Anatomical relationship between arteries and veins in the paraumbilical region.

Veins in the paraumbilical region were investigated in eight fresh cadavers, in which radiopaque materials were injected into both the arterial and the venous systems, to determine their locational relationship to the arteries. Veins in the skin and subcutaneous tissue consisted of venae comitantes and non-venae comitantes. The main trunk of the non-venae comitantes was the superficial inferior epigastric vein, and it formed a polygonal venous network in the skin layer. A large communicating vein, which did not accompany an artery, connected the venous network to a vena comitans of a large paraumbilical arterial perforator. Venous blood that had perfused the dermis of the paraumbilical region had two kinds of pathways to a deep vein: through the superficial inferior epigastric vein to the femoral vein and through the vena comitans to the deep inferior epigastric vein.     

The carpal synovial sheaths and their vascularization]

The synovial sheaths of the flexor digitorum of 70 pieces of fresh cadavers have been studied on the whole of their length as far as the basis of the fingers: 20 have been injected with a latex or a physiologic solution, after the ablation of the palmar aponeurosis and of the superficial palmar arch. The arteries of the 50 other pieces have been injected with coloured latex solution from humeral artery. The proximal limit of the superficial sheaths is located 5 centimetres above the radiocarpal articular line and this of the deep sheaths 7 centimetres. In the metacarpal area, the superficialis central sheath presents peritendinous expansions, which realise an uninterrupted connection with each digital sheath. It is the aponeurotic and vascular extrinsic compressions, which simulate the interruption of these expansions. The proximal synovial arteries have a muscular origin. The antibrachial collateral arteries, 3 pairs in number, arise from the radial and the ulnar arteries. The distal synovial arteries come from the palmar arches and from their branches: superficial branches for the superficial sheaths and deep branches for the deep sheaths. There is many anastomoses between the different synovial arteries. Two are particularly developed and connect the proximal arteries to the palmar arches: the superficial longitudinal anastomotic artery; which runs close along the medial edge of the median nerve; the deep longitudinal anastomotic artery, which gives the nutritious branches for the tendons of the flexor digitorum. This disposition allows to create two synovial flaps of gliding and vascular help, centred on the anastomotic longitudinal arteries, pediculated on the volar archs and distal-ward rotated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Novel technique for venous augmentation in a free deep inferior epigastric perforator flap

Venous congestion in a free deep inferior epigastric perforator flap threatens the viability of the flap and can lead to eventual flap loss. We describe a novel technique for flap salvage by anastomosing the ipsilateral superficial inferior epigastric vein to a venae comitantes of the deep inferior epigastric pedicle. When recognized intraoperatively, venous congestion can be relieved immediately without the need for additional dissection of recipient vessels. This technique can also be used during reexploration for flap congestion. We routinely preserve length on the superficial inferior epigastric vein for potential flap salvage.     

Venae comitantes as a source of vein grafts

The use of vein grafts is commonplace and often essential in microvascular surgery. Typically, these are obtained from the superficial venous system, and most commonly from the lower extremity using branches or segments of the greater or lesser saphenous veins. Unfortunately, on rare occasions these usual donor sites may have been totally exploited. This potential dilemma can be solved by using the deep venae comitantes as autogenous vein grafts. By way of example, these can be venae comitantes of the free flap itself, or via salvage of parts using a vena comitans that accompanied a major limb source vessel.     

掌短肌皮瓣的临床应用

目的 掌短肌皮瓣的应用解剖及临床应用掌短肌皮瓣修复拇指指腹缺损的效果。方法 选择３０例灌注红色乳胶成人上肢标本，观测掌短肌皮瓣的血供、神经分布；上对９例拇指指腹缺的病例，应用吻合血管的掌短肌皮瓣进行修复。三 肌皮 的血供有４个来源：即尺动脉干、掌浅支的肌皮支和皮支、掌深支和小指尽侧固有动脉的肌皮支。其静脉回流为上述动脉的伴行静脉。感觉神经为尺神经浅支和尺神经的尺动脉支。临床９例拇指指腹缺损，应用掌     

Venous drainage in retrograde pedicle flaps: experimental study in rats

This study was performed to investigate the venous drainage in reverse island groin flaps in a rat model. Two groups of 10 rats were studied. All rats of group A had a groin reverse flap with a complete pedicle (artery and venae comitantes). In rats of group B, an arterial groin reverse flap (artery without venae comitantes) was performed. For the two groups, the perivascular tissue was excised. Nine flaps in the group A and seven flaps in the group B, survived without partial or complete necrosis. Microscopic examination showed venous dilatation in the two groups. There was no significant difference between the two groups. These results confirm that venous drainage of the arterial reverse flow flap without venae comitantes is performed by venae arteriosa. However, venae comitantes probably ensure venous drainage when they are respected.     

