Pure perforator free sensory proximal ulnar artery perforator flap for resurfacing hand defects.

OBJECTIVE: This prospective study was performed to investigate the distribution of proximal ulnar artery perforating vessels through three-dimensional blood vessel reconstruction and examine the presence and consistency of the perforating vessels intraoperatively. METHODS: For anatomical guidance, three-dimensional blood vessel reconstruction was performed to determine the consistent presence of perforating vessels in the proximal ulnar artery. A free proximal ulnar artery perforator flap was then transferred in 17 patients to resurface skin defects on the hands. Color Doppler ultrasound was used to identify and mark the perforating vessels. Intraoperative evaluation was conducted to check for anastomosis of the perforating vessels at the marked sites and assess the vessel anastomosis conditions. RESULTS: No vascular crisis, flap necrosis, or wound infection occurred after surgery in 15 patients. Postoperative follow-up was conducted for 6 to 36 months. The appearance of the flap was satisfactory, the texture of the flap was soft, sensation was well restored, and hand function was not limited. The mean two-point discrimination of the flap was 7.6 ± 2.2 mm. CONCLUSIONS: Free sensory proximal ulnar artery perforator flap transfer is a safe and reliable surgical technique with respect to restoration of both the appearance and sensory function of the hand.

Perforator artery repair in revascularization of extremity degloving injuries.

INTRODUCTION: This article aims to expand the microsurgical treatment options for extremity degloving injuries with perforator artery repairs of the specific degloved angiosomes in upper and lower extremity. METHODS: Fourteen perforator arteries were repaired in seven patients. Four of them had circumferential degloving and 3 of them have non circumferential degloving injury. All had repair of the perforator arteries of the specific degloved segments. Four patients had additional vein repairs but none of the patients had AV shunts. RESULTS: All perforators provided adequate arterial supply to their specific angiosomes with some necrotic areas in neighboring angiosomes. CONCLUSIONS: Perforator artery repair within the degloved tissues provides a direct arterial supply successfully even if one could not find an intact venous plexus.

A Comparative Study of Finger Pulp Reconstruction Using Free Distal Ulnar Artery Perforator Flaps and Reverse Dorsal Homodigital Island Flaps.

PURPOSE: This study aimed to compare and analyze the outcomes of finger reconstruction using free distal ulnar artery perforator (FDUAP) and reverse dorsal homodigital island (RDHI) flaps. METHODS: The study included 27 patients with finger pulp defects that were reconstructed using FDUAP or RDHI flaps. Standardized assessment of outcomes included objective sensory recovery, duration of operation, range of motion in the repaired fingers, pain at the reconstructed finger pulps and donor sites, and recovery time before returning to work. Subjective assessment of outcomes included the cold intolerance, aesthetic appearance, and functional recovery. RESULTS: All flaps in the series showed complete survival. The average surgical time for the RDHI flaps was significantly smaller than that for the FDUAP flaps. Sensory recovery was significantly better with FDUAP flaps than with RAHI flaps. No significant differences were detected between the 2 procedures regarding range of motion, cold intolerance, or pain of the injured finger pulps and donor sites. The outcomes of aesthetic result and functional recovery satisfied all patients. Optimal cosmetic satisfaction was obtained in the FDUAP flap group. CONCLUSIONS: Although both types of flaps offer a satisfactory approach for finger reconstruction with small-to-medium defects, FDUAP flaps are more suitable for such operations because of the better sensory reconstruction and aesthetic results.

Treatment of Recurrent and Persistent Carpal Tunnel Syndrome: The Fasciocutaneous Dorsal Ulnar Artery Flap.

Surgical treatment of recurrent and persistent carpal tunnel syndrome by repeat carpal tunnel release combined with soft tissue nerve coverage results in a higher success rate for symptomatic relief in the presence of a scarred median nerve. Several techniques, including local pedicled flaps, transposition flaps from the distal forearm, and free flaps, have been described, but consensus regarding a preferred technique has not been reached. The dorsal ulnar artery flap or Becker flap is a local fasciocutaneous flap based on a dorsal perforating branch of the ulnar artery that can be used for soft tissue coverage of the median nerve. Advantages of this technique are the quick and easy dissection and low donor site morbidity. Studies of its use for the treatment of recurrent carpal tunnel syndrome are limited.

Vascular territories of the medial upper arm-an anatomic study of the vascular basis for individualized flap design.

