Venae Comitantes Research Articles

SCIV-only versus VCs-only conduit: Which is optimal for multipaddle and chimeric SCIAP flaps?

BackgroundSuperficial circumflex iliac vein and venae comitantes was qualified for traditional superficial circumflex iliac artery perforator flaps. Optimal approaches for multipaddle and chimeric SCIAP flaps remains elusive. The purpose of this study is to investigate validities of SCIV-only and VCs-only conduit for such extended SCIAP flaps. MethodsA retrospective study was conducted from August 2015 to July 2023 at the author's institution. All patients who underwent multipaddle and chimeric SCIAP flaps with complete follow-up information were involved. The multipaddle SCIAP flaps included 2, 3, and 4-paddle variations, while the chimeric series involved cutaneous-iliac and cutaneous-sartorius SCIAP flaps. A comparison was made between the primary outcomes of the SCIV-only group and VCs-only group in terms of the proportion of these variations and complications, as well as operation duration, and wound healing time. ResultsOf 195 patients,VCs-only conduit accounts for 85.6% (n=167), and 14.4% (n=28) for SCIV-only approach. In SCIV-only group, 89.3% were performed for 2-paddle flaps. In VCs-only group, 167 flaps were drained by this approach, including 43 (25.8%) cases of 2-paddle, 38 (22.8%) cases of 3-paddle, 22 (13.2%) cases of 4-paddle, 36 (21.6%) cases of cutaneous-iliac, and 28 (16.8%) cases of cutaneous-sartorius flaps. The utilization rate of the VCs-only conduit was 63.2% in 2-paddle, 92.7% in 3-paddle, and 100% in 4-paddle and chimeric SCIAP flaps. ConclusionThis study stands in support of VCs-only drainage for multipaddle and chimeric SCIAP flaps due to its effective drainage capacity of suprafascial and subfascial tissues.

Arteriovenous Shunts: Their Location and Role in Physiology, Pathology, and Tissue Transfer. A Preliminary Report in the Upper Limb.

Tiny arteriovenous (AV) shunts of 10-150 µm (0.01-0.15 mm) are documented in the hands and feet. Larger shunts up to 0.5 mm (500 µm) have been discovered by the authors in the inner canthus and the human eye. This study seeks their possible existence in the upper limb. Radiographic lead oxide cadaver injection and dissection studies of 14 archival and six new upper limbs were examined. AV shunts of 0.1-0.5 mm were discovered between the brachial, ulnar, and radial arteries and their venae comitantes and between their arterial perforators and the subcutaneous veins. This pilot study provides insight into the possible function of these large AV shunts associated with blood flow variation in temperature, blood pressure, tissue transfer, flap prefabrication, and flap necrosis.

Superficial Veins in the Cubital Fossa Regions among the Nepalese and Indian Medical Students of a Medical College in Nepal: A Descriptive Cross-Sectional Study

Background The veins in the upper limb are classified as superficial or deep, with deep veins, such as the venae comitantes and axillary vein, coming after the major arteries. The subcutaneous tissue contains the superficial veins, which link to the deep veins. These veins include the basilic, cephalic, median cubital, and median antebrachial veins. These superficial veins are clinically significant for phlebotomy, transfusion, and cardiac catheterization, and it joins the median cubital vein at the elbow. It is essential to comprehend the structure and patterns of cubital superficial veins in order to design dialysis access and minimise hazards. Materials and Methods Studying the superficial venous organisation in the cubital fossa of 192 MBBS preclinical sciences students, ages 18 to 24, was a cross-sectional observational study carried out at the Nobel Medical College Teaching Hospital in Nepal. A tourniquet and skin marker/tailor's chalk were used in the study to examine 384 anterior aspects of the arms. Six sets of veins were distinguished from the skin's veins. Tiny veins, cubital wounds, or thick tissue layers disqualified students. Results A study of 192 preclinical sciences students at Nobel Medical College Teaching Hospital in Biratnagar found that type II variant was the most common venous pattern in the cubital fossa region, followed by type I in 24.75%, and the lowest being the type VI pattern in 3.35%. Conclusion It was discovered that the patterns of superficial veins at the cubital fossa did not significantly alter based on the gender or nationality of the individual. Overall, the most common venous pattern was type II, though type I was more frequently seen in female subjects but the difference was statistically insignificant.