The venae comitantes clipping test for the evaluation of the venous drainage of the radial forearm free flap

Risks of failure of the radial forearm free flap (FRFF) are mainly related to venous congestion. Two different venous drainage system have been described for the FRFF, but the choice of the best one is still controversial. The superficial systems have a larger diameter and a thicker wall veins which makes them easier to anastomose. The deep system provides most part of the venous outflow if the caliber of the venae comitantes (VCs) is adequate. We propose an intra‐operative method to evaluate the FRFF venous drainage: the VCs clipping test. The test has been used in the choice of the vein to anastomose in 12 consecutive patients with oral cavity post oncological defects reconstructed with the FRFF. The cephalic vein was included in the flap; the VCs were individually clipped with small liga‐clips and divided with the radial artery still patent. The flap was kept with arterial inflow and superficial venous outflow till the recipient site was ready. If there were no signs of venous stasis, the VCs were kept clipped and the cephalic vein anastomosis was made. If clinical signs of venous stasis were revealed, the largest of the VCs was anastomosed to a vein of adequate caliber in the neck. No signs of flap venous congestion were observed in the postoperative period. No flap necrosis occurred. In this small series of patients the venae comitantes clipping test showed to be an easy, reliable and reproducible method to assess intra‐operatively which vein to anastomose. © 2015 Wiley Periodicals, Inc. Microsurgery 36:647–650, 2016.     

An alternative approach in the treatment of Dupuytren's contracture skin defects: first dorsal metacarpal artery island flap

Skin defects are often present following surgery for Dupuytren's contracture. The first dorsal metacarpal artery island flap (FDMA) has been used by others for soft tissue reconstruction about the radial and dorsal aspect of the hand, thumb and fingers. We have used it successfully to fill the skin defects often seen following palmar fasciectomy for Dupuytren's contracture. The thin nature of the flap makes it suitable for this application. The FDMA arises from the radial artery just before the radial artery enters the first dorsal interosseous muscle and divides into three branches: 1 to the thumb, 1 to the index finger (radiodorsal branch) and a muscular branch. It is the radiodorsal branch that supplies the skin over the index finger. The island flap based on this artery includes the dorsal terminal branches of the radial nerve and venae comitantes. The flap is formed to include the fascia of the first dorsal interosseous muscle to avoid injury to a possible deep artery and to yield sufficient fat to promote venous drainage. The flap is passed subcutaneously through the first web space and sutured in place to cover the skin defect in the palm. A full thickness skin graft is used to cover the defect over the proximal phalanx of the index finger.     

第一掌骨背侧血管蒂岛状皮瓣的应用解剖

目的研究第一掌骨背侧４种血管蒂岛状皮瓣的应用解剖学基础。方法对３２只新鲜尸手标本,分别行血管染料灌注、血管造影、透明标本后,进行显微解剖学观察。结果（１）桡动脉腕背支、拇指桡侧指背动脉、第一掌背动脉的拇指尺侧支、拇指桡掌侧动脉掌指关节周围支、拇主要动脉分出的拇指尺侧指背动脉等５支血管,共同构成第一掌骨背面区域筋膜层的血管网;并与拇指背皮神经呈节段性伴行。（２）供区内有２条同行浅静脉干,存在静脉瓣膜。结论该供区可设计成拇指桡侧指背动脉、拇指桡侧血管筋膜蒂、拇指尺侧指背动脉筋膜蒂和拇指背皮神经伴行血管蒂等４种类型的岛状皮瓣,可顺行或逆行移位修复创面。     

Lateral sural cutaneous artery island flap in the treatment of soft tissue defects at the knee

This paper describes a flap for covering defects around the knee. Dissections of 20 legs showed that in the majority the lateral sural cutaneous artery branched from the popliteal artery and descended along the posterolateral aspect of the leg together with two venae comitantes and the lateral sural cutaneous nerve. An island flap was designed, pedicled on these vessels and nerve, and was used in 17 patients with defects around the knee, including acute trauma (three cases), soft tissue tumours (three cases), unstable scar or ulcer (seven cases), and chronic osteomyelitis or infected open fractures with tissue loss (four cases). All the flaps survived entirely and possessed normal sensation. Furthermore, it was not necessary to sacrifice the main vessels of the lower leg.     

Survival of a free radial forearm flap without venous return

The radial forearm free flap is an ideal transfer for intraoral reconstruction because of its large vessels and pliable nature. In the case presented, a proximally-based forearm flap was transferred for reconstruction of an intraoral defect in the buccal and retromolar region after carcinoma resection, but there was no venous flow from either cephalic vein or venae comitantes following completion of the arterial anastomosis. In order to reduce the congestion in the flap, an end-to-end anastomosis between the distal end of the radial artery and the ipsilateral lingual vein was performed. Despite the absence of venous return, flap survival was complete.     

