Venae Comitantes Research Articles

Venous Drainage of the Radial Forearm Flap

The purpose of this study is to compare complications between the superficial and deep venous drainage systems of the free radial forearm flap to aid in selection of venous drainage in a commonly used flap. A retrospective cohort of 370 radial forearm free flaps performed between 1998 and 2008 were reviewed. Multiple population and outcome variables were compared among outcome groups. A technique was implemented to explore the venae comitantes at the wrist crease to determine their adequacy before a full-scale flap elevation. There were a total of 21 venous complications requiring re-exploration (5.7%) and 5 flap failures (1.4%). The incidence of inadequate venous outflow was 2.2% when the venae comitantes were used alone and adding a cephalic vein for drainage salvaged half of the flaps. The incidence of inadequate venous outflow was 3.8% when the cephalic vein was used alone and adding a venae comitans for drainage salvaged all the flaps. The problem of inadequate outflow in the radial forearm flap is more commonly seen when selecting the cephalic vein, or using both the deep and superficial systems together. When of adequate caliber, the venae comitantes should be selected as the sole venous outflow for this flap.

Successful Salvage of Venous Thrombosis of a Free Flap by Creation of a Venocutaneous Fistula

This report describes the creation of a venocutaneous fistula to salvage a free fibular osteocutaneous flap compromised by extensive venous thrombosis. This technique has previously been described for salvage of digital replants, but this is the first report of a venocutaneous fistula being used to salvage a free flap. A 21-year-old woman underwent a 9-cm resection of the distal left tibia for an aneurysmal bone cyst. A contralateral right fibular osteocutaneous free flap was used for reconstruction. On postoperative day 2, the skin paddle showed evidence of venous congestion. Reexploration demonstrated extensive thrombosis throughout the entire venous system of the flap. The venae comitantes were transected as far back as possible and brought to the surface of the skin through two small stab wounds to allow venous egress. After a short course of heparin and dextran, the skin flap healed uneventfully and both osteosynthesis sites consolidated. A venocutaneous fistula provides a path of relatively low resistance for venous outflow, improving the arterial inflow-venous outflow balance for a short time until neovascularization and collateral venous channels develop. The venocutaneous fistula technique may be considered for salvage of free flaps compromised by extensive venous thrombosis.

Use of the descending branch of the lateral femoral circumflex vessels as a composite interposition graft in lower extremity reconstruction

The prevailing treatment for distal third lower extremity defects is with autologous free tissue transfers. In the trauma patient, these reconstructions are wrought with challenges, including the selection of appropriate recipient vessels, avoiding the zone of injury, and choosing the appropriate flap for transfer, all while maintaining perfusion to the foot. With distal defects and a large zone of injury, the free flap pedicle may need additional length to cover the defect and reach the recipient vessels without excess tension. The creation of an arteriovenous loop from an autologous vein graft is the usual solution. We present a case where additional pedicle length was needed to have a free flap completely cover a distal leg defect and connect to the anterior tibial vessels proximally. The saphenous vein was not available as an interposition graft; therefore, the descending branch of the lateral femoral circumflex artery and venae comitantes were used as a composite arteriovenous interposition graft.

Islanded Posterior Tibial Artery Perforator Flap for Lower Limb Reconstruction: Review of Lower Leg Anatomy

Sir: We read with great interest the recent article entitled “Lower Limb Reconstruction Using the Islanded Posterior Tibial Artery Perforator Flap,” by Dr. Mark Schaverien et al.1 We congratulate the authors on their article, which provides a review of the anatomy, their surgical technique, and indications for use of the posterior tibial artery perforator flap. This article prompted a lengthy discussion among plastic surgeons at our institution. However, our review of lower limb anatomy differs slightly from that described by the authors in this article. In 1997, the posterior tibial artery perforators and their fasciocutaneous territories were described by Whetzel et al.2 A number of studies have described the lower limb arterial supply, including the anterior tibial, peroneal, sural, and posterior tibial artery perforators. Schaverien and Saint-Cyr published a detailed anatomical study of the lower extremity perforators using arteriovenous latex cure and cadaver dissection in 1998.3 In this article, the authors describe the posterior tibial artery perforators as “arising from within the intermuscular septum between the soleus and the flexor hallucis longus.” According to our review of the above studies and anatomy textbooks, the posterior tibial artery traverses the deep posterior compartment of the lower leg. The posterior tibial artery perforators and their two associated venae comitantes pass through two intermuscular septae: between the soleus and flexor digitorum longus; and the medial aspect of the tibia and the flexor digitorum longus (not the flexor hallucis longus, which lies lateral to the posterior tibial artery).2–5 The islanded posterior tibial artery perforator flap does seem to be a reliable, versatile fasciocutaneous flap for use in reconstruction of lower limb soft-tissue defects. However, as with any flap, it is vital to have accurate knowledge of the vascular and musculoskeletal anatomy of the flap and surrounding tissue before proceeding with such an endeavor. In addition, it would be interesting to determine whether there are any differences in complication rates based on the location of injury (e.g., lower leg, ankle, heel). Megan C. Jack, M.D. Martin I. Newman, M.D. Department of Plastic Surgery Cleveland Clinic Florida Weston, Fla. Yoav Barnavon, M.D. Hollywood Memorial Hospital Hollywood, Fla. DISCLOSURE The authors have no financial interests with respect to the content of this communication or the article being discussed.

