Abstract
Background
Arterialised venous flaps (AVFs) are a flexible reconstructive option for hand defects with advantages including minimal donor site morbidity, abundant donor sites and relative ease of harvest. However, venous congestion and partial necrosis remain common drawbacks. Shunt restriction is a reported method of optimising the latter and improving flap survival. We illustrate a ‘how-to’ surgical process flow and report our experience with a series of these flaps in the reconstruction of hand defects.
Methods
Hand defects from 9.4 to 18.8 cm2 (Median 14.1 cm2) within 2 weeks of injury were included in this series. Type III and IV AVFs, with ‘II’ and ‘H’ donor venous patterns, were harvested from the volar forearm. Survival, ischaemia/necrosis, venous congestion and total active motion (TAM) were assessed during follow-up.
Results
A total of six shunt-restricted AVFs were performed (2013 to 2017). One flap was lost to efferent venous thrombosis day 10 post-operative secondary to noncompliance and unrelated trauma sequelae. The remainder maintained good perfusion with no partial full-thickness loss, despite anticipated mild–moderate congestion and pre-emptive leeching. TAM at 7 months post-operative or later varied according to original underlying joint involvement.
Conclusions
AVFs are a potentially underutilised reconstructive option for hand defects which provide thin, pliable and well-contoured soft tissue whilst minimising donor-site morbidity and hand stiffness. Strategies such as shunt restriction have been shown in previous studies to enhance their reliability and outcomes, avoiding partial thickness necrosis, and may hence broaden the use of AVFs.
Level of evidence: Level IV, therapeutic study.
Similar content being viewed by others
Data availability
All results published.
Code availability
Not applicable.
References
Nakayama Y, Soeda S, Kasai Y (1981) Flaps nourished by arterial inflow through the venous system: an experimental investigation. Plast Reconstr Surg 67(3):328–334
Mimoun M, Baux S, Kirsch JM, Fahed I (1986) An original flap: the arterialized venous flap. Ann Chir Plast Esthet 31(3):219–224
Yoshimura M, Shimada T, Imura S, Shimamura K, Yamauchi S (1987) The venous skin graft method for repairing skin defects of the fingers. Plast Reconstr Surg 79(2):243–250
Reynoso R, Haddad JL, Sastre N (2000) A few considerations regarding enhancement of arterialized skin flap survival. Microsurgery 20(4):176–180
Chen HC, Tang YB, Noordhoff MS (1991) Four types of venous flaps for wound coverage: a clinical appraisal. J Trauma 31(9):1286–1293
Rozen WM, Ting JW, Gilmour RF, Leong J (2012) The arterialized saphenous venous flow-through flap with dual venous drainage. Microsurgery 32(4):281–288. https://doi.org/10.1002/micr.21949
Lin YT, Henry SL, Lin CH, Lee HY, Lin WN, Lin CH, Wei FC (2010) The shunt-restricted arterialized venous flap for hand/digit reconstruction: enhanced perfusion, decreased congestion, and improved reliability. J Trauma 69(2):399–404. https://doi.org/10.1097/TA.0b013e3181bee6ad
Yan H, Brooks D, Ladner R, Jackson WD, Gao W, Angel MF (2010) Arterialized venous flaps: a review of the literature. Microsurgery 30(6):472–478. https://doi.org/10.1002/micr.20769
Goldschlager R, Rozen WM, Ting JW, Leong J (2012) The nomenclature of venous flow-through flaps: updated classification and review of the literature. Microsurgery 32(6):497–501. https://doi.org/10.1002/micr.21965
De Lorenzi F, van der Hulst RR, den Dunnen WF, Vranckx JJ, Vandenhof B, Francois C, Boeckx WD (2002) Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series. J Reconstr Microsurg 18(7):569–574; discussion 575–567. https://doi.org/10.1055/s-2002-35093
Wharton R, Creasy H, Bain C, James M, Fox A (2017) Venous flaps for coverage of traumatic soft tissue defects of the hand: a systematic review. J Hand Surg Eur 42(8):817–822. https://doi.org/10.1177/1753193417712879
Inada Y, Fukui A, Tamai S, Mizumoto S (1993) The arterialised venous flap: experimental studies and a clinical case. Br J Plast Surg 46(1):61–67
Woo SH, Kim SE, Lee TH, Jeong JH, Seul JH (1998) Effects of blood flow and venous network on the survival of the arterialized venous flap. Plast Reconstr Surg 101(5):1280–1289
Moshammer HE, Schwarzl FX, Haas FM, Maechler H, Pierer G, Wiltgen M, Koch H (2003) Retrograde arterialized venous flap: an experimental study. Microsurgery 23(2):130–134. https://doi.org/10.1002/micr.10108
