Venous Flap Research Articles

Different Modalities of Coverage of Acute Dorsal Hand Defects (Meta Analysis Study)

Abstract Background Injuries to the dorsal aspect of the hand often result in exposed tendons, joints, nerves, and bones, presenting significant challenges for reconstructive surgery. Various techniques, including skin grafts, local flaps, and free tissue transfer, are utilized to address acute dorsal hand defects, with the primary goal of restoring functionality while minimizing aesthetic impact. Aim of the Work This study aimed to review and analyze outcomes from previously published papers to evaluate different flap modalities' efficacy in dorsal hand defect coverage. Patients and Methods A comprehensive review of the literature was conducted to identify studies reporting outcomes of flap procedures for dorsal hand defects. Included studies varied in sample size, demographic data, and follow-up duration. Results The analysis revealed the limitations of conventional skin flaps, leading to the emergence of thinner flaps and free flaps as alternative options. While free flaps have become the standard for their versatility, thinner flaps offer advantages in aesthetics and reduced need for debulking procedures. Patient satisfaction rates were generally high across modalities, although outcomes varied based on individual factors and surgical techniques. Aesthetic outcomes did not significantly differ between flap types, with venous flaps demonstrating superior visual outcomes. Conclusion Dorsal hand reconstruction poses challenges necessitating meticulous surgical planning and postoperative care. While various flap modalities offer viable options, continued research is needed to optimize outcomes and address individual patient needs effectively.

Treatment of Patients With Electrical Injury by Using Modified Forearm Venous Flap: Retrospective Case Series Study.

Severe hand electrical injuries often occur in functional areas such as joints; the repair requires attention to both appearance and function due to the visibility of the hand. This study aimed to present the clinical experience of successfully repairing hand electrical injuries using improved forearm venous flaps. From 2020 to 2022, 15 cases of severe hand electrical injuries were diagnosed, including 10 males and 5 females. Among them, 6 cases were repaired in the first web space, 4 in the thumb, 3 in the index finger, 2 in the middle finger, 2 in the ring finger, and 2 in the little finger. The size of venous flaps ranged from 2.0 cm × 1.8 cm to 12 cm × 4.0 cm. All patients underwent repair using improved forearm venous flaps. The follow-up period ranged from 5 to 8 months. All flaps survived without serious complications. All patients were satisfied with the postoperative aesthetics and function of their hands. The improved forearm venous flap is a simple and reliable method for repairing hand electrical injuries.

Use of perfusion device for free flap salvage after ischemia in swine

In free flap reconstruction, improving flap tolerance to warm ischemia (WI) is fundamental. WI is the result of a venous or arterial thrombosis, which can only be addressed through surgical revision. No additional treatments have shown superior efficacy at salvaging free flaps after or during WI. Custom perfusion machines (PM), used to reduce the intensity of lesions of the flap stored in cold ischemia, have not been evaluated for WI flap salvage. This proof-of-concept study assessed whether the Lifeport® perfusion machine could improve the salvage procedure's success rates after one hour of venous WI. Five different groups were evaluated with four porcine latissimus dorsi free flaps included in each group. Depending on the group, the flaps were subjected to one hour of WI followed by revascularization, static hypothermic submersion, or dynamic Lifeport® perfusion. Additionally, two flap perfusion liquids were evaluated: KPS-1® and IGL-1®. Biopsies were performed before in vivo warm ischemia of the flap, after in vivo warm ischemia of the flap, and after one and two hours of preservation. Interstitial edema, muscular cell size and muscular diffuse necrosis were quantified by histological assessment. Static submersion did not demonstrate any efficacy for venous flap salvage. Dynamic perfusion on Lifeport® machine showed a significant improvement in tissue parameters. Thrombi and fibrine, present during the WI period, were no longer visible inside vessels and the perfusion machine flow evacuated the inflammatory cells and their substrates from the flap. The flap weights did not increase during perfusion time, confirming the benefits of the Lifeport® perfusion machine. Evaluating Lifeport® advantages on human free flap salvage is necessary to confirm the benefits for the tissue and to increase post-operative results after congestive free flap revision surgery.

Reliability of Early Detection of Venous Flap Congestion by Measuring Blood Glucose Level in Albino rat; Experimental study

Reliability of Early Detection of Venous Flap Congestion by Measuring Blood Glucose Level in Albino rat; Experimental study

Various Free Flap Reconstruction Techniques after Hand and Foot Melanonychia Ablation: A Case Series.