Palmar arch reconstruction using dorsal venous arch of foot for revascularisation of multiple digits

A case of trauma causing total loss of superficial and deep palmar arches of hand with ischemia of all the digits was managed using dorsal venous arch of the foot to reconstruct the palmar arch. The ends of the venous arch were anastomosed to radial and ulnar arteries and the tributaries to the arch were coapted to the cut ends of the common digital vessels and princeps pollicis. The surgery yielded gratifying results, successfully revascularising all the digits.KEY WORDS: Dorsal venous arch graft, finger revascularization, palmar arch reconstruction     

Further experience with the bipedicled neurovascular island flap in thumb reconstruction

A procedure is described for the transfer of sensibility to the thumb by means of an island flap. The donor site is the dorsoradial surface of the index finger. The flap is supplied by two neurovascular pedicles. The palmar one includes the digital artery of the index and the dorsal branch of the palmar digital nerve. The dorsal pedicle includes the dorsoradial artery and nerve of the index and one or two superficial veins. This procedure was used in 29 patients without early postoperative complications. The advantages of the method are the resurfacing of the prehensile surface of the thumb by a flap with good arterial and venous supply while preserving the innervation and the palmar skin of the donor finger.     

指尖冲压性断指再植体会

目的 介绍指尖冲压性离断的治疗效果和经验总结。方法 对85例103指指尖冲压性断指进行再植,吻合指固有动脉终末端或指动脉弓分支或指固有动脉终末端与指动脉弓分支吻合或动静脉转流,尽可能多吻合指掌侧静脉,对各类型平面的指尖离断的断指均进行再植。结果 各型成活率分别为：Ⅰ型83.9％,Ⅱ型72.5％,Ⅲ型57.1％。结论 只要冲压性离断的指体仍较完整,清创时能找到可供吻合的血管,应予以再植。高质量的血管的吻合技术和良好的静脉血回流是保证再值成功的关键。     

Usefulness of vascular bundle interposition of the descending branch of the lateral circumflex femoral vessels for free flap reconstruction of the calvarial defect

Usefulness of the descending branch of the lateral circumflex femoral vessels as a vascular bundle interposition graft was introduced. Large calvarial defect with no recipient vessel for direct anastomosis was successfully covered with free flap nourished by the cervical vessels through the vascular bundle interposition graft of the descending branch of the lateral circumflex femoral artery and its venae comitantes. The vascular bundle interposition has remarkable advantages over the venous graft regarding its patency and durability, especially in the head and neck region in which grafted vessels is difficult to be set on the straight. The descending branch of the lateral circumflex femoral vessels can be harvested up to 20 cm, and its diameter is suitable for interposition between conventional free flaps and recipient vessels in the head and neck region.     

Free toe transfer with plantar metatarsal arteries and dorsal venous pedicle. Report of 18 cases

Eighteen free second toe were used for pollicization other than the conventional method. From the first and second plantar metatarsal arteries junction of the both digital arteries of the second toe were dissected retrogradely and anastomosed to the deep of superficial palmar arch or terminal branch of the radial artery. The venous return was established between the dorsal venous arch and cephalic vein. These vessels were found to have much bigger diameters and less anatomical variation than those used by conventional methods. Seventeen transplantation were considered successful both functionally and cosmetically. One cases had persistent spasmodic contraction of the recipient arteries, so the transplant was salvaged by subclavicular pedicle including the sutured nerves and the attached soft tissues as introduced by Lu in 1964. Our method for reconstruction of the thumb or finger can avoid frequent anatomical variation and smaller diameter of the anastomosed vessels.     

The Free Abdominoplasty Flap and Its Use in Breast Reconstruction: An Experimental Study and Clinical Case Report

In search for a free microvascular flap which would give abundant reconstructive material as well as a satisfactory donor site the free abdominoplasty flap was developed. The flap is designed on the area between the umbilicus, the pubic region and the anterior superior iliac spines and is based on the inferior epigastric vessels on one side only. In eight regular abdominoplasty procedures elevation of this flap and keeping the blood flow intact through the isolated vessels did not jeopardize the viability of the flap. Angiography of the specimens showed a good perfusion. The free abdominoplasty flap has been used for breast reconstruction in 2 cases of radical mastectomy. The first was a failure because of venous thrombosis. In the second case 3 veins were anastomosed, 2 venae comitantes to the inferior epigastric vein and the contralateral superficial epigastric vein and the result was favourable.     

Scalp free flap reconstruction using anterolateral thigh flap pedicle for interposition artery and vein grafts

We experienced satisfactory outcomes by synchronously transplanting an artery and vein using an anterolateral thigh flap pedicle between the vascular pedicle and recipient vessel of a flap for scalp reconstruction. A 45-year-old man developed a subdural hemorrhage due to a fall injury. In this patient, the right temporal cranium was missing and the patient had 4×3 cm and 6×5 cm scalp defects. We planned a scalp reconstruction using a latissimus dorsi free flap. Intraoperatively, there was a severe injury to the right superficial temporal vessel because of previous neurosurgical operations. A 15 cm long pedicle defect was needed to reach the recipient facial vessels. For the vascular graft, the descending branch of the lateral circumflex femoral artery and two venae comitantes were harvested.The flap survived well and the skin graft was successful with no notable complications. When an interposition graft is needed in the reconstruction of the head and neck region for which mobility is mandatory to a greater extent, a sufficient length of graft from an anterolateral flap pedicle could easily be harvested. Thus, this could contribute to not only resolving the disadvantages of a venous graft but also to successfully performing a vascular anastomosis.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.