Turbocharging of Deep to Superficial Venous System for Vessel Depleted Neck in Radial Forearm Free Flap: A Case Report of One Neck Vein for Drainage of Both Venous Systems

Dual venous anastomosis in radial forearm free flap surgery increases chances of flap survival as compared to anastomosing only the superficial system. A 48-year-old male patient who had received three previous microsurgical reconstructions and radiotherapy presented with recurrent oral cavity carcinoma. Two of these reconstructions were anastomosed to the left side neck vessels. The recurrence was in the left half of the soft palate. The left neck and underlying vessels were severely scarred and fibrotic, and only 2 cm of the left internal jugular vein (IJV) could be circumferentially mobilized for anastomosis, allowing for only one venous anastomosis. The radial forearm free flap was harvested and a tributary of the cephalic vein was preserved in the proximal part to act as a conduit for drainage of one of the venae comitantes. The cephalic vein was anastomosed end-to-side to the IJV and one venae comitantes to the preserved tributary in end-to-end fashion. The flap survived and the patient was discharged in a week. This novel method helps to drain both venous systems through one available neck vein.

Submental Artery Perforator Flap Drained Solely With the Vena Comitans of Facial Artery.

The submental artery perforator flap (SMAPF) is an alternative to reconstruct oral and maxillofacial defects secondary to oral cancers. However, vascular anomalies or surgical damage often lead to vascular crises or harvest failure. Our clinical findings suggest that the vena comitans of the facial artery (cFA) very commonly exist. This study aimed to investigate the reliability of the cFA as a sole venous reflux route for the SMAPF. The patients were from the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Jilin University. All patients were treated for oral cancer between January 2016 and September 2022. Seventeen SMAPFs were successfully raised to reconstruct the postoperative defects, of which 7 had cFA as the sole reflux route. The size of the flaps varied from 4.0×3.0cm to 12.0×3.0cm. All flaps survived. Patients were followed from 1 month to 5 years. Satisfactory restoration of contour and functional outcomes were achieved at the recipient sites. The scars were well camouflaged in the submental region. No local or regional recurrence was detected during follow-up. Patients had an overall 2-year survival rate of 100% with no suspected flaps-related recurrence. The cFA as the sole venous reflux route for SMAPF is reliable for flap harvesting and is applicable for immediate defect reconstruction secondary to cancer resection.

Analysis of Vascular Anatomy in Deep Inferior Epigastric Perforator Flap

Abstract Objectives The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. One of the existing challenges of the procedure is maintaining a pedicle of suitable length and diameter for flap survival. In this study, we analyzed the vascular anatomy of bi-pedicle DIEP flap cases in terms of the vessel diameter, the rate of secondary venae comitantes, and pedicle length to determine the efficacy of microvascular anastomosis and venous drainage. Methods We retrospectively evaluated 108 patients who underwent immediate breast reconstruction using free bi-pedicle DIEP flaps between 2012 and 2019. The patient characteristics, diameters of the deep inferior epigastric artery (DIEA) and accompanying veins (DIEVs), DIEA pedicle length, vessel re-anastomosis rate, flap failure rate, and fat necrosis were recorded. Results Comparison of the right side and left side diameters and pedicle lengths obtained showed no significant differences (p > 0.05). A total of 148 sides (68.52%) of flaps had double venous drainage, whereas 68 sides (31.48%) of flaps had one. Vein congestion occurred in 5 cases, and all involved with just one DIEV anastomosis. No arterial occlusions were observed. Conclusions This is an analysis of extensive clinical data in terms of DIEA, DIEV, and pedicle length. The low vein congestion rate observed reveals adequate venous drainage was achieved in the DIEV system for DIEP reconstruction. Adequate deep inferior epigastric vessel pedicle length and vessel size, as well as greater than 60% of flaps with secondary DIEV, may allow comfortable microsurgery with reduced complications.