Secondary Maxillofacial Reconstruction with the Radial Forearm Free Flap: A Standard Operating Procedure for the Venous Microanastomoses

The radial forearm free flap (RFFF) is commonly used in reconstructive surgery. With respect to the maxillofacial region, several venous anastomotic techniques (e.g., single or double anastomoses) have been described, but the debate as to which alternative is preferable is ongoing. A complicating factor is the unpredictable anatomical situation in patients undergoing secondary operation. No recommendations are available for the surgical strategy in such cases. We present a standard operating procedure (SOP) applicable for secondary reconstructions, postulating double anastomoses as the method of choice, and evaluate its efficacy. The following parameters were retrospectively analyzed for 120 patients with secondary (41; 34.2%) or primary (79; 65.8%) reconstruction following the instructions of SOP and compared between the study groups: age; sex; history of radiotherapy; side of the donor arm; flap size; preparation and use of the cephalic vein and reasons for its non-inclusion; included venae comitantes; recipient veins; arterial anastomoses; revisions, flap survival, and mortality within thirty days after operation. The method of choice was applicable in 26 (63.4%) secondary and 52 (65.8%) primary reconstructions (no difference; P=0.841), resulting in 100% flap viability in both groups. In the remaining cases, single venous anastomoses were performed, resulting in 73.3% flap viability in secondary and 100% in primary reconstructions. Flap survival in secondary reconstructions was significantly higher when double anastomoses were conducted (P=0.012). The results suggest the necessity of double venous anastomoses in secondary maxillofacial reconstructions with RFFF.

