Venous Flap Research Articles

Clinical applications of free arterialized venous flaps

Venous flaps are flaps by which tissue perfusion is accessed through the venous network. Despite originally being questioned due to potential perfusion problems, as the dynamics of tissue perfusion have been more fully comprehended, venous flaps appear to have a far wider range of application than first thought. In our study, we analyzed the clinical results of the applications of free arterialized venous flaps along with the factors that can affect flap survival. Forty-one flaps were assessed retrospectively. Type of the trauma, traumatized area, the time duration between trauma and application of the flap, donor area, type and count of the anastomosis, encountered complications, and flap survival rates were analyzed. Regression and classification trees were used to study the relationship between flap surface area, anastomosis count, and flap survival. Circulatory abnormalities such as early congestion and edema were seen in 53.6% of the applied flaps. A total of four flaps (9.7%) developed necrosis which presented as full thickness in three flaps and partial thickness in one flap. It can be said that there was a weak but positive correlation between the size of the flap area and the number of anastomosis. Although the results of arterialized venous flaps are inconsistent in the literature, those flaps can be preferred as an alternative treatment option in single finger defects where tissue compatibility and cosmetic results are quite impressive. In the meantime, syndactylized venous flaps are the preferred method regarding multiple finger soft-tissue defects.

Comparison of ischaemic preconditioning with surgical delay technique to increase the viability of single pedicle island venous flaps: An experimental study

The aim of the present study was to investigate the effect of ischaemic preconditioning compared with the surgical delay procedure in an effort to increase the survival rate of single pedicle island venous flaps. Eighteen male Wistar albino rats (250–350 g) were included. A 3 × 4 cm flap was planned at the right lower abdomen of the rat. Superficial epigastric vein constituted the pedicle of the flap. The rats were divided into three groups, each consisting of six rats. In the control group, a single pedicle venous island flap was elevated on each rat and no other surgical procedure was performed. In the ischaemic preconditioning group, ischaemic preconditioning was performed and, in the surgical delay procedure group, the surgical delay technique was performed before flap elevation. The mean necrosis areas were 56.85 ± 14.60%, 28.73 ± 15.60%, and 12.08 ± 3.65% in the control, ischaemic preconditioning, and surgical delay procedure groups, respectively. The necrosis areas were significantly smaller in the ischaemic preconditioning group and surgical delay procedure groups compared to the control group (p = 0.004 and p < 0.001, respectively). The necrosis areas were similar in the ischaemic preconditioning and surgical delay procedure groups. Histopathological parameters including necrosis, abscess formation, and skin ulceration scores were significantly lower in the ischaemic preconditioning group than in the control group, whereas the study groups were similar. In conclusion, ischaemic preconditioning may serve as an adjuvant technique in increasing venous island flap viability.

Retrograde Arterialized Free Venous Flaps for the Reconstruction of the Hand: Review of 14 Cases

Although the literature is encouraging with regard to the survival rate of arterialized free venous flaps, previously reported difficulty in healing owing to early venous congestion and subsequent epidermolysis continues to prevent their widespread application. We report 14 arterialized free venous flaps for primary reconstruction of the hand, with inflow in the arterialized vein running against the valves. Between February 2010 and May 2012, we performed 14 arterialized free venous flaps, each of which included at least 2 veins running in parallel. The arterialized vein was anastomosed in a retrograde manner, with the inflow running against the valves. All flaps were customized with regard to dimension, shape, quality of skin, pedicle length, vessel size, inclusion of additional anatomical structures, and donor site. The flaps were used to cover small, medium, and large defects; 2 flaps were larger than 100 cm(2). Three flaps were injected with indocyanine green on the table after harvesting, to visualize the vascular tree of the flap. These 3 flaps were then monitored with systemic indocyanine green injection and an infrared camera for 3 days postoperatively. All but 1 flap survived. Venous congestion and epidermolysis were observed in 2 small flaps. The flaps injected with indocyanine green displayed a ramified vascular tree with no arteriovenous flow-through phenomenon. Arterialized free venous flaps with retrograde arterial flow offer thin and pliable coverage that fits easily around the contours of the hand. They are easy to harvest, with little donor site morbidity. Tendons or nerves can be incorporated for reconstruction of composite defects. Our series suggests the possibility of routine use of a free venous flap with retrograde arterial flow for reconstruction of the hand. Therapeutic IV.