D62. Incidence of Patent Retrograde Flow through Vena Comitans in DIEP Flaps

D62. Incidence of Patent Retrograde Flow through Vena Comitans in DIEP Flaps

Clinical Outcomes of Arteriovenous Grafts Using the Superficial Vein versus Venae Comitantes as Venous Outflow.

The superficial veins are commonly used in conventional autogenous arteriovenous fistulas and the placement of prosthetic grafts. When they are unsuitable, however, the use of the deep veins (venae comitantes) is generally considered to be a reasonable alternative. This study conducted a comparative analysis of clinical outcomes for arteriovenous grafts between 2 groups based on the type of venous outflow: superficial veins or venae comitantes. In total, 151 patients who underwent arteriovenous grafts from November 2005 to March 2022 were retrospectively analyzed. The patients were divided into 2 groups: group A (superficial veins, n=89) and group B (venae comitantes, n=62). The primary, secondary patency, and complication rates were analyzed in each group. A propensity score-matched analysis was performed. In total, 55 well-balanced pairs were matched. Kaplan-Meier analysis revealed no significant differences in the primary patency rate between the 2 groups at 1-year, 3-year and 5-year intervals (group A, 54.7%, 35.9%, 25.4% vs. group B, 47.9%, 16.8%, 12.6%; p=0.14), but there was a difference in the secondary patency rate (group A, 98.2%, 95.3%, 86.5% vs. group B, 87.3%, 76.8%, 67.6%; p=0.0095). The rates of complications, simple percutaneous transluminal angioplasty, and stent insertion were comparable between the groups. Although this study demonstrated not particularly favorable secondary patency rates in the venae comitantes group, the venae comitantes may still be a viable option for patients with unsuitable superficial veins because there were no significant differences in the primary patency and complication rates between the 2 groups.

Venous anatomy of the superficial circumflex iliac artery perforator flap: A cadaveric and clinical study

Reconstructive surgeons frequently face challenges with free tissue transfer when transplanted flaps are thicker than intended. This is especially pronounced in lower limb cases, where the soft tissue below the knee is thin. The supra-fascial superficial circumflex iliac perforator (SCIP) flap overcomes this problem, but venous congestion remains a concern. We aim to examine the venous anatomy of the SCIP flap through cadaveric dissections and clinical data analyses to enhance the understanding of the venous anatomy and reduce venous congestion in future procedures. Eight cadaveric groins underwent venous dye injection and dissection to identify the superficial circumflex iliac vein (SCIV) and venae comitantes (VC) vascular networks. The venous anatomy was studied for dominant drainage. From April 2015 to December 2019, we conducted 102 SCIP flap reconstructions, mainly using the superficial circumflex iliac artery's superficial branch. Clinical data were analyzed and correlated with cadaveric dissections. SCIP flaps were categorized into three groups: dual drainage (VC and SCIV) in group I, SCIV-only in group II, and VC-only in group III. Correlations between clinical cases and cadaveric dissections revealed the SCIV as an independent drainage system with oscillating links to the VC. The SCIV is approximately twice the diameter of the VC, and the area of each vascular network suggests codominance. No significant difference in flap loss or venous congestion rates was noted when SCIV was the sole drainage, compared with VC or dual drainage. The SCIP flap with one artery and SCIV anastomosis, exhibits low venous congestion rates. Surgeons should consider SCIV for safe SCIP flap reconstruction.

Form and Function: Technique for Free Functional Gracilis Harvest With Greater Saphenous Vein for Large Skin Paddle.

