Venous Flaps Dr. Mohamed El Rouby ‫د. محمد أحمد الروبي‬ Lecturer of Plastic Surgery ‫مدرس جراحة التجميل‬ +20101556023 or +20126531265 or  arterialized venous "flow-through" flap (VFTF) provides a unique and creative option for difficult reconstructions of the hand.  VFTFs are thin and pliable with vessels similar in size to those of the hand. Their harvest results in minimal donor site morbidity.  Composition: skin, subcutaneous tissue, and a plexus of veins + additional tissues creating a composite VFTF. (more difficult because success is dependent on spatial distribution of multiple components rather than just inflow and outflow circuits). • Sensory nerves such as the brachial cutaneous and saphenous nerves to create a sensate flap or to graft nerve defects at the recipient site. • Tendon has been included to reconstruct tendons, ligaments, and joints capsules. • One author has reported inclusion of tibial bone with a saphenous venous flap for reconstruction of soft tissue and bony defects in the hand. physiology of VFTF:  Unlike conventional flaps where the nutrient capillary beds are supplied by an inflow artery and drained by an outflow vein, the VFTF has no arterial inflow circuit. All flow proceeds into and out of the flap via the venous plexus.  The exact physiology of VFTF survival has not been determined. Three theories have been prosed: • Reverse Shunting • Reverse Flow • Capillary Bypass  Reverse shunting depends on primitive A-V channels or connections which are able to contract or dilate in response to nervous and chemical stimuli. With denervation, these channels allow retrograde flow from the veins to the arterioles  antegrade flow through the nutrient capillary beds and out through the veins.  Reverse flow depends on retrograde flow from the veins through the nutrient capillary bed into the arterioles and then antegrade flow back out the veins via A-V shunts or other capillary beds. Both of these theories depend upon some antegrade flow through the nutrient capillary beds.  The capillary bypass theory (discounts the need for the capillary bed). It relies studies, which confirm that normal tissue can extract up to 50% of the oxygen content of blood prior to it reaching the capillary beds. The VFTF survive on the lower oxygen content supplied by antegrade flow through the venous plexus.  Regardless of which physiologic mechanism is responsible, sufficient nutrition is available to keep the flap alive until peripheral neovascularization occurs restoring

conventional antegrade physiology. With the correct flap design, in selected patients, VFTFs are reliable.  Larger flaps require a more extensive venous plexus for complete survival.  Studies have shown that VFTFs designed with a central venous plexus with two or more efferent veins have a survival pattern similar to that of a conventional flaps which have an inflow artery and outflow vein.  VFTFs are pale after transplantation (for several hours) & Viability and flow through can be monitored by palpation of its pulse or Doppler evaluation  After several hours the flap regains capillary refill (i.e. opening of the arterial-venous shunts triggered by ischemia in the overlying skin)  Over the next days to weeks the flap will appear congested and ecchymotic (Evaluation by capillary refill is obscured. Palpation of the pulse or Doppler evaluation is used)  After about 2 weeks congestion resolves and superficial epidermalysis is removed uncovering pink healthy tissue. Factors affecting survival of VFTF: • Fine network of veins • Donor site (characters of superficial venous system) • Recipient site (infection) There are several potential VFTF donor sites: • Distal Volar Forearm • Proximal Volar Forearm • Upper Arm • Dorsum Digit/Hand • Medial Thigh/Leg • Dorsal Foot  The superficial venous system located distally on the extremity is: • less likely to have valves, • has more extensive networking • more intimately associated with and supportive of its overlying skin.  VFTFs harvested from the leg and upper arm are nourished by the saphenous and basilic vein respectively. These flaps are useful when long vascular conduits or a larger soft tissue paddle is required.  The smaller venous systems cannot be visualized and their extent cannot be determined at the time of flap design. (designed over the main vein). Classification of the VFTF is based on the vascular "hook-up. • Arterialized Venous Flap  A-V-A  A-V-V • Total Venous Perfusion  V-V-V  The VFTF placed between two arteries in an A-V-A fashion functionally reconstructs that artery.  The VFTF placed between an artery and vein (A-V-V) functionally creates an A-V fistula.  The VFTF placed between two veins (V-V-V) (This further restricts its maximum size to less than that of an arterialized VFTF).  The A-V-A orientation is useful in difficult replantations. The blood, which flows through the flap not only nourishes the flap but also revascularizes the replanted tissues. (e.g.

Ring avulsion amputations  The crush component necessitates soft tissue replacement, and the avulsion component necessitates vessel replacement).  The A-V-V orientation is particularly useful in fingertip resurfacing.  The V-V-V orientation can be employed to fill soft tissue defects and cover exposed tendon on the dorsum of the finger.  The VFTF does not replace conventional flaps, which utilize local tissue. It offers an excellent option when adequate adjacent tissue sources like cross-finger flaps are not available: • Injury to multiple digits • Unlar hand injuries • Radial hand injuries • Defects greater in size than the cross-finger flap • Thumb injuries • Patient will not accept additional scars on adjacent digits  Advantages: • Revascularized and resurface • Single stage procedure • Thin/pliable tissue • Low donor morbidity • Spares donor artery • Good cosmetic result • Can include composite tissue  Disadvantages: • Requires microvascular techniques • Requires a two person team • Longer hospitalization  Although size constraints limit its use in general reconstructions throughout the body, it has unique clinical efficacy in small and moderate sized defects. In selected cases, it represents an excellent option available to the creative microsurgeon when planning complex reconstructions of the hand.

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