Surface enlargement of a new arterialised venous flap by the surgical delay method.

The delay method is a surgical, pharmacological and combined method that includes two or more time separated phases, which gives bigger flap surface. In our research we explored the possibility of flap surface enlargement in a new arterialised venous flap (AVF) on an experimental rabbit ear model by the delay surgical method. The aim of this research was to establish vitality surface of our AVF and to maintain the difference in flap vital surface between AVF flaps, with or without performing the delay surgery method. We used both ears of "Big Chinchilla" rabbits in 10 experimental male animals, divided into two groups, average weight 3-3.5 kg, and average age 8-10 months. In the first (experimental) group, a venous flap was arterialised by our method. In the second (control) group, the venous flap was arterialised 14 days after the delay surgical method. AVF surface was measured on the 1 and 14 days by the method of trapezoid rule. Vital surface on our AVF experimental model was bigger than 87% of elevated flap surface after the delay surgical method. Vital surface on AVF without delay on our experimental model was bigger than 30% of elevated flap surface (p < 0.001). Analysis of previous experimental models on the rabbit ear, non-delayed and delayed (to enlarge flap surface) led us to conclusion that previously created experimental models of non-delayed AVF are hemodynamically negative. Our experimental non-delay AVF model is hemodynamically more positive than previously created models of non-delay AVF and provides better conditions for AVF survival and enlargement of vital flap surface of elevated flap. On the other hand, surgical delay method significantly enlarges vital surface of AFF.

Free saphenous venous flap and its modifications: Turbo- and supercharged.

Free saphenous venous flap and its modifications: Turbo- and supercharged.

The Effect of Hemodynamic Remodeling on the Survival of Arterialized Venous Flaps

ObjectiveTo evaluate the effect of hemodynamic remodeling on the survival status of the arterialized venous flaps (AVFs) and investigate the mechanism of this procedure.Materials and MethodsTwo 7 x 9 cm skin flaps in each rabbit (n=36) were designed symmetrically in the abdomen. The thoracoepigastric pedicle and one femoral artery were used as vascular sources. Four groups were included: Composite skin grafts group and arterial perfusion group were designed in one rabbit; AVF group and hemodynamic remodeling group by ligation of the thoracoepigastric vein in the middle were outlined in another rabbit. Flap viability, status of vascular perfusion and microvasculature, levels of epidermal metabolite and water content in each group were assessed.ResultsHighly congested veins and simple trunk veins were found using angiography in the AVF group; while a fairly uniform staining and plenty of small vessels were observed in the hemodynamic remodeling group. The metabolite levels of the remodeling group are comparable with those in the arterial perfusion group. There was no statistically significant difference in the percentage of flap survival between the arterial perfusion group and hemodynamic remodeling group; however, significant difference was seen between the AVF group and the hemodynamic remodeling group.ConclusionsUnder the integrated perfusion mode, the AVFs are in an over-perfusion and non-physiological hemodynamic state, resulting in unreliability and unpredictability in flap survival; under the separated perfusion mode produced by remodeling, a physiological-like circulation will be created and therefore, better flap survival can be expected.

Vascular surgery, microsurgery and supramicrosurgery for treatment of chronic diabetic foot ulcers to prevent amputations.