(1) Purpose: The management of melanonychia is highly controversial. With growing melanonychia, in case of doubt, the entire lesion should be examined. It may appear similar to nail melanoma or may turn into melanoma. Here, we present surgical cases of nail bed total removal and free flap reconstruction. (2) Methods: Between 1 January 2020 and 31 December 2022, eleven patients were operated on for growing melanonychia, involving the hand and foot. After complete resection of the nail root and plate, immediate reconstruction was performed using a fasciocutaneous free flap. The authors describe the procedures in detail with a few illustrations and clinical photographs depicting the techniques. (3) Results: All patients underwent complete nail unit removal around the anatomic boundaries of the nail. Histology showed a nevus and no malignancy in all cases. We used three onychocutaneous flaps, three hypothenar flaps and five venous flaps. All flaps survived, with one case of partial necrosis which spontaneously healed with secondary intention. In the follow-up periods, there was no recurrence or nail regrowth. (4) Conclusions: These free flap techniques are very useful for total nail bed defect reconstruction after melanonychia lesion total ablation.

Venous Free Flap with Interposition Bypass Graft for Arteriovenous Fistula Preservation: A Case Report.

Cutaneous squamous cell carcinoma (CSCC) overlying an arteriovenous fistula (AVF) is rare and presents unique challenges. This case report describes a method of fistula preservation after CSCC excision using a flow-through venous free flap. The saphenous vein of the venous flap was used as flow-through segment for AVF preservation. The flap was inserted along the dorsal aspect of the forearm wound and microvascular anastomosis of the arterial inflow was completed using a vein just proximal to the radiocephalic fistula anastomosis. Venous outflow was established by creating an end-to-end vascular anastomosis between the cephalic vein and the greater saphenous vein. A separate subcutaneous vein was used to provide a low-pressure outflow for the flap to avoid congestion. This case demonstrates an option for AVF preservation that has not been previously described. It also highlights the importance of a multidisciplinary approach for the safe treatment of CSCCs overlying AVFs.

Prefabricated venous flap, an advanced free venous flap for distant transfer: An experimental rat study

Abstract Background Arterialized venous flap can improve the survival of traditional free venous flap. Arterialized venous flaps are, however, still not popularly selected as the first choice for microsurgical reconstruction because of its nutrient insufficiency. Materials and Methods Eighty-four Lewis rats (10–12 weeks old, 350–400 g) were used. Left hemivertical chest-and-abdominal skin flap (4 × 14 cm2) was the experimental model. Five protocols were designed and performed: protocol I (n = 18), nutrition territory study; protocol II (n = 18), immediate A-V anastomosis; protocol III (n = 12), prefabricated venous flap (PFVF) transformed from pedicle-based skin flap; protocol IV (n = 18), PFVF transformed from perforator-based skin flap; and protocol V (n = 18), PFVF transformed from capillary-based skin flap. The all transformed PFVFs had a 2-week delay procedure from the original skin flaps. Results The hemivertical chest-abdomen skin flap contains 3 nutrient vessels: superior, inferior, and midabdominal. The PFVF coming from the perforator-based skin flap showed significantly superior than other 2 methods with the best survival rates after arterialization, followed by the capillary-based skin flap and then the pedicle-based skin flap. Conclusions The PFVFs after delay procedure and arterialization have been proved to greatly increase the flap survival than traditional free venous flap. Delay procedure has benefits for the transformation from the nutritional skin flaps into PFVFs, which is especially true in perforator-based skin flaps. Such transformation is a 2-stage procedure. Prefabricated venous flaps might offer a “last case scenario” surgery as an option to reconstruct wound defects where no other suitable skin flaps are available. Further investigation is warranted.

Validation and efficacy of 'pure' venous lymph node flap in a rat lymphoedema model.

The venous lymph node flap (vLNF) is regarded as an arterialized or 'pure' venous flap, subject to which type of vessel provides blood supply to the flap. However, whether the vLNF drainage function is maintainable or sufficient for the treatment of lymphoedema is yet to be elucidated. In this study, the venous flow-through lymph node flaps or 'pure' vLNF was investigated in a rat's tail (lymphoedema model), and the therapeutic effect was analysed to clarify its potential value for the treatment of lymphoedema. The subjects (rats) were divided into three groups, the experimental group ('pure' vLNF group), the control group (lymphoedema group), and the baseline group. The tail circumference and diameter were recorded for 5 weeks after the operation. Five weeks after surgery, the lymphatic drainage function was evaluated using indocyanine green (ICG) lymphography, while the skin thickness and collagen layer were assessed by histological analysis. The average diameter and circumference of the experimental group were significantly shorter than the control group (p < 0.01). When comparing ICG lymphography within the three groups, the baseline group showed that the ICG entered the inguinal lymph node and appeared in the liver while the ICG still accumulated in the oedematous tail with no fluorescence emerging in other parts of the rat's body, in the control group. In the experimental group, the ICG entered the vLNF via the flap junction with the rat's tail and fluorescence emerging in the rat's liver. When comparing the three groups above with the control group, the experimental group's skin and collagen layer thickness were significantly improved (p < 0.01). Lymphatic recanalization was shown to appear between 'pure' vLNF and the recipient area. Moreover, vLNF was shown to drain lymph fluid via the venous system, thus relieved swelling and fibrosis of the lymphoedematous tissue. Consequently, this could represent a new potential surgical approach for the treatment of lymphoedema.

