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Application of Concatenated Arterialized Venous Flaps in Finger Reconstruction

Lin, Yu-Te, MD, MS*; Loh, Charles Yuen Yung, MBBS, MSc, MS, MRCS

doi: 10.1097/SAP.0000000000001633
Microsurgery
Free
SDC

Venous flaps from the distal volar forearm are said to be suitable flaps for finger reconstruction. The pliability of the forearm venous flap makes it easy to follow the curvature of the finger contour. The thickness of the flap makes it appropriate as a flap for finger resurfacing. Following the venous network at the palmar forearm, diverse patterns of the venous flaps can be designed. This article describes the use of a 2-concatenated paddle, flow-through arterialized venous flap design for simultaneous resurfacing of 2 separate defects on a single digit. A technique that can be used to reduce postoperative venous congestion will be highlighted in this article.

From the *Department of Plastic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan; and

St Andrew’s Center for Plastic and Reconstructive Surgery, Broomfield Hospital, Essex, United Kingdom.

Received May 19, 2018, and accepted for publication, after revision August 3, 2018.

Conflicts of interest and sources of funding: None declared.

Reprints: Yu-Te Lin, MD, MS, Department of Plastic Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Rd, Keelung City 204, Taiwan. E-mail: linutcgmh@gmail.com.

Current reconstructive microsurgery emphasizes the low morbidity of the donor site. Venous flap is one of the examples that this type of flaps does not sacrifice any major artery. Venous flaps from the distal volar forearm are said to be suitable flaps for finger reconstruction.1–4 The pliability of the forearm venous flap makes it easy to follow the curvature of the finger contour. The thickness of the flap makes it appropriate as a flap for finger resurfacing. Following the venous network at the palmar forearm, diverse patterns of the venous flaps can be designed.

This article describes the use of a 2-concatenated paddle, flow-through arterialized venous flap design for simultaneous resurfacing of 2 separate defects on a single digit. A technique that can be used to reduce postoperative venous congestion will be highlighted in this article, which may encourage others to utilize such flaps.

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CASE REPORTS

Case 1

A 59-year-old male patient experienced a friction burn on his fingers by a power belt. Multiple lacerations along with full thickness burns of the wound edges were noted on the middle and ring fingers. Two separated defects with tendon exposure on the ring finger were noted (Figs. 1A, B). The larger defect, 2.5 × 5.5 cm2, coursed spirally from the ulnar dorsal proximal phalanx to the volar proximal interphalangeal joint. The other defect, 1.5 × 3 cm2, was on the radial dorsal surface of the middle phalanx. The 2 defects were 1 to 1.5 cm apart. There was no flexor or extensor tendon injury but injury of the ulnar digital nerve of the ring finger was suspected. A concatenated venous flap from the distal volar forearm was planned for the reconstruction along with a segment of cutaneous nerve for grafting.

FIGURE 1

FIGURE 1

The superficial venous network over the ipsilateral forearm was marked before application of the tourniquet. A Surgilon sheet was used as a template for delineating the defects and flap planning. The template was placed over the forearm, where the most suitable veins pattern was marked. An axial vein was planned for arterialization, which had an antegrade flow through the pattern and connected 2 subsequent flaps. A parallel vein with minimal cross connections was also included in the larger flap as additional venous drainage. A parallel vein was more difficult to design in the smaller flap at the proximal forearm (Fig. 2). The concatenated flaps were dissected suprafascially under loupe magnification within 40 minutes. Subcutaneous tunnels were created between the 2 defects and between the defects and the recipient veins. The afferent end of the axial vein was repaired to ulnar digital artery, whereas the efferent end was repaired to a dorsal vein as antegrade fashion. The parallel vein of the larger flap was passed through another tunnel and was repaired to a second dorsal vein. The donor site was closed primarily.

FIGURE 2

FIGURE 2

Venous congestion was seen in the smaller flap and resolved spontaneously without any flap necrosis after 7 days. No episode of venous congestion was noted in the larger flap. Hand therapy was commenced 2 weeks after and continued for 6 months. Donor site (Fig. 3) and the larger flap healed primarily uneventfully. No secondary debulking procedure was performed, and 15 degrees of extension lag was noted (Figs. 4A–D).

