TY - JOUR
AU - MD, Serdar Ozturk,
AB - Abstract Flap choices for the coverage of the proximal phalangeal soft tissue defects of the finger and web space burn contractures are limited. A unipedicled distally based venous flap was raised from the third or fourth metacarpal area of the hand for proximal phalangeal soft tissue defects of the finger and web space burn contracture. For clinical use, we operated seven male patients using this venous flap. Superficial necrosis involving two flaps did not interfere with flap survival. Mild edema and venous congestion occurred in all flaps. All flaps survived completely. The mean follow-up period of the flaps was 6 months, ranging from 3 to 14 months. A well-planned distally based venous flap is an useful option for the coverage of the proximal phalangeal soft tissue burn defects of the finger and web space burn contracture of the hand. A small amount of the useful flap options are present for the coverage of the proximal phalangeal soft tissue burn defects repair of the finger and web contractures of the hand.1 Selected ones such as the third and fourth metacarpal arterial flaps may be used for soft tissue burn defects of the proximal finger area. The pedicles of the third or fourth metacarpal arterial flaps consist of small arterial branches and may not be obtained in all the cases.2 As an alternative, a unipedicled venous flap, which is based on superficial veins, was harvested from the third or fourth metacarpal area of the hand. In this study, applicability of this type of flap was discussed with clinical cases. METHODS AND CLINICAL APPLICATIONS Between May 2006 and December 2008, seven male patients were operated with distally based venous flap technique. The indications for surgery were soft tissue burn defects exposing tendons or vital structures and third or fourth web space burn contractures (Table 1). Three patients were treated with venous flap for third-degree acute burn injury in proximal phalangeal region of the hand, and four patients had web space contracture caused by burn injury for >7 years ago during childhood (7, 9, 12, 14 years ago). We did not use this type of flap even if there is an involvement of the hand dorsum superficially with phalangeal burn injury. The unipedicled venous flaps with 4 × 2 cm (five patients) and 4 × 1 cm (two patients) in size were planned on the third metacarpal area by tracing a significant superficial vein. Table 1. Demographic data of patients View Large Table 1. Demographic data of patients View Large Operative Technique Surgery was performed under arm tourniquet preplaced with axillar block anesthesia without exsanguination. A dorsal vein trace was marked on the dorsum of the hand during the third or fourth metacarpals. Skin paddle was centered previously on this significant dorsal vein by marking. Then, the skin above the pedicle was undermined, and the pedicle was dissected. Care was taken to prepare the pedicle in the same width with the skin paddle by preserving the perivenous areolar tissue. Dorsal vein was ligated proximally and cut off. The flap was elevated distally until the pivot point and inset to the defect into the proximal, dorsal medial, or lateral sides of the third and fourth finger. Pivot point or rotational arc was located beyond the course of vein, averagely 0.8 cm proximal to the metacarpophalangeal joint. Subcutaneous tunneling was attempted for flap to transfer up into the soft tissue defect. After tourniquet was released, no arterial pulse was seen in the elevated flaps. Then, the flap was sutured in the defects with 5–0 nylon suture. Donor site was closed primarily. CASE REPORTS Case 1 A 22-year-old man presented with a radial-lateral skin defect on proximal phalanx of the left fourth finger caused by electric injury with low voltage (Figure 1). Bone, ligamentous structures and vital digital structures were exposed after debridement. A unipedicled venous flap with 4 × 2 cm in size was planned on the third intermetacarpal area by tracing a significant superficial vein (Figure 2). The flap was harvested based on its vein including a large amount of periareolar tissue and inset to the defect (Figure 2). The pedicle length was 28 mm. Edema appeared in the early postoperative period. The flap healed well and an acceptable result acquired (Figure 3). Figure 1. View largeDownload slide Soft tissue defect in fourth finger radial side (above, left), venous flap plan (above, right), and flap raising (below, left) after the flap inset to the defect. Figure 1. View largeDownload slide Soft tissue defect in fourth finger radial side (above, left), venous flap plan (above, right), and flap raising (below, left) after the flap inset to the defect. Figure 2. View largeDownload slide Soft tissue defect in fourth finger radial side (above, left), early postoperative view of flap (above, right), and late postoperative view (below, left and right). Figure 2. View largeDownload slide Soft tissue defect in fourth finger radial side (above, left), early postoperative view of flap (above, right), and late postoperative view (below, left and right). Figure 3. View largeDownload slide Incomplete third web space syndactyly of right hand caused by burn injury (above, left), flap plan (above, middle), and flap raising (below, left) after flap inset to the defect (below, right). Figure 3. View largeDownload slide Incomplete third web space syndactyly of right hand caused by burn injury (above, left), flap plan (above, middle), and flap raising (below, left) after flap inset to the defect (below, right). Case 5 A 20-year-old man presented with third web space syndactyly in the right hand caused by burn injury occurred in childhood. After contracture release, the