Suzuki Y, Suzuki K, Ishikawa K (1994) Direct monitoring of the microcirculation in experimental venous flaps with afferent arteriovenous fistulas. Br J Plast Surg 47(8):554–559. https://doi.org/10.1016/0007-1226(94)90139-2
Yan H, Fan C, Zhang F, Gao W, Li Z, Zhang X (2013) Reconstruction of large dorsal digital defects with arterialized venous flaps: our experience and comprehensive review of literature. Ann Plast Surg 70(6):666–671. https://doi.org/10.1097/SAP.0b013e3182433575
Woo SH, Kim KC, Lee GJ, Ha SH, Kim KH, Dhawan V, Lee KS (2007) A retrospective analysis of 154 arterialized venous flaps for hand reconstruction: an 11-year experience. Plast Reconstr Surg 119(6):1823–1838. https://doi.org/10.1097/01.prs.0000259094.68803.3d
Cherubino M, Corno M, Valdatta L, Adani R (2017) Thumb reconstruction with thin proximal ulnar perforator free flap. J Hand Surg 42(2):e133–e138. https://doi.org/10.1016/j.jhsa.2016.11.026
Guiotto M, di Summa PG, Argentino G, Cherubino M (2021) The proximal ulnar perforator flap (PUPF) for hand digital reconstruction: an anatomical study. J Plast Surg Hand Surg:1–5. https://doi.org/10.1080/2000656X.2021.1873793
Lin YT, Loh CYY, Lin CH (2020) Flaps based on perforators of the digital artery. Hand Clin 36(1):57–62. https://doi.org/10.1016/j.hcl.2019.08.007
Quaba AA, Davison PM (1990) The distally-based dorsal hand flap. Br J Plast Surg 43(1):28–39. https://doi.org/10.1016/0007-1226(90)90042-x
Chang DH, Hsieh CY, Chang CW, Chang KC, Chan CL (2021) Using dorsal metacarpal artery perforator flap in the soft tissue reconstruction of traumatic finger defects: a single-center study. Ann Plast Surg 86 (2S Suppl 1):S113-S118. https://doi.org/10.1097/SAP.0000000000002656
Chen J, Chen Q, Li S, Wang Y, Wang W, Tan J (2019) [Repair of soft tissue defect of fingers with modified arterialized venous flap]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 33 (4):475–478. https://doi.org/10.7507/1002-1892.201811114
Lin YT, Hsu CC, Lin CH, Loh CY, Lin CH (2016) 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 69(10):1389–1396. https://doi.org/10.1016/j.bjps.2016.05.013
Kruer RM, Barton CA, Roberti G, Gilbert B, McMillian WD (2015) Antimicrobial prophylaxis during Hirudo medicinalis therapy: a multicenter study. J Reconstr Microsurg 31(3):205–209. https://doi.org/10.1055/s-0034-1395395
Patel KM, Svestka M, Sinkin J, Pt R (2013) Ciprofloxacin-resistant Aeromonas hydrophila infection following leech therapy: a case report and review of the literature. J Plast ReconstrAesthetSurg 66(1):e20-22. https://doi.org/10.1016/j.bjps.2012.10.002
Mokhtar K, Culnan DM, Lineaweaver WC (2020) Evolving antibiotic resistance of Aeromonas species in finger replantation. Surg Infect (Larchmt) 21(2):158–160. https://doi.org/10.1089/sur.2019.067
Verriere B, Sabatier B, Carbonnelle E, Mainardi JL, Prognon P, Whitaker I, Lantieri L, Hivelin M (2016) Medicinal leech therapy and Aeromonasspp infection. Eur J Clin Microbiol Infect Dis 35(6):1001–1006. https://doi.org/10.1007/s10096-016-2629-5
Kakinoki R, Ikeguchi R, Nankaku M, Nakamua T (2008) Factors affecting the success of arterialised venous flaps in the hand. Injury 39(Suppl 4):18–24. https://doi.org/10.1016/j.injury.2008.08.028
Acknowledgements
The authors would like to express their sincere gratitude to the hand therapists of The Canberra Hospital for their expert care and follow-up of the patients involved in this study.
Author information
Authors and Affiliations
Contributions
Dr Ross Farhadieh conceived the study and design. Material preparation, data collection and analysis were performed by Dr Sean Leow, with assistance from Dr Justin Yousef and the guidance of Dr Ross Farhadieh. The manuscript was written by Dr Sean Leow with assistance from Dr Justin Yousef, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This is a retrospective study. The local ethics committee has confirmed that no ethical approval is required.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Patient consent
Patients signed informed consent regarding publishing their data and photographs.
Conflict of interest
Sean Kwang Howe Leow, Justin Yousef and Ross D. Farhadieh declare no competing interests.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Leow, S.K.H., Yousef, J. & Farhadieh, R.D. Reconstruction of traumatic hand defects with shunt-restricted arterialised venous flaps — a surgical process flow and our experience. Eur J Plast Surg 45, 149–158 (2022). https://doi.org/10.1007/s00238-021-01819-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00238-021-01819-z