Conditioning of microvascular venous flaps in rats

Venous-only perfusion flaps have not been used widely because of the associated high failure rate. Tissue conditioning offers a broad scope of techniques that can be applied pre-, peri-, or postoperatively to promote the adaptation of the affected tissue to any subsequent stress. This study aimed to assess the survival rates associated with a pure venous perfusion flap and investigate whether the timing of the vascular conditioning can affect free flap survival. Forty-four rats were included in the experiment. Group I underwent veno-arterial anastomoses with epigastric graft with pure venous perfusion without tissue conditioning. Groups II and III were pretreated for 7 or 14 days with ischemic conditioning. These groups were compared with a control group (group IV) of conventionally perfused flaps. After the initial surgery, all flaps were assessed clinically, photometrically, and by indocyanine green videoangiography. The flap success rates were 0% in group I, 49.97% ± 24.34% in group II, and 64.95% ± 20.36% in group III. The control group showed an overall survival of 89.3% ± 6.51%. With suitable conditioning, pure venous blood supply can provide adequate perfusion in the rat epigastric flap model. The timing of vascular conditioning appears to be critical for flap survival.

First dorsal metacarpal arterialized venous (FDMAV) flap: intraoperative salvage of an ischemic FDMA flap by arteriovenous supercharging—a case report in thumb reconstruction

First dorsal metacarpal arterialized venous (FDMAV) flap: intraoperative salvage of an ischemic FDMA flap by arteriovenous supercharging—a case report in thumb reconstruction

Utilization of the Rat's Tail as a Novel Model for Arterialized Venous Flap.

Arterialized tissues provide longevity and coverage of critically exposed tissue, and in pliable areas of the body, thin flaps are needed. Arterialized venous flaps provide all the aforementioned qualities, yet unpredictability in flap perfusion requires further investigation in experimental studies. Existing animal models are thicker in nature and rarely mimic commonly used venous flaps in clinical practice. A novel design of the rat's tail provides an ideal model for arterialized venous flaps. Eleven venous flaps were harvested from the rats' tail, all presenting with two parallel veins in configuration. Arterialization of veins using the femoral artery was done in either along-valve or against-valve fashion, with the purpose of testing the flap's response to different clinical configurations. The vessel diameter and flap thickness were measured. Flap viability was monitored for 7 days after surgery to ensure stable flap viability. Thickness of the tail flap ranged from 1.0 to 1.2 mm, while the abdomen skin thickness ranged from 1.4 to 1.5 mm. The mean diameter of the lateral veins was 0.85 ± 0.08 mm, which was in between the average femoral artery diameter (mean 0.76 ± 0.1 mm) and the average femoral vein diameter (1.28 ± 0.2 mm). Four of the nine against-valve flaps achieved more than 50% flap survival, while all along-valve flaps achieved flap viability of more than 75%, as evident by indocyanine green imaging. This flap demonstrates similar properties to thin venous flaps used in clinical situations. Standardization of this model can push forth better understanding of the arterialization phenomenon in venous flaps for future studies.

The clinical application of arterialized venous flaps in repairing large area of soft tissue defects of extremities

Background The reconstruction of microsurgery emphasizes the low morbidity of donor sites. The arterialized venous flaps (AVFs) are tissue flaps harvested without conventional vascular pedicles. However, reports of high necrosis rates and poor understanding of physiology hindered the application of many surgeons in clinical practice. Recently, experimental and clinical studies have demonstrated the feasibility and relative reliability of various AVF techniques. This study aims to report the clinical results of the arterialized venous free flaps in reconstructing soft tissue defects of limbs and propose methods to improve flap perfusion, extending the indications for using the flaps based on the authors’ clinical experiences. Methods We retrospectively reviewed the records of 16 patients that underwent arterialized venous free flaps for limb wound reconstruction from January 2019 to June 2021. Following the venous network on the calf’s tibial side, large venous flaps can be designed. Results Of the 16 cases, 14 (87.50%) cases (including 8 cases significantly congested with tension blisters) showed complete survival, and 2 (12.5%) cases, which had only one vein performed anastomosis of the efferent vein according to the vascularity of the recipient bed, showed partial necrosis. In all cases, no infection or other specific complications occurred in the donor areas. Conclusion The rate of congestion and necrosis of arterialized venous flaps is still challenging, but it will be suitable for large soft tissue defects of limbs in the future.