defect was reconstructed with a venous flap with 4 × 1 cm in size that was harvested from the third intermetacarpal area (Figure 4). Pedicle length was 32 mm. Superficial necrosis occurred, but complete flap survival was achieved (Figure 5). Figure 4. View largeDownload slide Preoperative view (above, left) and early postoperative superficial necrosis (above, right), late postoperative view, and complete flap survival (below, left and right). Figure 4. View largeDownload slide Preoperative view (above, left) and early postoperative superficial necrosis (above, right), late postoperative view, and complete flap survival (below, left and right). Figure 5. View largeDownload slide Fourth web space contracture of left hand (above, left), flap plan (above, right), after flap raising (below, left), and after flap transfer to the defect (below, right). Figure 5. View largeDownload slide Fourth web space contracture of left hand (above, left), flap plan (above, right), after flap raising (below, left), and after flap transfer to the defect (below, right). Case 7 A 23-year-old man presented with fourth web space contracture in the left hand caused by burn injury occurred in childhood. After contracture release, the defect was reconstructed with a venous flap with 4 × 2 cm in size that was harvested from the third intermetacarpal area (Figure 6). Pedicle length was 29 mm. Venous congestion occurred in the early postoperative period. Complete flap survival with acceptable result was achieved (Figure 6). Figure 6. View largeDownload slide Preoperative web space burn contracture view (above, left), early postoperative view (above, right), and late postoperative view (below, left, and right). Figure 6. View largeDownload slide Preoperative web space burn contracture view (above, left), early postoperative view (above, right), and late postoperative view (below, left, and right). RESULTS All flaps survived completely. Two superficial flap necroses did not alter complete flap survival. Mild edema and venous congestion occurred in all flaps. The mean follow-up period was 6 months, ranging from 3 to 14 months. Sensory recovery was observed in three of the seven flaps during the follow-up. Mean vascular pedicle length for raising flaps was 28.4 mm. Five flaps had 4 × 2 cm and the remaining two flaps had 4 × 1 cm dimension. Demographic data of the patients were listed in Table 1. DISCUSSION Clinical application of unipedicled venous flaps is based on the experimental works.3,–6 In a rabbit model, it was shown that total survived area of a pedicled venous flap (adding also superficial necrosis) was 82.5% after transfer if perivenous areolar tissue and nerve were included in the pedicle.4 Tang et al7 demonstrated that the venous flap was supplied by its axial vein during the first 3 days until neovascularization. Yücel and Bayramiçli5 stated that the smaller flap size, a rich perivenous areolar tissue into the pedicle, and the presence of a vascular wound bed help in improving the survival rates of unipedicled venous flaps. Even though we observed two superficial necroses in two flaps, they were survived. We also observed venous congestion in all flaps, but this situation recovered. Various studies confirmed that small arterial channels surrounding the vein were in the perivenous areolar tissue.8,–11 Likewise, in the hand, the vascular connections between dorsal and palmar digital arterial branches are derived from this innominate arterial source in the perivenous areolar tissue in the dorsum of proximal phalanx.12 According to Chang,13 perivenous tissue is added to the pedicle-developed flap to form a random pattern flap, which includes a significant vein. Furthermore, if the large superficial vein was left in continuity with a distally based pedicle, it could cause congestion and jeopardize flap viability. It should be carefully ligated at 1 to 2 cm distal to the pedicle.14 Another study showed that the venous flap perfusion occurs along the axis of the subcutaneous vein passing through the flap.15 Ligation of the subcutaneous vein not only causes mechanical trauma to the perivenous areolar tissue but also prevents perfusion of the vessels from the same vein. As Murata et al16 have noted, two conditions should be required for venous flap survival. First, the pedicle should include a vein having perivenous areolar tissue and second, the recipient bed should have at least moderate vascularization. In our venous flap, care was taken to prepare the pedicle in the same width with the skin paddle by preserving the perivenous areolar tissue. All flaps survived completely in our case series. Multiple reconstructive methods have been used for the treatment of postburn scar contractures, including excision followed by reconstruction using skin grafts, local flaps with or without tissue expansion, free-tissue transfer, and a combination of these methods.17 Unfortunately, satisfactory results are difficult to achieve. Skin grafts usually result in some degree of contraction because of various factors, such as insufficient vascular supply. Local flaps must be the first choice for the reconstruction of the contracture in burn area. However, the availability of unaffected healthy skin adjacent to this area limited the use of local flaps that acquired with transposition, rotation, and advancement. Other alternatives are regional flaps that can be used in these situations, such as cross-finger flap18 and dorsal metacarpal artery flap,19 according to availability. For wider defects after postburn scar contracture release, local flaps donor-site closure often requires skin grafting. If local flap is not available, free flap may be a choice for burn reconstruction.20 However, if