IntroductionDiabetic foot ulcers occur in approximately 2,5% of patients suffering from diabetes and may lead to major infections and amputation. Such ulcers are responsible for a prolonged period of hospitalization and co- morbidities caused by infected diabetic foot ulcers. Small, superficial ulcers can be treated by special conservative means. However, exposed bones or tendons require surgical intervention in order to prevent osteomyelitis. In many cases reconstructive surgery is necessary, sometimes in combination with revascularization of the foot.There are studies on non surgical treatment of the diabetic foot ulcer. Most of them include patients, classified Wagner 1-2 without infection. Patients presenting Wagner 3D and 4D however are at a higher risk of amputation. The evolution of microsurgery has extended the possibilities of limb salvage. Perforator based flaps can minimize the donorsite morbidity.Patients and Methods41 patients were treated with free tissue transfer for diabetic foot syndrome and chronic defects. 44 microvascular flaps were needed. The average age of patients was 64.3 years. 18 patients needed revascularization. 3 patients needed 2 microvascular flaps. In 6 cases supramicrosurgical technique was used.ResultsThere were 2 flap losses leading to amputation. 4 other patients required amputation within 6 months postoperatively due to severe infection or bypass failure. Another 4 patients died within one year after reconstruction. The remaining patients were ambulated.DiscussionLarge defects of the foot can be treated by free microvascular myocutaneous or fasciocutaneous tissue transfer. If however, small defects, exposing bones or tendons, are not eligible for local flaps, small free microvascular flaps can be applied. These flaps cause a very low donor site morbidity. Arterialized venous flaps are another option for defect closure.Amputation means reduction of quality of life and can lead to an increased mortality postoperatively.

Large Prefabricated Skin Flaps Based on the Venous System in Rabbits

Flap prefabrication offers a bridging role between traditional reconstructive surgery and tissue engineering; however, because flap prefabrication is based on the concept of implanting a nourishing vascular pedicle in the target tissues before transfer, survival remains unreliable. Furthermore, the extended period required for neovascularization hampers its clinical application. Based on two different venous angiosomes involving two sides of thoracoepigastric veins (taken as the vascular carrier) in rabbits, a large abdominal flap measuring 12 × 13 cm was designed by anastomosing the transferred femoral artery with the thoracoepigastric vein distally and prefabricated by incision of the proximal and distal ends of the flap for 1 week. Traditional arterial flaps, arterialized venous flaps, and composite skin grafts of the same size were used as control groups. Flap viability, status of vascular perfusion and microvasculature, and level of epidermal metabolite in each group were assessed. The large prefabricated flaps achieved results similar to the traditional flaps in terms of flap viability, status of vascular perfusion and microvasculature, and level of epidermal metabolite. Large skin flaps with good quality can be prefabricated within a shorter period for aesthetic and plastic surgery reconstruction using the inherent venous system. This technique may prove to be a viable alternative for successful flap prefabrication.

Influence of the pedicle orientation and length on viability of unipedicled venous island flaps

The use of unipedicled venous flaps has been limited due to their unconventional perfusion patterns and inconsistent survival. Further information regarding the optimal conditions required for unipedicled venous flap coverage is needed to increase flap survival. The purpose of this study was to investigate the effect of the pedicle orientation and length on the viability of unipedicled venous flaps based on a review of our clinical experience. Thirty-one skin and soft tissue hand defects of 29 patients were treated with unipedicled venous flaps. Sixteen defects were treated with proximally pedicled flaps and 15 were treated with distally pedicled flaps. Five of the 16 proximally pedicled flaps and eight of the 15 distally pedicled flaps had pedicle lengths ≥ 5 cm. All proximally pedicled flaps survived, and distally pedicled flaps with pedicle lengths <5 cm (n = 7) also survived. Distally pedicled flaps with pedicle lengths ≥5 cm (n = 8) developed congestion within 1-2 days after surgery, and external bleeding was applied. Four of the eight flaps survived completely, and partial necrosis developed in the other four. The results demonstrate that proximally pedicled venous flaps of the hand can survive regardless of pedicle length. Distally pedicled venous flaps can also survive completely when pedicle length is <5 cm. Distally pedicled venous flaps with pedicle lengths ≥5 cm should be used with caution.

Revascularization of Arterialized Venous Flaps through a Total Retrograde Reverse Blood Flow: Randomized Experimental Trial of Viability.