Retrograde Free Venous Flaps for Extremity Reconstruction: A Roadmap.

Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6–15). The flap dimensions ranged from 6 cm2 to 136 cm2. All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm2). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats.

Long-term results of wide local excision with concurrent venous free flap reconstruction in subungual melanoma

Purpose: Wide local excision (WLE) has been used as an alternative to amputation for preserving the length of the digit in subungual melanoma (SUM). For reconstruction, a free flap could be a more suitable option than a skin graft or a local flap. We investigated the clinical value of WLE with concurrent venous free flap reconstruction in SUM located on the finger and toe.Methods: Seventeen patients underwent WLE with a concurrent arterialized venous free flap between January 2011 and December 2015. Venous flaps were harvested from the forearm or foot dorsum and inset using a through- or against-valve type.Results: The mean tumor area was 1.3±0.9 cm2, and the mean resection margin was 5.6±2.3 mm. In histologic analyses, the mean tumor thickness was 1.2±1.1 mm. The mean duration of the follow-up period was 75.5 months. Three patients had local recurrence and one patient had distant metastasis. Reconstruction of the fingers and toes using a venous flap was effective and could be performed without major complications. Patients were satisfied with the functional and aesthetic results.Conclusion: WLE provides an acceptable local control rate and offers a safe and conservative alternative for the treatment of SUM of the fingers and toes. Concurrent venous free flaps could be a desirable option for aesthetic and functional reconstruction.

A dorsalis pedis venous flap containing a U-shaped venous arch for the reconstruction of fingertip defects.

In small-area soft tissue defects of the fingers, venous flaps have the advantages of easy design and harvesting, and also a thin and flexible texture. Although the artery-vein-vein (A-V-V) pattern is the safest pattern, the tiny veins in the finger pulp make anastomosis difficult. We have designed a modified blood flow pattern flap using the dorsum of the foot as the donor site and anastomosing the U-shaped blood vessels in the venous flap with the two digital arteries in an artery-vein-artery (A-V-A) pattern to reconstruct the digital arterial arch without the need for venous anastomosis. Our study included 22 patients with 23 fingertip defects. In the 23 fingers, 18 flaps survived completely and four had only partial marginal necrosis. The donor site healed well without significant scar hyperplasia.Level of evidence: IV.

Clinical study of upper one third leg defects

Large soft tissue leg defect involving upper and middle third remains a therapeutic challenge. Clinical study of management of upper one third defects was done to analyze the various reconstructive procedures for leg defects and also to enhance the quality of work done to produce good results with minimal complications as possible. This Prospective Clinical study conducted in the department of Plastic and Reconstructive surgery, includes 20 cases of upper one third of leg defects admitted. Patients &gt;15years of age with Soft-tissue defects of upper one third leg requiring flap cover are included in this study. The operative procedure was chosen according to the nature and size of the defect. The earliest flap cover was given within 1 week of trauma. Primary flap cover was given in 10 (50%)patients, delayed primary flap cover in 9 (45%) patients and secondary flap cover in 1 (5%) patient. In 14 (70%) patients Gastrocnemius flaps were done, of which Gastrocnemius muscle flaps with SSG were done in 9 patients (45%) and Gastrocnemius Myocutaneous flap in 5 patients (25%). Fasciocutaneous Flaps in 4 patients (20%), Venous flap in one patient (5%) and Advancement Flap in 1 patient (5%) were done.

Venous Flap Reconstruction following Wide Local Excision for Primary Cutaneous Malignancies in Extremities.