free flaps fail, then donor-site morbidity can be a major concern for many patients. This can result in recontracture after the reconstruction. Donor-site closure can be performed easily in distally based venous flap and is a good alternative to avoid undergoing microsurgery and skin graft complications. A small number of flap choices from hand dorsum have been described for finger soft tissue reconstruction. The third or fourth dorsal metacarpal artery island flaps can be used for finger soft tissue coverage. Advantage of the dorsal venous flaps in the hand is easier to be dissected compared with the third or fourth dorsal metacarpal artery flaps because interosseous muscle fascia is not pierced with venous vessel. The third or fourth dorsal metacarpal arterial branches may be only accidentally involved in the venous flap pedicles. Rezende et al21 previously reported that the third and fourth dorsal metacarpal arteries are small branches for arc of rotation, although they were found in >90% of cadaveric specimens. Lai-Jin and Xu2 also agreed and stated that the dissection of the pedicle should be performed cautiously to keep sufficient surrounding adipose tissue, in case the flap based on the fourth dorsal metacarpal artery is chosen. In this situation, harvesting flaps involving digital or metacarpal arteries may impair the vascular supply to the related digits. Venous flaps prevent sacrifice of this important arterial source. Because the perfusion area of venous flaps are less than that of traditional arterial flaps, their use is limited in small defects.16,22,23 If they were transferred to repair for the small-to-moderate defects, superficial necrosis does not occur.24 We did not use such flaps if there is a superficial involvement of the hand dorsum with phalangeal burn injury and were not included in the case series. We think that dorsal venous network may be involved in the dorsum of the hand burn injury. The technique presented here is advantageous because it is easy to perform, useful options to cover soft tissue finger burn defect and web burn contracture release, and it avoids microsurgery and skin graft complications. Donor site is closed primarily, and finally this approach ensures a repair of third-degree burn wounds in the hand exposing multiple vital anatomical structures, ie, bone, tendon, joint, vessel, and nerve. More studies with more patients are necessary to highlight the real impact of this flap technique. CONCLUSION Well-planned distally based venous flap is a useful option for the coverage of the proximal phalangeal soft tissue burn defects of the finger and web space burn contracture of the hand. REFERENCES 1. Karacaoglu E, Gokce A Perforator-based reverse radial forearm flap to reconstruct multiple third-degree burn defects of the fingers. J Burn Care Res  2008; 29: 398– 402. Google Scholar CrossRef Search ADS PubMed  2. Lai-Jin L, Xu G The reverse dorsal metacarpal flap: experience with 153 cases. Ann Plast Surg  2006; 56: 614– 7. Google Scholar CrossRef Search ADS PubMed  3. Fukui A, Tamai S, Maeda M, Inada Y, Mii Y, Mine T The pedicled venous flap. An experimental study. Br J Plast Surg  1993; 46: 116– 21. Google Scholar CrossRef Search ADS PubMed  4. 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Br J Plast Surg  1993; 46: 285– 7. Google Scholar CrossRef Search ADS PubMed  9. Noreldin AA, Fukuta K, Jackson IT Role of perivenous areolar tissue in the viability of venous flaps: an experimental study on the inferior epigastric venous flap of the rat. Br J Plast Surg  1992; 45: 18– 22. Google Scholar CrossRef Search ADS PubMed  10. Smith RJ, Fukuta K, Wheatley M, Jackson IT Role of perivenous areolar tissue and recipient bed in the viability of venous flaps in the rabbit ear model. Br J Plast Surg  1994; 47: 10– 14. Google Scholar CrossRef Search ADS PubMed  11. Adamo C, Rubino C Venous flaps and perivenous areolar tissue: an experimental study in rats. J Reconstr Microsurg  1996; 12: 179– 81. Google Scholar CrossRef Search ADS PubMed  12. Bene MD, Petrolati M, Raimondi P, Tremolada C, Muset A Reverse dorsal digital island flap. Plast Reconstr Surg  1994; 93: 552– 7. Google Scholar CrossRef Search ADS PubMed  13. Chang SM The pedicle of neurocutaneous island flaps. 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J Bone Joint Surg Am  1969; 51: 1257– 63. Google Scholar CrossRef Search ADS PubMed  19. Earley MJ, Milner RH Dorsal metacarpal flaps. Br J Plast Surg  1987; 40: 333– 41. Google Scholar CrossRef Search ADS PubMed  20. De Lorenzi F, van der Hulst R, Boeckx W Free flaps in burn reconstruction. Burns  2001; 27: 603– 12. Google Scholar CrossRef Search ADS PubMed  21. de Rezende MR, Mattar Júnior R, Cho AB, Hasegawa OH, Ribak S Anatomic study of the dorsal arterial system of the hand. Rev Hosp Clin Fac Med Sao Paulo  2004; 59: 71– 6. Google Scholar CrossRef Search ADS PubMed  22. Chavoin JP, Rouge D, Vachaud M, Boccalon H, Costagliola M Island flaps with an exclusively venous pedicle. A report of eleven cases and a preliminary haemodynamic study. Br J Plast Surg  1987; 40: 149– 54. Google Scholar CrossRef Search ADS PubMed  23. Foucher G, Norris RW The venous dorsal digital island flap or the “neutral” flap. Br J Plast Surg  1988; 41: 337– 43. Google Scholar CrossRef Search ADS PubMed  24. 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TI - Distally Based Venous Flap for Proximal Phalangeal Soft Tissue Burn Defect and Web Space Burn Contracture
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e3181abffe7
DA - 2009-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/distally-based-venous-flap-for-proximal-phalangeal-soft-tissue-burn-dkvqQNvTRu
SP - 643
EP - 647
VL - 30
IS - 4
DP - DeepDyve
ER -