Journal reading 20180614 department of plastic surgery, CYCH, Chiayi, Taiwan

1. Presenter: PGY盧敬文
Supervisor: VS陳坤翰
2018.6.14

2. Introduction
• Venous flaps:
flaps whose blood flow is supplied by afferent and efferent veins.
• can be raised from any area in the superficial venous system.
• Not completely understanding the flap circulation physiology,
• venous congestion, ischemia, and frequent loss of flaps.

3. Patients and methods
• 41 arterialized venous flaps in 40 patients
• btw 1992-2011
• 34 patients: female
• Median age: 24.2(min 2-max 55).

4. Indications for Venous flaps
(a) In fingertip tissue lost where the defect exceeds dimensions of
conventional homodigital or heterodigital flaps.
(b) In amputations involving segmental soft-tissue defects, as flow-through flaps in
revascularization/replantation.
(c) Soft-tissue defects on adjacent fingers directly related to multiple finger injuries.
(d) For stump closure after unsuccessful revascularization or replantation in
multiple finger injuries (as a temporary syndactylized flap involving multiple
fingers)
(e) As salvage operations after unsuccessful local/free flap application attempts.
(f) Circumferential or large longitudinal (volar/dorsal) tissue loss in single finger
injury.

5. • 1 patient: soft-tissue defect on her first toe.
other: hand injuries.
17: left hand injuries, 22: right hand injuries.
• 30 (75%): multiple finger injuries.
(n = 40)

6. • 21(52.5%): crush injuries.
other causes of injury: Rolling belt, ring injury, and burns
• Venous flaps were performed:
primarily in 29 patients (72.5%)
secondary interventions in 11 patients (27.5%) between days 3 and 25.

7. • Average flap size: 13.7 cm2 (min 3 cm2- max 30 cm2).
• Forearm volar side: donor area in 38 of 41 flaps.
1 venous flap designed over saphenous vein which was used for a traumatic
amputation over first toe.
Other donor areas: dorsum of the hand (n = 1)
dorsum of the foot (n = 1)

9. Surgical technique
1. Operations with a tourniquet inflated 30 mmHg over the DBP.
2. Debridement of injured area and identifying the recipient a. and v.
3. Flaps designed to involve veins with “H,” “Y,” or “ʎ” pattern for
rectangular shape defects.
• High pressure inflow blood divert towards flap periphery
• The central vein NOT used as a draining vein especially in larger flaps.
• The neighboring veins usually added to subcutaneous tissue
 increase intensity of vascular network

11. • Efferent vein and digital artery
anastomosis: at least proximal phalanx
level
 obtain maximum arterial flow.
• Proximal arterial anastomosis preferred in
our series
• Efferent vein is directed towards finger
dorsum especially PIP joint
 a diffuse venous network can be found
• After dissection, the flap was flipped
over in the direction of venous flow
• attempt to connect the small afferent
vein to the largest artery possible
Afferent veinEfferent vein
digital artery

12. • insufficient circulation: one or more extra anastomoses were tried to
be added
• One afferent and two efferent anastomoses: sufficient for small flaps.
• skin islands slightly larger than the defect area
 avoid postoperative peripheral necrosis
• Accompanying extensor tendon defects treated with:
tendocutaneous venous flaps,
or tendon grafts covered with venous flaps
• Tendocutaneous venous flaps were applied to 2 patients in our series.

14. • According to Chen’s venous flap
classification:
5 type IV (A-V-A) flow-through
36 type III (A-V-V) arterialized venous
flaps
• Along the valve pattern flow-through
flaps were used for:
• replantation/revascularization in 3 patients
• and for soft-tissue defects in 2 patients.
Wharton, R.H., Creasy, H.H., Bain, C., James, M.J., & Fox, A.C. (2017). Venous flaps
for coverage of traumatic soft tissue defects of the hand: a systematic review. The
Journal of hand surgery, European volume, 42 8, 817-822.

15. Result
• flap losses:
1 patient had superficial
3 patients presented with full-thickness flap necrosis (9.7%)

16. • 3 of the flaps which developed necrosis were applied with one
afferent artery and two efferent vein anastomosis.
• 1 flap with necrosis was a flow-through flap with one afferent and
one efferent artery anastomosis which had been used for finger
revascularization.

17. • 3 patients were reoperated in the early stage due to circulatory failure.
1st: kinking of the afferent artery with a thrombus at the 5th postoperative
hour
2nd: efferent vein anastomosis was added at 9 hour postoperatively
3rd: thrombosis was detected in the efferent vein at the 18th hour
postoperatively which was treated with reanastomosis.
All of these three flaps survived.

18. • no necrosis was seen in flaps with surface area larger than 9.5 cm2.
• It can be said that there is a weak but
positive correlation between number of anastomosis and
flap surface area

19. Discussion
• Venous flaps: flow-through flaps as a vessel carrier
arterialized venous flaps in soft-tissue reconstruction.
• thinner tissue  used as composite flaps especially in finger dorsal
tissue defects.
• 2 cases with extensor tendon defect  tendocutaneous compound flap
coverage
• Venous flaps can also be applied after unsuccessful finger
replantations or local flap surgery.

20. • Arterializing the venous network causes a high-pressure flow in the
central vein in the flap.
• early postoperative period  Congestion and cyanotic appearance
• In our study, half of the patients presented with these problems
but most of them healed without requiring an additional treatment.

21. • To increase the flap survival rate, decreasing the high arterial flow
could be attempted.
• the retrograde arterializations:
cause blood to be resisted in the vein wall valve system
pushed into the flap periphery.

22. • some positive factors reduce high inflow blood pressure:
• involvement of rich venous plexus
• draining via maximum efferent veins
• establishing dual venous anastomosis.
• Pre-arterialization, chemical and surgical delay, and expansion
procedures
 shorten this unstable “to and fro” or plasmatic imbibition period.

23. • We only found that our total failures (9.7%) have been seen in smaller
flaps <9.5 cm2.
• We observed slight positive correlation between number of
anastomosis and flap surface.

24. • High survival rate can depend on
factors as follows:
(a) Rich venous plexus especially
H,
Y, and ʎ pattern;
(b) Adding forearm fascia to the
flap;
(c) adding per venous cuff to the
afferent and efferent veins;
(d) Small caliber afferent vein;
(e) Good quality and largest
possible donor artery selection;
(f) not to choose central vein as a
draining vein;
(g) the more larger flap the more
efferent anastomosis;
(h) involvement of all possible
veins nearby in order to
increase available vessels for
anastomosis when necessary;
(i) intra-operative observation of
afferent phase of perfusion
(j) healthy anastomosis outside of
injury zone by taking afferent
and efferent veins long enough.

25. • The primary limitation in our study is the limited number of flaps,
and not having compared the other types of venous flap methods
with the arterialized antegrade venous flap method.

26. Thank you for your attention!