FIGURE 3

FIGURE 3

FIGURE 4

FIGURE 4

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Case 2

A 11-year-old male patient experienced from scarring and flexion contracture of the right ring finger after a degloving injury (Fig. 5). Three defects on the palmar surface of the finger from release of the contracture. The distal-most defect at the distal interphalangeal joint was grafted with a full thickness skin. The defects on the metacarpophalangeal and the proximal interphalangeal joints were “T-shaped,” where flap reconstruction was indicated (Fig. 6). To efficiently design for primary closure of the donor site, a 2-concatenated paddle flow-through arterialized venous flap was harvested from ipsilateral forearm (Fig. 7).

FIGURE 5

FIGURE 5

FIGURE 6

FIGURE 6

FIGURE 7

FIGURE 7

Two λ-pattern skin paddles4 were connected by a flow-through arterialized vein. The tissue between the 2 venous flaps was debulked until the connecting vein was seen. The skin removed was used as a full-thickness skin graft. The second vein included in each skin paddle was ligated at the bifurcation and was repaired to 2 recipient veins to reduce the intraluminal pressure by the arteriovenous shunting. The donor site was closed primarily. Venous congestion was mild in both skin paddles. Superficial epidermolysis was noticed more on the proximal skin paddle of the concatenated flaps (Fig. 8). All wounds healed without complications. A hand-based splint to keep the finger in full extension was applied 24 h/d except removal for hourly exercises in the first 3 months. Night splinting was maintained for 6 months (Figs. 9A, B).

FIGURE 8

FIGURE 8

FIGURE 9

FIGURE 9

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DISCUSSION

Simultaneous reconstruction of separate defects on a finger can be challenging. One option is to convert the separated defects into one. To resurface the separate defects with individual flaps is another option. The disadvantages are the lack of recipient vessels, increased donor site morbidity, and intraoperative time. A chimeric flap with separated tissue components may be possible but are mostly relatively too bulky to resurface 2 separated defects on a finger.

Nakayama et al5 first described arterialized venous flaps in rat experiments in 1981. Since then, the venous flap was popularized for hand and finger reconstruction. Several advantages of forearm venous flaps have been described in the literature,1–4 such as matching and thin skin for hand and finger reconstruction, ease of harvest, long pedicle, matching diameter of pedicles for digital vessels, low donor-site morbidity, and versatility by including palmaris longus for simultaneous tendon reconstruction. The abundant venous network also allows us to harvest the concatenated skin paddles based on the flow-through veins. These characteristics are ideal indications for the use of arterialized venous flaps to resurface separated defects in the hand.

Venoarterial communications (reverse shunting) have been observed using angiography, which possibly explain why it works.6,7 Crossing of microcirculation in all the arterioles and venules was also observed both in the arterialized and venous flow-through venous flaps under a microscope.8 Physiologically, the blood flows according to normal pressure gradient from high to low. In a venous flap, the tissue venous pressure has to exceed the intraluminal pressure before venous drainage occurs. In arterialized venous flaps, it was hypothesized that the venous blood was drained to the arteries when the tissue pressure exceeds arterial pressure in the diastolic phase.9 Nonetheless, venous congestion is usually observed during the first few days after arterialization and the condition usually resolves after neovascularization. Partial loss of the venous flaps was commonly reported in the literature.

Several strategies for improving venous congestion in venous flaps have been devised (Table 1). Retrograde arterialized venous flaps, that is, perfusion against the venous valves in the flap, were described to enhance the perfusion of the periphery of a venous flap in vitro.10 However, high incidence of venous congestion was noted in clinical settings.11 The delayed arterialized venous flap was shown to improve survival of a large arterialized venous flap.12–14 Nonetheless, arteriovenous shunts need to be created 2 weeks before the flap was transferred, which makes it a 2-stage procedure. Venous congestion was considered a normal finding in arterialized venous flap.11 However, partial loss of the flap may induce fibrosis and contracture of a finger. An additional efferent venous drainage can decrease venous insufficiency.15 In our first patient, the larger flap that included an additional vein was observed to be normal in color and texture resembling a conventional flap, whereas venous congestion was evident for the smaller flap with the only axial flow-through arterialized vein. In the second patient, a second shunt-restricted vein was repaired in both concatenated flaps. The arterialized vein flowing through the first flap was blocked at the efferent end in the second flap. The arterial flow was forced to the periphery through the venoarterial shunting but was blocked by the hemoclips at the bifurcations from the arterial flow.16 When intraluminal pressure was close to the venous pressure, drainage occurred through the anastomosis.