Background:Arterialized venous flaps (AVFs) have been used for reconstruction of soft tissue defects throughout the body. Several different revascularization models have been performed, but venous drainage through the arterial system has not been studied. In our total retrograde reverse blood flow (TRRBF) perfusion model, the arterial blood flow enters through the venous system and venous drainage exits through the arterial system.Methods:We developed a novel experimental model in rabbit ears to evaluate the capacity of TRRBF perfusion pattern to allow AVF viability. The ears were assigned to 3 groups: group 1, total devascularization without revascularization (n = 3); group 2, TRRBF (n = 12); and group 3, conventional AVF (n = 12). The ears were observed during a 30-day follow-up period, and clinical serial assessment of edema, cyanosis, and necrosis was performed. Tissue oxygenation was determined at the beginning and end of the follow-up. Histological analysis was performed.Results:Necrosis was found in 3/3 (100%) ears in group 1, 3/12 (25%) in group 2, and 0/12 (0%) in group 3 (95% CI, 0.505–0.994; P = 0.0001). In group 2, edema was higher (5/12, 41.66%) than in group 3 (0/12, 0%) (95% CI, 0.0135–0.65; P = 0.041). Cyanosis and venous congestion was of greater intensity and duration in group 2 than in group 3 (10.33 ± 4.51 vs 4.5 ± 2.06 d).Conclusions:Although evolution is torpid and prolonged in ears with TRRBF, 9/12 (75%) survived, suggesting that TRRBF can be used as a rescue method.

Freie, arterialisierte venöse Lappenplastiken zur Deckung an Hand und Fingern

Soft tissue defects on the hand and on the fingers with exposed functional structures require a thin and sturdy closure. If skin grafts or local flaps are not possible the arterialized venous free flaps represent a good alternative. This retrospective study included all arterialized venous free flaps used for hand and finger defects since 2005. We evaluated type and technique (for example antegrade vs. retrograde arterial inflow and the number of veins) and size of the flaps. Flap harvesting time was also examined. 11 venous flaps were used for resurfacing hand and finger defects. Most of them were retrogradely arterialized. 10 of 11 flaps healed uneventfully. Due to a thrombosis in an outflowing vein one flap was lost at the sixth postoperative day. Median size of the arterialized flaps was 6×4 cm and the median time for flap harvest was 38 (27-51) min. The donor site was primarily closed in 2 cases and in 9 cases with a skin graft. Arterialized venous free flaps represent a reliable and safe option for resurfacing hand and finger defects. Easy and fast harvesting due to the visible venous vascular system is an advantage. The flaps are thin, pliable and can be easily adjusted to the needs of the defect. Using conservative measures it is possible to control side effects like venous pooling, swelling and purplish discoloration. With arterialized venous free flaps early hand therapy is possible, in contrast to heterodigital and local flaps. In comparison to other free flaps it is not necessary to sacrifice an artery at the donor site.

Reconstruction of Large Dorsal Digital Defects With Arterialized Venous Flaps

Coverage of the dorsal aspect of the fingers is difficult, especially when the defect is large and multiple digits are involved with composite tissue loss and very few conventional flaps are suitable in dealing with such situation. The purpose of this study was to present our experience of reconstruction of the large dorsal digital defects with the arterialized venous flap (AVF) and evaluate its merits and demerits in this clinical setting with a comprehensive review of literature. From August 2008 to December 2010, 7 composite palmaris longus venous flaps and 5 AVFs were used in the reconstruction of extensive dorsal digital injuries in 8 patients, and a comprehensive review of literature regarding the reconstruction of dorsal digital defects with AVFs was carried out. All the flaps survived completely. The outcomes were very satisfactory for functional recovery, aesthetic appearance, and sensation restoration at an average follow-up of 11.8 months; the literature review also revealed the similar results. On the basis of our experience and literature review, AVFs are reliable and good candidates for resurfacing large dorsal digital defects when local flaps are not available or insufficient for coverage. Composite AVF with palmaris longus tendon is an optimal choice for 1-stage reconstruction of dorsal composite finger injuries.

Delay of the reverse pedicled venous island flap: Clinical applications

In patients with hand or foot injuries, the delay procedure of the reverse pedicled venous flap was applied, including the loose areolar tissue around the pedicle vein. As preliminary clinical observations, five patients were treated with delay and the results compared with those of four patients without delay. The delay procedures were two types: type 1 was circumferential incision with ligature of the proximal vein, and type 2 was a bipedicled flap without ligature of the pedicle vein. Two weeks later, the flap was transferred to the defect. In the patients treated without delay, the maximum limit of the perfectly survived flap sizes was 4.0 × 2.0 cm. However, in the patients treated with delay, the perfectly survived sizes were 5.0 × 3.0 cm and 10 × 4.0 cm in type 1 delay and 12 × 5.0 cm in type 2 delay. The delay procedure appeared to stabilise the reverse pedicled venous flap and to expand its clinical applications.