The Role of Inconstant Perforating Arteries in Harvesting Radial Flaps

Sir: We read with great interest the article by Saint-Cyr et al.1 regarding cutaneous perforators of the radial artery. In that study, a cadaveric dissection was performed to determine the size, location, and cutaneous territory of perforators originating from the radial artery. Knowledge of these perforators allows the surgeon to perform distally based radial artery flaps, avoiding sacrifice of the radial artery. Nevertheless, in rare cases, the same result can be achieved using inconstant perforators arising from vessels other than the radial artery. We recently treated a 45-year-old man affected by traumatic injury of the dorsal aspect of the right hand for whom a radial flap was proposed. Doppler examination and the Allen test were used to assess functional radial-ulnar anastomoses. The first incision was made at the ulnar side over the flexor carpi ulnaris, and the dissection began from the same side toward the radial artery. During the dissection, an unexpected perforator artery was found. The vessel measured 0.8 cm in diameter and was accompanied by two venae comitantes. After accurate and gentle dissection, the artery was demonstrated to originate from the superficial palmar arch and measured 4.6 cm in length. The radial artery was not vestigial and had a regular caliber (Fig. 1). A superficial vein was isolated and preserved up to 2 cm proximally, to obtain additional microvascular venous drainage (Fig. 2). The arterial branches originating from the radial artery were sectioned and the flap was harvested. After positioning the flap on the recipient site, microanastomosis between the superficial vein of the flap and the dorsal venous network was performed. The postoperative period was uneventful.Fig. 1.: A 12 × 5-cm skin paddle is drawn in the middle third of the dorsal aspect of the right forearm. The first incision was made at the ulnar side over the flexor carpi ulnaris, and the dissection began from the same side toward the radial artery. During the dissection, an unexpected perforating artery with two venae comitantes was found, originating from the superficial palmar arch. The artery measured 0.8 cm in diameter, whereas the whole pedicle measured 1.5 cm in diameter. The radial artery was not vestigial and had a regular caliber.Fig. 2.: The flap is centered on the perforating vessel. On the proximal edge of the flap, a superficial vein is isolated and preserved up to 2 cm proximally to obtain additional venous flap drainage. The arterial branches originating from the radial artery are sectioned. A 5-cm skin incision is performed to allow tunnelization of the flap.In our opinion, the surgeon should always take into account the eventuality of inconstant vessels,2 such as perforating arteries, median arteries, or ulnar superficial arteries. These vessels could not always be detected by arteriography and are invisible on Doppler examination. In our case, a nonvestigial radial artery was found and a perforating vessel arising from the palmar arch was used in harvesting the radial flap. Great support to the surgeon's work is given by imaging. Computed tomographic angiography is considered the standard preoperative study and should be systematically used. We believe that exact knowledge of the vascularization of the patient's forearm, provided by computed tomographic angiography, is strictly necessary for the surgical planning of the flap, revealing perforators originating from the radial arteries and inconstant perforator vessels. Nevertheless, the intraoperative finding of inconstant pedicles originating from perforators other than those arising from the radial artery should motivate the surgeon to find new reconstructive solutions. From this perspective, we conclude that dissection for a radial flap should be preceded by computed tomographic angiography and performed with surgical loupes, starting at the ulnar side toward the radial artery. Forearm anatomy is often unpredictable and the surgeon should consider moment by moment all the reconstructive chances to avoid sacrifice of the radial artery. Therefore, great attention should be paid to every perforator encountered because it could bring new reconstructive scenarios. DISCLOSURE The authors have no financial interest to declare. Luca Vaienti, M.D. Riccardo Gazzola, M.D. Giovanni Palitta, M.D. Dipartimento di Scienze Medico Chirurgiche Università Degli Studi di Milano IRCCS Policlinico San Donato Milan, Italy Enrico Vaienti, M.D. Università Degli Studi di Parma Parma, Italy

One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

The authors' goal was to determine whether one or two venous anastomoses results in superior blood flow through microvascular free flaps. During flap harvest, blood velocity was measured in each of two venae comitantes using Doppler ultrasonography. Next, one of the two veins was occluded with a microvascular clamp and blood velocity was measured in the open vein. The clamp was then removed and placed on the other vein, and blood velocity was measured in the first vein. The pedicle was divided and microvascular anastomosis of either one or two veins was performed. Venous blood velocity was then compared between flaps with one versus two venous anastomoses. Eighty-one free flaps were performed. Before pedicle division, the peak venous blood velocity in each of the two venae comitantes averaged 6.3±4.8 cm/second. When one of the veins was occluded, the peak venous blood velocity increased to 19.5±17.3 cm/second (p<0.00001). One venous anastomosis was performed in 69 flaps and two venous anastomoses were performed in 12 flaps. The mean blood velocity in flaps in which one venous anastomosis was performed was greater than the mean blood velocity in either vein when two venous anastomoses were performed (13.1±7.3 cm/second versus 7.5±4.3 cm/second, respectively; p=0.001). When one vena comitans is occluded, blood velocity in the second vena comitans increases significantly. Venous blood velocity is significantly greater after a single venous anastomosis than in either of two veins when two venous anastomoses are performed. These results argue against routinely performing two venous anastomoses.

Supraclavicular Artery Flap

Supraclavicular artery-based flaps provide aesthetic and functional coverage for the head and neck region. Fourteen formalin-fixed cadavers were dissected bilaterally, and 28 supraclavicular arteries were evaluated. The origin of the supraclavicular artery was transverse cervical artery in 62.9% and suprascapular artery in 37.1% of the cases. The origin of the artery was at the level of the medial third of the clavicle in 3.7%; 3.7% of the cases were at the junction of medial and middle third of the clavicle, 33.3% at the level of middle third of the clavicle, 11.1% at the junction of middle and lateral thirds, 44.4% at the level of lateral third, and 3.7% at the level of acromioclavicular joint. The mean values of the results were as follows: The diameter of the artery was 1.0 mm at the origin. The distance of the origin of the artery from sternoclavicular joint and from the upper border of the clavicle was 76.4 and 22.2 mm, respectively. The average length of the artery was 70.8 mm. In all dissections, the artery was deep to the platysma muscle. Forty-one percent of supraclavicular arteries accompanied the middle supraclavicular nerve, whereas 59% of the arteries run with lateral supraclavicular nerve. The supraclavicular artery had a parallel course to the 2 horizontal imaginary lines passing from the coracoid process and acromion in 63% of the cases; 18.5% of the arteries were oblique, and 18.5% were vertical to the imaginary lines. The venae comitantes were double in all dissections.

Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography

Deep inferior epigastric artery perforator (DIEP) flap harvest is associated with a significant rate of venous congestion; however, the reason for this has not yet been fully explained. Contrast-enhanced magnetic resonance angiography enables detailed evaluation of both the arterial and venous anatomies. A retrospective review of DIEP flaps that underwent preoperative contrast-enhanced magnetic resonance angiography was performed. Outcomes were compared with preoperative radiologic reporting of contrast-enhanced magnetic resonance angiographic imaging, and anatomical data from the scans were also analyzed. Review of 54 DIEP flaps with venous system reporting was performed. Seven DIEP flaps suffered venous congestion, all of which were raised on perforators without direct connections between the venae comitantes and the main arborization of the superficial inferior epigastric vein. In the 47 DIEP flaps without venous congestion, 46 were raised on at least one perforator with a direct venous connection between the perforator venae comitantes and the main arborizations of the superficial inferior epigastric vein. There was an extremely significant association between the absence of a direct connection with the perforator venae comitantes on magnetic resonance angiography and the occurrence of venous congestion (p < 0.0001). Sixty-eight percent of all perforators had direct venous connections, which were significantly more likely to be located in the medial row. DIEP flaps elevated on perforators with venae comitantes with direct venous connections to the main arborization of the superficial inferior epigastric vein are significantly associated with a very low incidence of flap venous congestion. Contrast-enhanced magnetic resonance angiography allows detailed appraisal of the venous anatomy, which may minimize the risk of DIEP flap venous insufficiency and the need for salvage procedures.

Internal Mammary Artery Perforators for the Salvage of a Superficially Dominant Free Flap Breast Reconstruction

Sir: The deep inferior epigastric perforator (DIEP) flap is becoming widely popular for autologous breast reconstruction because preservation of the rectus abdominis musculature can lead to less abdominal wall morbidity and postoperative pain. Alternatively, a muscle-sparing free transverse rectus abdominis musculocutaneous flap offers many similar advantages. In both cases, deep inferior epigastric vessels are usually anastomosed to the recipient internal mammary vessels in the third intercostal space. However, perforating vessels from the internal mammary circulation have also proven to be reliable recipients for anastomosis.1,2 Using the internal mammary perforators primarily obviates the need for partial rib resection and allows the internal mammary vessels to be preserved for potential future use as coronary revascularization grafts. To our knowledge, use of internal mammary perforators for salvage of a congested flap with patent internal mammary anastomoses has not been previously described. In a recent case of a bilateral free flap breast reconstruction, we noted mild congestion in half of the flap, shortly after dividing the superficial inferior epigastric vein (SIEV). The congestion improved slightly with time while the flap remained connected to the deep circulation, and the decision was made to complete the procedure as a muscle-sparing free transverse rectus abdominis musculocutaneous flap with one arterial anastomosis from the deep inferior epigastric artery to the internal mammary artery, and two venous anastomoses from the inferior epigastric venae comitantes to the two internal mammary veins that were present. The other half of the flap had a normal appearance, and a DIEP flap was performed to reconstruct the left breast. However, the right breast flap appeared mildly congested at the completion of the operation, initially improved, and then worsened over the first postoperative day, necessitating operative exploration. At the time of exploration, all arterial and venous anastomoses were found to be widely patent but, once the SIEV was opened, a continuous jet of venous flow was seen, indicating venous congestion despite the two venous anastomoses (Fig. 1). We augmented the venous outflow by coupling a saphenous vein graft between the SIEV and a perforating vein of the internal mammary circulation in the second intercostal space that had been left intact during the mastectomy (Fig. 2). After placement of the interposition graft, the abnormal tissue turgor and congested color of the flap improved immediately and remained normal throughout the postoperative course.Fig. 1.: A continuous jet of venous blood from the SIEV after venotomy in preparation for salvage vein grafting.Fig. 2.: A saphenous vein graft interposed between the SIEV of the flap and a perforating vein of the internal mammary circulation.This case demonstrates the importance of preserving alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant hemiflap can become congested, even when harvested as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously reported a technique for venous augmentation in a DIEP flap by draining the SIEV to one of the venae comitantes.3 Other options for venous augmentation include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle to the cephalic vein4 or to recipient thoracodorsal, lateral thoracic, or intercostal veins.5 Internal mammary perforators should be added to the list of venous augmentation recipient vessels. We recommend routine dissection and preservation of the superficial inferior epigastric vessels during flap harvest, and close communication with the breast surgeons to preserve any sizable internal mammary perforators found during the mastectomy. No additional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult. DISCLOSURE No financial support or benefits have been received by any of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article. Brian D. Cohen, M.D. Nicholas Vendemia, M.D. Division of Plastic and Reconstructive Surgery New York-Presbyterian Hospital New York, N.Y. Jason A. Spector, M.D. Division of Plastic and Reconstructive Surgery Weill-Cornell Medical Center/New York-Presbyterian Hospital New York, N.Y. Christine H. Rohde, M.D. Division of Plastic and Reconstructive Surgery Columbia University Medical Center/New York-Presbyterian Hospital New York, N.Y.

