluation.

Heterodigital Vascular Island Flap for Simultaneous Resurfacing and Revascularization of Digits

Devascularized digits with segmental skin and vessel loss require revascularization and resurfacing. This can be addressed by using a heterodigital vascular island flap. This flap brings with it an appropriately sized pristine artery of optimal length for revascularization and provides simultaneous skin cover. We describe 3 cases. Primary wound healing was achieved in all patients with good functional recovery and acceptable donor site morbidity. We compare the options available for reconstructing such defects and discuss other possible surgical indications for this flap.

A Modification of the Chinese Island Flap Technique for Simple Incomplete Syndactyly Release

This paper presents a modification of the technique described by Yao et al. using a vascular island flap based on a dorsal digital vessel, which allows transfer of the web proximally and retains the integrity of the web skin. The technique was used in nine patients, aged from 1 to 15 years at operation, with nine incomplete simple syndactylies. The results were assessed at a mean of 36 (range 5-60) months after surgery. No vascular compromise or web creep was noted. This technique enables transfer of web skin proximally in cases of simple, incomplete syndactyly, avoids the presence of scars in the web space and does not require skin grafts.

Vascularized Adipofascial Island Flap for Thenar Augmentation in Pollicization

The recommended treatment for Blauth types IIIB and IV congenital thumb hypoplasia is index pollicization and amputation of the functionless, hypoplastic thumb. Instead of completely discarding the functionless part, the authors retain a portion of the soft tissue as an adipofascial vascular island flap. This flap is inset at the base of the new thumb to simulate a thenar eminence and to improve the appearance of these hands. This flap was used to augment the thenar base in 14 hands in 14 children. Follow-up ranged from 1 to 26 years. All pollicizations were successful and there were no major complications. All of the adipofascial flaps improved the appearance of the thenar eminence and held up their shape in the long term. Use of an adipofascial island flap is recommended for thenar eminence augmentation in index pollicization of types IIIB and IV thumb hypoplasia. This tissue improves the appearance of the hand, is easy to harvest, and adds no morbidity.

The remucosalizing alar cartilage flap: a reconstructive option for repairing nasal septal perforations

The objective of this study is to assess the results of repairing septal perforations with a vascularized pedicled alar cartilage island flap. Using the external rhinoplasty approach, a vascularized flap of alar cartilage, harvested as a cephalic trim and pedicled on the ascending columellar branches of the superior labial artery was raised. Bilateral mucoperichondrial septal flaps were elevated and the alar flap was transposed and secured within the defect and bilaterally overlaid with temporalis fascia. Silastic sheets were placed and remained in situ until the grafts were revascularized from the peripheries of the defect as well as centrally from the alar flap. The revascularized temporalis fascia acted as a scaffold for nasal remucosalization. The alar flap also increased the long-term structural robustness of the repair. Between 1999 and 2003, 14 patients with septal perforations ranging from 10 to 31 mm underwent septal reconstruction using this technique. There were nine males and five females. The flap was successfully raised in all cases and long-term closure was maintained in 12 patients (86%). The alar cartilage flap is an effective technique for repairing septal perforations in selected patients. It provides vascularized tissue which nourishes the grafts during remucosalization, and a cartilaginous framework, which affords long-term structural support to the repair. It also obviates the need to transpose nasal mucosa and create a secondary defect. The rhinoplasty approach furthermore permits additional nasal deformities to be corrected at the same time.

Le lambeau pédiculé en îlot vasculaire proximal de fibula dans la reconstruction distale du fémur. Étude anatomique

The fibular pedicled proximal vascular island flap for distal femoral bone reconstruction described for the first time by Cariou on 1996, is studied in this article with an anatomical view. This anatomical morphometric study allows to assure the surgeon that this procedure can be done and to precise the surgical technique. The autors showed that, dependent on the length of the lower limb and the level of the fibular artery origin, 10 to 19 cm of femoral bone reconstruction could be done, after 180° flap rotation. The flap can be used, the fibula separated in two parts, for inferior femoral metaphysis reconstruction or for knee joint arthrodesis.

Le lambeau orbitonasogénien. Étude anatomique et clinique

How to use the orbitonasolabial flap in vascular island thanks to his pedicle based an angular vessel. An anatomic study based on 11 cadavers allows to check the existence of a constant pedicle. This flap was used on 6 patients aged 62 to 90 years old on an average period of 16 months to fill up jugular, orbital, nasolabial and inner canthal defects. Two complications have occurred, a superficial necrosis of the lower part of the flap having spontaneously healed and an ectropion on a senile part. It has been necessary to degrease a second time in 50% of the cases. Nevertheless, the flap can be considered reliable and able to cover tissue defect in the central facial region with minor aesthetic and functional sequel on the donor site.

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.

Clinical study of distally and proximally based lesser saphenous-sural nerve vascular island flap

目的 报道远端蒂及近端蒂小隐静脉-腓肠神经营养血管皮瓣修复下肢软组织缺损的效果.方法采用近端蒂及远端蒂、带腓肠神经或不带腓肠神经的小隐静脉-腓肠神经营养血管皮瓣,修复25例小腿胫前近、中、远段和踝周、足背及足跟皮肤缺损,皮瓣最小面积为5 cm×4 cm,最大面积为10 cm×15 cm.结果25例中远端蒂皮瓣22例,近端蒂3例,不带腓肠神经的皮瓣3例,皮瓣全部成活,皮瓣质地优良,外观及功能满意.结论该皮瓣可行近、远端带转移,皮瓣可带或4带腓肠神经,均有足够的血运.本皮瓣成活率高,操作简便,不牺牲主干血管,是修复小腿胫前、踝周及足跟部软组织缺损的理想皮瓣。

Metoidioplasty: a variant of phalloplasty in female transsexuals.

To describe metoidioplasty, a technique for creating a neophallus from an enlarged clitoris in female transsexuals, without needing the complex, multi-staged surgical construction of a large phallus, as this reconstruction is one of the most difficult in female transsexuals. From September 1995 to April 2002 metoidioplasty was used in 22 patients (aged 18-33 years). The technique is based on the repair of the most severe form of hypospadias and intersex. The 'urethral plate' and urethra are completely dissected from the clitoral corporeal bodies, then divided at the level of the glanular corona, and the clitoris straightened and lengthened. A longitudinal vascularized island flap is designed and harvested from the dorsal skin of the clitoris, transposed to the ventral side, tubularized and anastomosed with the native urethra. The new urethral meatus is brought to the top of the neophallus, and the skin of the neophallus and scrotum reconstructed using labia minora and majora flaps. The mean (range) follow-up was 3.9 (0.5-6) years; the neophallus was 5.7 (4-10) cm, considered satisfactory in 17 patients but the remaining five required additional phalloplasty. The complications were urethral stenosis in two and fistula in three patients. Metoidioplasty is an alternative to phalloplasty, allowing voiding while standing. In patients who desire a larger phallus, various techniques of phalloplasty can also be used.