Observation of blood circulation change in different flaps repair surgery for hand tissue

Objective To compare the color,temperature,tension and capillary filling in different flaps repair surgery,including free physiological flap,fascial pedicle skin flap,venous skin flap and cutaneous neurotrophic skin flap,so as to provide some directions for clinical observation.Methods From March 2011 to December 2011,totals of 221 patients with 223 flaps were involved in this study.They were divided into four groups:free physiological flap group(n =50),fascial pedicle skin flap group(n =66),venous skin flap group (n =57),cutaneous neurotrophic skin flap group (n =48).The peri-operation investigation was adopted,and the color,temperature,tension and capillary filling in different flaps after operation were observed and compared.Results In free physiological flap group,the incidence of grey and dark red respectively was 20％and 38％,and the rate of tension bullae and disappearing of capillary filling respectively was 32％ and 8％,which was significantly lower than that in others groups (x2 =20.64,49.90,36.99,36.16,respectively;P ＜0.01).Conclusions The blood circulation change must be paid more attention within 24 hours after operation in all the four flap.The observation of grey stage could be shortened to 2 hours,and the disappearing of capillary filling could be 12 hours.The four index of blood circulation of fascial pedicle skin flap must be observed within 7days after operation. Key words: Blood circulation; Free physiological flap; Fascial pedicle skin flap; Venous skin flap; Cutaneous neurotrophic skin flap

Utilizing the Vein Viewer Technology to Map Out a Venous Flap Preoperatively

Utilizing the Vein Viewer Technology to Map Out a Venous Flap Preoperatively

The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation

The treatment of comminuted fractures of the proximal interphalangeal joint is highly challenging due to the complexities of joint bio-mechanics and stability. The hemi-hamate osteochondral auto-graft has been popularised in this role, able to replace articular loss and restore joint stability. Recent evaluation of their long-term follow-up however has shown the early development of osteoarthritis and potential early cartilage loss, which may be due to the non-vascularised nature of the graft. We offer a new technique that maintains vascularisation of the transferred hamate fragment, and investigate the anatomical vascular basis for the technique. Dissection and angiographic studies of ten cadaveric specimens were undertaken, exploring the vascular anatomy of the dorsal hamate. A clinical case of hemi-hamate osteochondral free flap is presented, including preoperative, intraoperative and postoperative investigation of the relevant vasculature. Cadaveric studies demonstrated dorsal vascular supply to the hamate from the central of three dorsal carpal arches. The arch was supplied by the dorsal branch of the ulnar artery. Multiple supracapsular veins are present for use in flap venous drainage. This vascular pattern was found to be constant. A clinical case of hemi-hamate osteochondral free flap harvest demonstrated the same vascular anatomy intraoperatively. The digital artery was used as a recipient for microvascular anastomosis. Postoperative computed tomographic angiography and nuclear bone scan confirmed flap perfusion. The hemi-hamate osteochondral flap has a reliable anatomical vascular basis, and is clinically feasible as a technique for early vascularisation of the osteochondral fragment to sustain the transferred articular cartilage.