Venae Comitantes as a Potential Vascular Resource to Create Native Arteriovenous Fistulae

The arteriovenous fistula (AVF) represents the gold standard for hemodialysis (HD) vascular access. In some critical cases, use of the deep venous circle may represent an alternative approach and venae comitantes could be employed for this purpose. Sixty patients with chronic renal failure in which the deep venous circle was used to create an AVF were identified; of the 48 who had a direct anastomosis between the brachial artery and vena comitans, 42 had a long-term follow-up (mean follow-up 59 weeks), while six were lost to follow-up. Immediate success (patency and palpable thrill) was achieved in 88% of cases (primary and early failure 12%). Primary accessibility rate was 62%, while 11 patients required a second surgical approach to make the vein accessible to needling. Secondary accessibility rate of 71% was due to surgical revisions. In the 80-week observation period, the complication rate was 10% with irreversible loss of the AVF in all these cases. Cumulative patency was 71% at the 80th week. Including all 42 patients, technical and functional success rate, defined as vein accessibility to needling and chance of an adequate HD treatment, was 62%. AVF employing venae comitantes may represent a suitable alternative in the absence of other vascular accesses for HD.

Two New Techniques for Correcting Venous Congestion in the Free DIEP Flap for Breast Reconstruction: An Analysis of Venous Augmentation in 581 DIEP Flaps

Two New Techniques for Correcting Venous Congestion in the Free DIEP Flap for Breast Reconstruction: An Analysis of Venous Augmentation in 581 DIEP Flaps

Surgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft

We describe our surgical technique for harvesting the free vascularized superficial radial nerve graft based on the radial artery and its venae comitantes. Anatomy and preoperative preparation are also presented, as well as the indications and some contraindications.

Cannulation of the impalpable section of radial artery: preliminary clinical and ultrasound observations

Cannulation of the impalpable section of radial artery: preliminary clinical and ultrasound observations