Background:Cutaneous malignancies in the extremities are relatively common, and radical treatment such as ray amputation was performed for certain advanced skin cancer cases in the past. The concept of surgical treatment of primary cutaneous malignant tumor has gradually changed, and preservation of the extremity by performing the appropriate excision and reconstruction became possible. Various reconstructive methods after the resection of malignant tumors such as skin grafts, local flaps, and free flaps, including perforator flaps have been noted. Due to limitations and some disadvantages of these reconstructive materials for extremities, the arterialized venous flap arose as an alternative method. The arterialized venous flap, which has arterial inflow through an afferent vein perfusing the flap and venous outflow through the efferent veins, is considered to function as a great reconstructive material for distal extremities. Although efficacy of this flap has been noted in the past, usage of the flap considering the oncological aspects and application of the flap to the toes and feet have never been reported.Methods:Thirteen reconstructive cases from October 2005 to October 2016 using venous flaps after excision of primary cutaneous malignancy in the distal extremities were performed in our institution.Results:For all cases, satisfactory functional and cosmetic outcomes were observed.Conclusions:Reconstruction using the arterialized venous flap is considered a reliable and versatile method. Careful application of this flap satisfies functional, cosmetic, and oncological aspects of all distal extremities with cutaneous malignancy.

Safe perioperative tamoxifen use in autologous breast free flap reconstruction: systematic review and meta-analysis.

Perioperative tamoxifen remains a valuable therapeutic modality for breast cancer patients. Studies in the existing literature have suggested a potential increased risk of thrombotic complications in autologous breast free flap reconstruction patients exposed to tamoxifen perioperatively. However, several recent publications have questioned the validity of these associations. Therefore, we aim to perform a systematic appraisal of the existing literature to determine if perioperative tamoxifen exposure increases the risk of flap complications in autologous breast-free flap reconstruction patients. A systematic literature search was performed using: PubMed, EMBASE, Cochrane Central, Web of Science, EBSCOHost, ClinicalTrials.gov, and TRIP databases from their inception up to April 2021. Articles analyzing the impact of perioperative tamoxifen in autologous breast free flap patients were included. The outcomes assessed were total flap loss, overall flap complications, thrombotic flap complications, which was defined as the sum of arterial and venous flap thrombi, and systemic venous thromboembolism (VTE). Pooled estimates and relative risk were calculated using a random effects model. 9294 Articles were screened and 7 were selected for analysis, which included 3669 flaps in 2759 patients. Compared to patients who did not receive tamoxifen perioperatively, those who received tamoxifen did not have an increased risk of thrombotic flap complications (pooled RR 1.06; 95% CI 0.61-1.84), total flap loss (pooled RR 2.17; 95% CI 0.79-5.95), overall flap complications (pooled RR 1.04; 95% CI 0.76-1.41), or systemic VTE (pooled RR 1.93; 95% CI 0.72-5.13). The heterogeneity of the studies was not significant for any of the outcomes. The purpose of this study was to update the current understanding of the impact of perioperative tamoxifen on autologous breast free flap reconstruction outcomes. The existing literature supports that the perioperative continuation of tamoxifen in breast free flap patients is not associated with an increased risk of thrombotic flap complications, total flap loss, overall flap complications, or systemic VTE.

Arterialised venous loops and complex flap reconstruction: can silicone and Doppler monitoring make them safer?

Arterialised venous loops and complex flap reconstruction: can silicone and Doppler monitoring make them safer?

Repair of Compound Dorsal Defects of the Digits Using a Free Antegrade Palmaris Longus Tendocutaneous Venous Flap

To investigate the clinical effect of repairing small dorsal digit compound tissue defects using a free palmaris longus tendocutaneous flap nourished by venous blood. In a retrospective analysis of patients treated between March 2010 and October 2017, 18 patients were identified as having small compound tissue defects, which were repaired using a free palmaris longus tendocutaneous flap nourished by venous blood. The average age of the patients, including 15 male and 3 female patients, was 34 years (range, 22-55 years). The mean wound size was 6 cm2 (range, 2.0× 1.5 to 3.5× 2.0 cm2). All the patients had dorsal defects. The average length of extensor tendon defect was 2.0 cm (range, 1.0-3.0 cm). The mean area of the flap was 7 cm2 (range, 2.5× 2.0 to 4.0× 3.5 cm2). The donor sites were primarily closed. All 18 flaps survived. A vascular crisis due to a venospasm occurred within 48 hours in 3 flaps, but ultimately, all the flaps survived. The patients were followed-up for a mean period of 10 months (range, 3-15 months). All the patients returned to their previous work after 10-12 weeks. No pain or scar contracture was reported in either the recipient or donor site. The free antegrade palmaris longus tendocutaneous venous flap enabled the repair of compound tissue defects of the dorsal digit, resulting in acceptable aesthetics, repaired tendon defects, and wound coverage. This surgical method is an option for the reconstruction of small compound defects of digits with extensor defects. Therapeutic IV.