A Further Strategy for Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Sir:FigureWe read with great interest the recent article by Dr. Sbitany and colleagues regarding the strategies for recognizing and managing intraoperatively the abdominal free flap venous congestion in breast reconstruction.1 As the authors highlighted, intraoperative venous congestion is multifactorial and, when not technically related (selection of inadequate perforator and/or unreliable venous anastomosis), depends mainly on the anatomical dominance of the superficial venous system. The authors reported a series of 1201 patients who underwent abdomen-based autogenous breast reconstruction without any preoperative imaging perforator assessment. Among these, 11 cases exhibited intraoperative venous congestion without evidence of venous thrombosis. Of these, 10 were transverse rectus abdominis musculocutaneous flaps and one was a deep inferior epigastric artery perforator (DIEP) flap. The presence of an engorged superficial inferior epigastric vein (SIEV) along with brisk bleeding when declamped, and flow-through anastomosis on the strip test and on Doppler ultrasound imaging, emphasized that congestion was attributable to the dominance of the superficial venous system that was not adequately drained by the deep system. Their suspicions were confirmed intraoperatively, as the congestion resolved after the ipsilateral SIEV was connected. As described in the past by Rohde and Keller in 2005,2 they anastomose the SIEV to the deep system by creating a superficial-to-deep venous loop within the flap. The venous drainage into the contralateral deep inferior epigastric vein is ensured by the H-communications naturally present between the two retrograde internal mammary veins.3 The technique described represents a valid alternative to more tedious procedures, such as using distant recipient veins. We share with Sbitany et al. recognition of the method for superficial venous congestion. However, by using preoperative imaging such as multidetector-row computed tomography, we do study the superficial venous flap hemodynamics, by evaluating both the midline venous communication and the deep-to-superficial venous system communications at the level of the selected perforator.4 By enhancing the preoperative perforator selection process, it is possible to reduce the rate of venous congestion resulting from the inadequate choice of perforator. When superficial venous congestion occurs, we routinely supercharge the venous outflow by anastomosing the SIEV to the homolateral internal mammary vein. Depending on how the deep inferior epigastric artery and vein and SIEV naturally accommodate once the flap is positioned on the chest wall for microanastomosis, we anastomose the deep inferior epigastric artery and vein and the SIEV, respectively, to the antegrade and retrograde internal mammary vessels or vice versa (Fig. 1).Fig. 1: Intraoperative photograph of a three-zone DIEP flap transferred to the chest wall for delayed breast reconstruction. The anastomoses are completed. The deep inferior epigastric artery and vein (DIEA/V) have been anastomosed to the antegrade limb of the internal mammary vessels (AIMV). Because of intraoperative superficial venous congestion, the flap has been venous supercharged by anastomosing the contralateral superficial epigastric vein (SIEV) to the retrograde internal mammary vein (RIMVein). After the latter anastomosis, the congestion resolved.This is an easier, faster, and reliable way of anastomosing the SIEV.5 The retrograde internal mammary vessels are ready for use after the preparation of the internal mammary vessels; thus, no further vessel dissection is needed. Both the artery and the vein have a good caliber, which makes the anastomosis easier and more reliable. Being at the same level of the main anastomosis (i.e., with deep inferior epigastric artery and vein), the flap insetting is not spoiled. According to our experience, retrograde internal mammary vessels (work in progress) should be taken into consideration as further reliable recipient vessels in autologous breast reconstruction for both flap pedicle anastomosis and venous supercharging. Marzia Salgarello, M.D. Giuseppe Visconti, M.D. Department of Plastic and Reconstructive Surgery Liliana Barone-Adesi, M.D. Breast Unit, Catholic University of Sacro Cuore, University Hospital A. Gemelli, Rome, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

Free arterialised flow-through venous flap with venous anastomosis as the outflow (A-A-V flap) for reconstruction after severe finger injuries

For reconstruction of volar defects, an arterialised flow-through venous flap (A-A flap) can be used to restore the soft tissues and the digital artery at the same time. However, there have been reports that the circulation of this flap is inadequate. This study used a venous flap with only one venous anastomosis for the outflow of an A-A flap (A-A-V flap) to solve this problem. Six patients with defects of the finger soft tissues and digital artery after severe finger injuries were performed. The venous flap with a Y-shaped vein was harvested. The digital artery was reconstructed, after which the other proximal vein of this flap was anastomosed to the dorsal subcutaneous vein. The flap survived in all patients and histological examination of flap tissue showed a nearly normal architecture. This study describes the good results obtained with an A-A-V flap, and discusses the utility of our flap in comparison with previously reported venous flaps.