Free functional gracilis transfer is a technique for restoration of upper extremity function following brachial plexus injury, as well as muscle loss from traumatic, oncologic, and congenital causes. However, when used for the latter applications, a functional muscle as well as large skin paddle can be required. Historically, skin paddle size was limited by venous outflow of the gracilis flap, using 1 or 2 venae comitantes, and large unreliable skin paddles resulting in partial necrosis. Therefore, to restore form and function, we herein present a technique of free functional gracilis muscle harvest with inclusion of adjacent greater saphenous vein for inclusion of a large skin paddle with 2 venous drainage systems.

The posterior approach to the thoracodorsal vessels for microsurgical free tissue transfer

The latissimus dorsi (LD) muscle is a workhorse flap in reconstructive surgery (e.g., breast reconstruction, chest wall defects, and lower limb trauma). The thoracodorsal artery and its venae comitantes supply this muscle. Recipient vessel options for microsurgical free flap reconstruction of the posterior thorax and lower back are limited. The thoracodorsal vessels are an excellent option due to their reliable anatomy and ease of access. In circumstances when the patient is best positioned prone, the posterior approach to access the thoracodorsal vessels is advantageous. We describe the technique to identify and isolate these vessels via a posterior approach.

Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience.

Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors. A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022. The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04). Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.

Comparitve study between synthetic Brachio - axillary and brachio – vena comitans grafts for hemodialysis

Comparitve study between synthetic Brachio - axillary and brachio – vena comitans grafts for hemodialysis

The profunda artery perforator flap for head and neck reconstruction

IntroductionThe profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. MethodsCadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. Results22 PAP flaps were studied. Each contained 1–6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3–15 cm), 11.4 cm (range 5–17 cm), and 17.5 cm (range 12.5–22 cm). Average pedicle length was 11.07 cm (range 7–16 cm), 11.78 cm (range 9–16 cm), and 11.23 cm (range 9–15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27–4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27–3.82 mm). Range of maximal primary closure was 6–11 cm. ConclusionPAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

The Anatomic Features and Role of Superficial Inferior Epigastric Vein in Abdominal Flap.

In lower abdominal flap representing transverse rectus abdominis musculocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric vein (SIEV) exists as superficial and independent venous system from deep system. The superficial venous drainage is dominant despite a dominant deep arterial supply in anterior abdominal wall. As TRAM or DIEP flaps began to be widely used for breast reconstruction, venous congestion issue has been arisen. Many clinical series in regard to venous congestion despite patent microvascular anastomosis site were reported. Venous congestion could be divided in two conditions by the area of venous congestion and each condition is from different anatomical causes. First, if venous congestion was shown in whole flap, it is due to the connection between SIEV and vena comitantes of DIEP. Second, if venous congestion is limited in above midline (Hartrampf zone II), it is due to problem in venous midline crossover. In this article, the authors reviewed the role of SIEV in lower abdominal flap based on the various anatomic and clinical studies. The contents are mainly categorized into four main issues; basic anatomy of SIEV, the two cause of venous congestion, connection between SIEV and vena comitantes of DIEP, and midline crossover of SIEV.

Apex of Triceps Aponeurosis: A Reliable Landmark to Localize the Radial Nerve.