TABLE 1

TABLE 1

Concatenated venous flaps from the distal forearm have been used to resurface the separated defects on and the foot and on the finger.17,18 The skin flap between the 2 concatenated flaps was de-epithelized and buried under the tunnel between the separated defects. The tunnel has to be wide enough to prevent compression. Without shunt restriction, the venous congestion was observed especially at the afferent flaps of both cases. These were due to higher intraluminal pressure for the venous return to the arterial flow-through vessel. Secondary healing of the wound margin was reported in both cases. In our patients, the in-between vessels were skeletonized to reduce the risk of compression. Although superficial epidermolysis was observed in the shunt-restricted flaps, the flaps survived without complications.

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REFERENCES

1. Yoshimura M, Shimada T, Imura S, et al. The venous skin graft method for repairing skin defects of the fingers. Plast Reconstr Surg. 1987;79:243–250.
2. Woo SH, Jeong JH, Seul JH. Resurfacing relatively large skin defects of the hand using arterialized venous flaps. J Hand Surg Br. 1996;21:222–229.
3. De Lorenzi F, van der Hulst RR, den Dunnen WF, et al. Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series. J Reconstr Microsurg. 2002;18:569–574.
4. Lin YT, Henry SL, Lin CH, et al. The shunt-restricted arterialized venous flap for hand/digit reconstruction: enhanced perfusion, decreased congestion, and improved reliability. J Trauma. 2010;69:399–404.
5. Nakayama Y, Soeda S, Iino T. A radial forearm flap based on an extended dissection of the cephalic vein. The longest venous pedicle? Case report. Br J Plast Surg. 1986;39:454–457.
6. Byun JS, Constantinescu MA, Lee WP, et al. Effects of delay procedures on vasculature and survival of arterialized venous flaps: an experimental study in rabbits. Plast Reconstr Surg. 1995;96:1650–1659.
7. Imanishi N, Nakajima H, Aiso S. A Radiographic perfusion study of the cephalic venous flap. Plast Reconstr Surg. 1996;97:408–412.
8. Lin CH, Wei FC, Mardini S, et al. Microcirculation study of rabbit ear arterial and venous flow-through flaps using a window chamber model. J Trauma. 2004;56:894–900.
9. Lam WL, Lin WN, Bell D, et al. The physiology, microcirculation and clinical application of the shunt-restricted arterialized venous flaps for the reconstruction of digital defects. J Hand Surg Eur Vol. 2013;38:352–365.
10. Moshammer HE, Schwarzl FX, Haas FM, et al. Retrograde arterialized venous flap: an experimental study. Microsurgery. 2003;23:130–134.
11. Koch H, Scharnagl E, Schwarzl FX, et al. Clinical application of the retrograde arterialized venous flap. Microsurgery. 2004;24:118–124.
12. Cho BC, Lee JH, Byun JS, et al. Clinical applications of the delayed arterialized venous flap. Ann Plast Surg. 1997;39:145–157.
13. Fukui A, Inada Y, Murata K, et al. A method for prevention of arterialized venous flap necrosis. J Reconstr Microsurg. 1998;14:67–74.
14. Wungcharoen B, Santidhananon Y, Chongchet V. Pre-arterialisation of an arterialised venous flap: clinical cases. Br J Plast Surg. 2001;54:112–116.
15. Woo SH, Kim SE, Lee TH, et al. Effects of blood flow and venous network on the survival of the arterialized venous flap. Plast Reconstr Surg. 1998;101:1280–1289.
16. Lin YT, Hsu CC, Lin CH, et al. The position of 'shunt restriction' along an arterialized vein affects venous congestion and flap perfusion of an arterialized venous flap. J Plast Reconstr Aesthet Surg. 2016;69:1389–1396.
17. Cheng TJ, Chen YS, Tang YB. Use of a sequential two-in-one free arterialised venous flap for the simultaneous reconstruction of two separate defects on the foot. Br J Plast Surg. 2004;57:685–688.
18. Hyza P, Vesely J, Stupka I, et al. The bilobed arterialized venous free flap for simultaneous coverage of 2 separate defects of a digit. Ann Plast Surg. 2005;55:679–683.
Keywords:

shunt restriction; venous flaps; venous congestion

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