Reconstruction of Dorsal Finger Injury Using Arterialized Venous Flap Combined with Palmaris Longus Tendon

Reconstruction of Dorsal Finger Injury Using Arterialized Venous Flap Combined with Palmaris Longus Tendon

Salvage of a recurrent trochanteric pressure sore with coxofemoral osteoarthritis using a superficial inferior epigastric artery propeller flap

Sir, The recurrence of pressure sores remains a problem in paraplegic patients. More than 35 % of operated patients will have a recurrence [1–3]. Recurrent ulcers can occur after fasciocutaneous flaps and also musculocutaneous flaps. Then, flaps must be parsimoniously used for covering pressure sores. The superficial inferior epigastric artery (SIEA) flap is well known as a free flap, especially for breast reconstruction. We report the interest of the SIEA propeller flap for covering a recurrent trochanteric pressure sore in a paraplegic patient. Mr. D. is a 52-year-old male, having a T3 paraplegia, secondary to a spinal cord injury 29 years ago. In less than 25 years, he experienced pressure sores in sacral, trochanteric, and ischiatic areas. On the right trochanteric region, he was successively treated by a tensor fascia lata myocutaneous flap, a vastus lateralis muscle flap, and a groin flap for two recurrences in 20 years. Recently, he developed another trochanteric pressure sore, associated with an osteoarthritis of the right coxofemoral joint (Fig. 1). The patient complained about hyperthermia and a limitation of the hip mobility (10° in flexion, 0° in adduction, and 0° in abduction), making the chest to bed transfers more difficult. A multidetector-row computed tomography was made to confirm the osteoarthritis and evaluate the cutaneous perforators of the abdominal region. No reliable perforators was found from the deep inferior epigastric artery, but the caliber (2.6 mm) and the course (130 mm) of the SIEA were appropriate to raise a skin flap. The larger direct perforator of the SIEA had a 1.2-mm caliber, a 41-mm length, and the ascendant directionality adequate for a large skin flap. The surgery started by a large excision of the infected soft tissues around the ulcer. A femoral head–neck resection was performed. After a large cleaning and freshening of the acetabulum, the origin of the SIEA was dissected. The dominant direct perforator was found and included in the flap. A skin paddle measuring 15 × 20 cm was raised. The flap was rotated up to 100° for covering the trochanteric defect, as a propeller flap [4] (Fig. 2). The donor site was primarily closed. The operative time was 3 h, including the femoral head–neck resection, flap raising, and coverage of the coxofemoral defect. The patient was completely healed 2 weeks postoperatively. No recurrence or postoperative infection occurred during a follow-up of 24 months (Fig. 3). At 1 month, the patient recovered a mobility of 65° (45–110°) in flexion, 20° (0–20°) in adduction, and 40° (0–40°) in abduction. The chest to bed transfers and the dressing were significantly improved postoperatively. Fig. 1 Preoperative view of the trochanteric pressure sore. A central suppurative fistula is surrounded with inflammatory skin lesions. This trochanteric ulcer is associated with an osteoarthritis of the right coxofemoral joint Fig. 2 Intraoperative view of the superficial inferior epigastric artery propeller flap. The superficial inferior epigastric artery (yellow arrow) is dissected at the lower part of the abdomen. The proximal dominant perforator and the superficial inferior epigastric ... Fig. 3 Postoperative view of the trochanteric reconstruction. The trochanteric area is completely healed without infection 24 months postoperatively. No recurrence has occurred 24 months after the surgery. A few visible longitudinal scar can ... Pressure sores reconstructive surgery in paraplegics is known for a high risk of recurrence. Musculocutaneous flaps have been mainly used for their thickness and blood supply in this indication. However, the results of this complex case confirm that there is no statistical difference in ulcer recurrence between myocutaneous flaps and fasciocutaneous flaps [5]. Reeducation and prevention of skin hyperpressure seem to be more important than a muscle transfer. This case also reports the interest of the SIEA flap when classical flaps are not available for local reconstructions, and when no reliable perforators (>0.5 mm) are present for a deep inferior epigastric perforator flap. The SIEA flap can be safely rotated around its pedicle, as a propeller flap, without venous congestion or flap necrosis. It is a versatile flap for the coverage of large and infected trochanteric pressure sore.