Reply

Sir: We have carefully read the comment of Dr. Uysal and colleagues regarding our recently published article, “Vascular Anatomy of the Supraclavicular Area Revisited: Feasibility of the Free Supraclavicular Perforator Flap.”1 First, we would like to thank the authors for the opportunity they give us to further discuss our work. We are aware of (and have appropriately cited) their remarkable experience with the flap and are happy to share our thoughts with them. In their comment, they raise some concerns about the dynamic part of the anatomical investigation. They are afraid that latex injection through the axillary artery may have caused a retrograde flow through the transverse cervical artery and that this might have impaired the efficacy of injection. The transverse cervical artery, as they correctly point out, is a branch of the subclavian artery. Injection through the axillary artery will cause—this is true—retrograde flow in the subclavian artery, but not in the transverse cervical artery, in which the injected latex will enter with an anterograde direction in both cases. The reason why the axillary access was chosen is that it is far from the region to be investigated. Median access to the subclavian vein might have interfered with dissection of the supraclavicular area without any apparent benefit. Second, the authors state that, after reading the article, they still think that the external jugular vein is safer based on their clinical experience. Venous drainage was the most significant weakness of this flap. In our study, we observed that venous drainage is accomplished through the superficial venous plexus and not through the transverse cervical artery venae comitantes and that the superficial cervical vein is the venous pedicle of the flap (a more detailed anatomical description has been published elsewhere).2 The superficial cervical vein eventually joins with the external jugular vein to ultimately drain in the subclavian vein. For this reason, to use the external jugular vein as a venous pedicle would be acceptable too and will create a venous turbocharging to the flap by joining the superficial cervical vein and any drainage coming through the external jugular vein. This is not needed for three reasons: Such a small flap does not need venous supercharging. The superficial cervical vein is smaller than the external jugular vein and this may often avoid undesired and bothersome size discrepancies. The primary drainage of the flap is through the superficial cervical vein. We encourage the authors to trust the superficial cervical vein when they will use this flap. Accessory comments are made on the indications of the flap. First, we would like to underscore that this flap was never presented as a “flap for all occasions.” Every case is different and reconstruction must always be tailored to that specific case. Microsurgery gives us the opportunity of having the whole body as a flap donor site, and with this flap we have another choice to further refine our outcome and minimize donor-site morbidity according to every single patient’s needs. Otherwise, we could very well cover every hole with only one flap if coverage was our only goal. The authors state that easier opportunities exist for reconstructions in cases such as those presented. This is true, without any doubt. However, ease is not a parameter that normally influences our choices. We believe that safety, reliability, final outcome, donor-site morbidity and, last but not least, the patient’s desires, among others, are the criteria that must influence our choice. The easiest procedure is seldom the best. Furthermore, this flap is not a difficult flap at all. As for any other anatomical region, the surgeon should know it very well. Surgeons familiar with head and neck surgery will find harvesting this flap to be very easy. Once again, we think that this flap can be a useful option in those cases in which: Tissue of such texture, color, and thinness is needed. A huge flap is not required. A long pedicle is not needed. A pedicled supraclavicular flap will not reach the defect. There is the wish to have a hidden, nonmorbid donor site. We think that the supraclavicular donor site, when primary closure is achieved, may be more appealing than a radial forearm flap donor site or an anterolateral thigh donor site in women. We also think that we should always seek improvements in our practice. We believe that, even though we would not use this flap every day, to have it as an alternative will help achieve better outcomes in selected cases. Adriana Cordova, M.D. Roberto Pirrello, M.D. Salvatore D’Arpa, M.D. Johannes Jeschke, M.D. Erich Brenner, M.D. Francesco Moschella, M.D. Chirurgia Plastica e Ricostruttiva Dipartimento di Discipline Chirurgiche ed Oncologiche Università degli Studi di Palermo Palermo, Italy

An Overview of Skin Flap Surgery in the Mainland China: 20 Years' Achievements (1981 to 2000)

Microsurgical anatomy and clinical applications have been widely and extensively practiced throughout the mainland of China since late 1970s. During the 1980s to 1990s, Chinese surgeons and anatomists developed many new flap donor sites and modifications, most of which were published in Chinese literature. These achievements were not fully realized by the Western surgeons. In this overview, we attempt to give a brief introduction of these contributions made by the Chinese authors in the mainland. Of the new flaps first or independently described by the Chinese, most were in the limbs. These flaps can be classified into three categories. First are free flaps with a main artery trunk, such as the radial forearm flap with radial artery, the medial leg flap with posterior tibial artery, and lateral leg flap with peroneal artery. Second are reverse-flow island flaps based on distal main vascular bundles (e.g., the radial artery and venae comitantes, the ulnar, the posterior tibial, and the peroneal arteries). Third are septocutaneous perforator flaps that avoid sacrifice of the main artery trunk, which include the anterolateral thigh flap, lateral lower-leg flap, dorsoulnar flap, distally adipofascial pedicled radial forearm flap, and so on.