The patient is anesthetized and placed in the lateral decubitus position with the elbow of the operative limb hanging freely over a bolster. A posterior midline incision centered over the fracture is made on the posterior aspect of the arm. The superficial and deep fascia are incised. The triceps aponeurosis is formed by the convergence and fusion of the lateral and long heads of the triceps. The most proximal confluence can be termed the "apex of the triceps aponeurosis." The radial nerve can be isolated approximately 2.5 cm proximal to the apex by developing an intramuscular plane. The remainder of the intramuscular dissection for plate fixation can then be performed safely without risking injury to the radial nerve. Numerous studies have established the relationship of the radial nerve to a fixed osseous point such as the medial epicondyle, lateral epicondyle, and angle of the acromion4-9. Additionally, the wide range of measurements of these anatomic relationships, as reported in various studies, makes it difficult for the operating surgeon to locate the radial nerve, especially in the setting of a fractured humeral shaft. For example, the reported distance of the radial nerve from the lateral epicondyle ranges from 6 to 16 cm and the distance from the angle of the acromion ranges from 10 to 19 cm. Even identification of the superficial branch of the radial nerve has been shown to help intraoperative localization of the radial nerve10. However, these studies have been conducted on cadavers with intact humeri, and their accuracy has not been demonstrated on the patients in the clinical milieu of trauma. The described soft-tissue landmark, which lies approximately 2.5 cm proximal to the apex of the triceps aponeurosis, reliably locates the radial nerve intraoperatively11. It is based on the anatomical fact that the origins of the lateral head (oblique ridge corresponding to the lateral lip of the spiral groove) and long head (infraglenoid tubercle of the scapula) are well above fractures of the middle and distal thirds of the humerus. Hence, the relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be disturbed in the setting of fractures distal to it, in sharp contrast with previously described osseous landmarks. Employing this anatomical understanding resulted in early localization of the radial nerve (within 6 ± 1.5 minutes of skin incision) and less blood loss (188 ± 13 mL)11. Patients are likely to retain their ability to perform active dorsiflexion of the wrist and fingers and have sensory preservation in the distribution of autonomous zone of the radial nerve after the procedure. The relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be disturbed in the setting of typical fractures distal to it; however, this may differ in cases of severely displaced or comminuted fractures, and the surgeon should be aware of this fact.The surgeon should remain careful to protect the vena comitans.

Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes.

Background:Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow.Methods:We retrospectively reviewed consecutive patients who underwent gender-affirming free-flap phalloplasty at our single institution from June 2017 through June 2021. The DIEA/V was used as recipient vessels, with the DIEA/V pedicle externalized via a passageway made through the external inguinal ring.Results:Thirty-eight consecutive free flaps (26 radial forearm free-flap phalloplasties, 10 anterolateral thigh phalloplasties, and two radial forearm free-flap urethroplasties) were performed. Mean age was 37.3 years; mean BMI was 25.7. Mean follow-up was 17.9 months. All flaps were anastomosed to the DIEA/V, without use of vein grafts. Most flaps (89.5%) had at least two veins anastomosed. To augment outflow, a saphenous vein branch was used in one of 38 (2.6%) cases and other superficial veins were used in two of 38 (5.3%) cases. One of 38 (2.6%) cases (early in our experience) resulted in total flap loss.Conclusions:Advantages of the DIEA/V as free-flap phalloplasty recipient vessels include a short, direct pathway for vessels, excellent donor-recipient vessel size match that allows end-to-end anastomoses, and elimination of risks associated with arterialized interposed veins. When venous outflow appears compromised, we recommend a low threshold to use additional local or saphenous veins, though this is rarely needed given the DIEV’s reliability.

Microsurgical anastomosis using anterior versus posterior tibial artery in lower limb free tissue transfer.

