Reconstruction and Revascularization of the Extremity with Venous Flaps after Traumatic Injury

Local procedures such as the cross-finger flap, island flap, and flag flap, etc. are well-described for the treatment of soft-tissue defects of the hand. Their effectiveness is, however, limited in cases of multi-digit injury, defects greater than 5 cm in length, and defects located on the radial side of the index, ulnar side of the small finger, and tip of the thumb. The bulkiness of conventional microvascular tissue transplantation can limit its overall effectiveness. The authors presented their experience with the transplantation of venous flaps for reconstruction of thin soft tissue cover of the hand.

A retrospective study between 6/2000 and 2/2005 involved 50 venous flaps that were transplanted for reconstruction of soft-tissue defects of the hand. Patient charts were reviewed to document multiple parameters of the cases. Indications for the venous flap included location, size, multi-digit injury, need for cover over vital structures, need for digital revascularization/replantaion, or reconstruction of tendon, nerve, or bone with composite venous flaps. The flaps were classified as AVA, AVV, AVA/A, AVV/V, or VVV, depending on their vascular anastomoses. Donor sites included SAPH (saphenous vein), CEPH (cephalic vein), VPF (volar proximal forearm), VDF (volar distal forearm), DH (dorsal hand), and DF (dorsal finger). Outcome was classified as successful in cases where there was 100% survival of the flap, partial thickness (PT) survival where there was loss of epidermis with maintenance of subcutaneous cover, and partial full thickness (PFT) if epidermis and subcutaneous tissue was lost but went on to heal by secondary intention. The flap was considered a failure if there was complete loss of the flap or significant loss that led to exposure of vital structures and need for an alternate procedure.

Forty flaps had 100% survival (80%), 5 flaps were considered PT (8%), 3 were considered PFT (6%), and 2 were considered failures (4%). There were often multiple indications for the venous flap in individual cases. Coverage of vital structure was the indication in 27, revascularization of the hand or a digit in 16, multi-digit injury in 8, location of the defect in 20, and digit replantation in 10 cases. Twenty-seven flaps were classified as AVA, 14-AVV, 1-VVV, 3-AVA/A, 4-AVV/V, and 1-AVA/VVV. Eight flaps had multiple inflow and/or outflow anastomoses to nourish larger flaps, to reconstruct simultaneous arterial inflow and venous out flow in ring avulsion replants, or to provide cover and revascularization for multiple digits by creation of digital syndactyly. The donor was the VDF in 40 patients (80%), VPF in 5 patients (10%), SAPH in 3 patients (4%), DH in 1 (2%), and DF in 1 (2%). Size of the flaps ranged from 2 × 2 cm to 9 × 6 cm. The majority of flaps were 2 × 3 cm.

Venous flaps can provide reliable coverage for small- and medium-sized soft tissue defects of the hand, when conventional methods are less effective. Venous flaps have the additional benefit of reconstructing vascular inflow and/or outflow to amputated and devitalized components.