The Reverse Radial Forearm Flap in Reconstruction of the Hand

Sir: We read with great interest the article “Soft-Tissue Coverage of the Hand following Sarcoma Resection” by Talbot et al.1 published recently in the Journal. Dr. Talbot and colleagues should be congratulated for focusing attention on this very difficult area for reconstruction. One of the flaps most commonly used in their series was the reverse radial forearm flap (20 percent of cases). We have used the reverse radial forearm flap in various reconstructive problems of the hand2 and would like to offer our thoughts on the subject and interest the readers in this very interesting flap. The reverse radial forearm flap has been proven to be a very reliable solution for reconstruction of the hand without necessitating the use of a microvascular flap. When the forearm flap is used as an island flap pedicled distally, its blood supply is based on a retrograde flow from the ulnar artery through the deep palmar arch. One could argue that ligating the radial artery could compromise the hand’s blood supply. It has been established, however, that the main blood supply of the hand comes through the ulnar artery and the deep palmar arch, whereas the radial and interosseous arteries are potential nutrient arteries of the hand. Provided that the ulnar artery is intact and well functioning, there are no functional or vascular consequences to the hand. Venous return has also been established to be retrograde through the venae comitantes. These have numerous valves, which are often at the same level between the two comitantes. This raises the unavoidable question of how immediate reverse flow through the veins can occur. There are three factors that make this backflow possible: When a distally based radial forearm flap is raised, the deep veins are denervated. Venous pressure in these veins is increased after ligation of their proximal ends. The veins are kept filled by blood from the wrist and hand. Each of these three factors alone, or even two of them together, would not be sufficient to allow backflow, but if all three factors are present simultaneously, as in a distally based radial forearm flap, immediate reverse flow through a venous valve can occur. This finely balanced combination of three necessary factors may explain why some distally based flaps become edematous or even require additional venous drainage. George J. Zambacos, M.D. Apostolos D. Mandrekas, M.D., Ph.D. Artion Plastic Surgery Center Athens, Greece

Flap pedicle vena comitant as a vein graft donor source

A vena comitant segment harvested from a flap's pedicle can be used as an interpositional vein graft in selected microvascular cases. When a vascular pedicle includes paired venae comitantes, one of these can prove suitable for use as a vein graft while still allowing for venous outflow of the flap. An additional operative site and procedure to harvest a vein graft can be avoided if a vena comitant segment can be used. We present eight cases in which pedicle vena comitant segments were used as interpositional vein grafts. In six cases, vena comitant grafts were used to supercharge or augment venous outflow in transverse rectus abdominis myocutaneous (TRAM) flaps used for breast reconstruction. A vena comitant graft was used to revise the venous anastomosis in one deep inferior epigastric perforator (DIEP) flap. The arterial anastomosis was revised with a vena comitant graft in a gracilis muscle free flap. Our experience demonstrates the viability and utility of using the flap pedicle's vena comitant as a source of vein graft in selected cases.

Distal revascularisation/replantation using the reversed radial artery

We describe a technique using the reversed radial artery for distal revascularisation or replantation in the hand. This technique has been used for revascularisation following crush avulsion injuries associated with a large zone of trauma and polydigit replantation. The technique involves dividing the radial artery and venae comitantes proximally and mobilising it distally into the hand for anastomosis. Temporary 'syndactylisation' of adjacent digits is also described. This can be used to convert multiple digits into a single vascular unit and to provide a bed for the transposed radial vessels. These techniques are an option when there is extensive injury to distal vessels such that end-to-end anastomosis is not possible and interposition venous micrografting may be difficult or prone to failure due to poor quality recipient vessels and the need to place grafts in a traumatised bed.

Anatomic study on the transverse cervical vessels perforators in the lateral triangle of the neck and harvest of a new flap: the free supraclavicular transverse cervical artery perforator flap

Vessels in the supraclavicular area and their contribution to skin vascularization have always been studied for flaps planning in head and neck reconstruction and many pedicled flaps have been described based on those vessels. Little has been written instead about the vascularization of the supraclavicular skin itself for the use as a free flap. The purpose of this anatomical study was to assess the vascularization of the supraclavicular skin and the possibility of finding an adequate pedicle to harvest it as a free flap in order to close the donor site directly. A total of 25 cadavers, 10 formalin fixed and 15 fresh, have been studied in cooperation with the Division for Clinical-Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, Austria and the Laboratoire d'Anatomie, Universiteé R. Descartes, Paris, France. The supraclavicular skin was nourished by perforators coming from the transverse cervical artery and constantly present in an average number of four. Venous drainage was accomplished through the superficial cervical vein, and not through the venae comitantes of the transverse cervical artery. Based on the results of this investigation, a free supraclavicular transverse cervical artery perforator (STCAP) flap seems to be feasible pedicled on perforators from the transverse cervical artery and drained by the superficial cervical vein. Due to its thickness and skin texture, it can be indicated for facial and intraoral defects, with the limitations of a relatively short pedicle. Primary closure of the donor site can be accomplished concealing the scar in the neck crease.