Soft tissue lower limb reconstruction often requires free tissue transfer. We investigated whether the target vessels used for micro-vascular anastomosis in the lower limb influences microsurgical outcomes. Data from Plastic Surgery Departments of a major tertiary hospital in the United Kingdom (Leeds General Infirmary, LGI) and Australia (Princess Alexandra Hospital, PAH) were retrospectively analysed. Patients who underwent lower limb free flap reconstruction using the posterior (PTA) or anterior tibial artery (ATA) were included. Patient demographics, free flap and microvascular anastomosis details were analysed. Primary outcome was flap failure. Secondary outcome was return to theatre. Two hundred and thirty-four free flaps were included (PAH 115; LGI 119). 60% were muscle flaps. Eighty-one percent of patients were male, with trauma the cause in 82%. PTA was used for microsurgical anastomosis in 70% of cases. Venae comitantes were preferred (96%) for venous anastomosis. PTA group showed a higher proportion of patients with trauma as the mechanism of injury. ATA group was more likely to have an end-to-end arterial anastomosis configuration. Total flap loss was 3.8%. There was no clinically significant difference in flap failure or return to theatre using ATA versus PTA. Incidence of lower limb free flap failure is low (<5%) and not influenced by use of ATA versus PTA for microsurgical anastomosis. The choice of target vessels for microsurgical reconstruction of the lower limb should be predicated upon factors other than aversion to one or another vessel. If all other microsurgical considerations are equal, the surgeon can exercise personal preference.

Harvesting Composite Arterial and Vein Grafts from Deep Inferior Epigastric Artery and Vein: A Safe Five-Step Method of Preparation.

As the use of stacked flaps and options for autologous breast reconstruction increase, the level of complexity in autologous breast reconstruction has risen. Frequently, these reconstruction types present technical challenges such as vessel mismatches and short pedicle length. In this study, the authors introduce their five steps of harvesting composite deep inferior epigastric artery (DIEA) and deep inferior epigastric vein (DIEV) grafts to overcome such challenges. The authors performed a retrospective review of patients who underwent microvascular reconstruction using DIEA/DIEV grafts from 2012 to 2020. The grafts were harvested using the five steps, as follows: step 1, a transverse, paramedian skin incision was made at the level of suprapubic crease; step 2, an oblique fasciotomy was made on the lateral rectus border; step 3, DIEA/DIEV vessels were identified and exposed past the confluence of two venae comitantes; step 4, DIEA/DIEV grafts were harvested while sparing motor nerves; and step 5, fascial closure was performed. A total of 40 DIEA/DIEV grafts were used in 25 patients (lumbar artery perforator flaps, n = 25; lateral thigh flaps, n = 1; superficial inferior epigastric artery flaps, n = 12; and flap salvage, n = 2) for breast reconstruction. The average time of harvest was 28 minutes, and there were two flap losses. In the authors' experience, DIEA/DIEV grafts can be safely harvested and used in flaps with short pedicles and small vessel size. Although the authors' experience was limited to breast reconstruction, the DIEA/DIEV grafts can be used for other types of reconstruction, especially for head and neck reconstruction.

Periosteal medial femoral condyle free flap for metacarpal nonunion.

BackgroundMetacarpal nonunion is a rare condition. The osteogenic capacity of periosteal free flap was investigated in five patients with metacarpal nonunion and impaired bone vascularization.Patients and methodsSurgery was performed between 64 and 499 days after the initial bone osteosynthesis. The average age was 27.6 (range 16–32) years. Nonunion was caused by excessive periosteal removal in two patients, extensive open trauma in three. Four nonunions were diaphyseal, one metaphyseal. A periosteal medial femoral condyle free flap was raised on the descending genicular artery for four patients, the superomedial genicular artery for one. After osteosynthesis with a plate, the flap was wrapped around the metacarpal, overlapping the bone proximally and distally. The recipient vessel were the dorsal branch of the radial artery and a vena comitans in the anatomical snuffbox in four patients, at the base of the first webspace in one.ResultsThe flap size ranged from 5 × 3.5 cm to 8 × 4 cm. No postoperative complication occurred. Radiological bone union was achieved 3 to 8 months after surgery. One patient had a full range of motion, one a slight extension lag of the proximal interphalangeal joint, two moderate joint stiffness of the proximal interphalangeal or metacarpophalangeal joint (one requiring plate removal and extensor tenolysis), one severe stiffness that allowed using a hook grip which was the aim of the surgery.ConclusionIn case of metacarpal nonunion with impaired bone vascularization, the periosteal medial femoral condyle free flap provides an effective and biomimetic approach to bone healing.