BACKGROUND: Fasciocutaneous flaps supplied by discrete perforator arteries can be raised in numerous parts of the human body and are routinely used in plastic surgery. The aim of this anatomical investigation was to provide a description of the vascular supply of the medial upper arm, to localize and measure the perforator arteries and to define potential perforator flap dimensions in pendency of individual anatomical conditions. MATERIAL AND METHODS: A total of 20 upper limbs from 11 fresh cadavers were examined. The brachial arteries were exposed and the medial perforator arteries selectively injected with methylene blue and india ink in an alternating sequence. The size of the angiosomes, the diameter and length of the perforators' pedicles and distances between the arteries and the medial epicondyle and apex of the axilla respectively were measured. RESULTS: On average, 4.55 ± 1.47 perforating arteries arose from the brachial artery and it's medial off branching arteries. Their mean diameter was 0.68 ± 0.27 mm and their pedicles had an average length of 3.62 ± 1.61 cm measured from suprafascial until arborisation. In 80% the first proximal perforator was present in an area of 4 cm radius at centre coordinates of (20/2). A constant distal perforator was found within a circle of 3 cm radius, of which the centre had the coordinates (8/1). The average size of the angiosomes was 121.1 ± 58.5 cm2 . Direct branches of the brachial artery feed circular shaped vascular territories, whereas superior ulnar collateral arteries (SUCAs) feed oblong shaped territories. CONCLUSION: This anatomical study provides valuable data of the medial arm flap in order to be applied clinically. © 2016 Wiley Periodicals, Inc.

[Superficial ulnar artery: Case report]. / À propos d'un cas d'artère ulnaire superficielle.

The anatomical variations of arterial axes of the upper limb are not uncommon and must be known to allow for safe surgical procedures and in order to limit the morbidity of these procedures. The superficial ulnar artery represents, after the variations in origin of the radial artery, the second most frequent variation in this area. When present, reconstructive procedures may be modified, especially when harvesting forearm free flaps, in order to choose this vessel as nourishing pedicle. The authors present the case of a superficial ulnar artery revealed intraoperatively while harvesting a radial forearm free flap, and a review of their cases in order to assess the frequency of this variation, and correlate it to literature.

Colgajo de perforantes de la arteria colateral cubital inferior para defectos por quemadura eléctrica en fosa cubital / Inferior ulnar collateral perforators flap to cover defects on antecubital fossa after electrical burn

Las quemaduras eléctricas producen lesiones profundas, especialmente las debidas a la entrada y salida de la corriente y al arco voltaico, que pueden dejar expuestas estructuras nobles y afectar áreas de flexo-extensión, como la fosa antecubital. Los defectos resultantes pueden cubrirse mediante colgajos libres o pediculados de brazo y antebrazo. Entre las distintas opciones quirúrgicas, el colgajo medial del brazo evita la interrupción de los ejes vasculares mayores y la secuela en la zona donante es discreta. Sin embargo, su uso está poco extendido por considerarse un colgajo de difícil disección debido a la variabilidad anatómica de las arterias colaterales cubitales superior e inferior que lo irrigan. Presentamos la cobertura para un defecto secundario a quemadura eléctrica en la fosa antecubital mediante un colgajo medial del brazo basado en las ramas perforantes de la arteria colateral cubital inferior. Aunque confirmamos en este caso la variabilidad vascular, la disección resultó sencilla y el resultado estético y funcional fue excelente (AU)

Electrical burns result in deep injury to tissues, especially those lesions produced by entrance and exit of electric flow and voltaic arc, that expose structures such as tendons, nerves or vessels when it happens at the antecubital fossa. Defects produced by electrical burns can be covered using free flaps or local pedicled flaps from arm and forearm. Among different surgical procedures, medial arm flap is a useful one, as it avoids interruption of main vascular axis of the arm and donor site sequelae are minimal. Never the less, its use is not extended due to its difficult dissection, as because the pedicle of the flap has a highly variable anatomical vascularity (superior and inferior ulnar collateral artery). We present a defect produced by electrical burn and its coverage using a local flap based on perforator branches from inferior ulnar collateral artery. Although vascular variability was confirmed, dissection was easy and an aesthetical and functional outcome was achieved (AU)

Superficial ulnar artery perforator flap.

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Reverse digital artery flap from radial and ulnar borders of palm.

Reconstructing skin defects of the volar aspect of fingers can be a challenging task due to a lack of local expendable tissue. The reverse digital artery flap is a versatile and reliable technique that can be used to manage such disabling injuries. Various authors have used this flap effectively, but most have used the digit itself as the donor site. This limits the size of the flap and also necessitates skin grafting to cover the donor site. Large reverse digital artery flaps can be raised from the radial and ulnar borders of the palm facilitating coverage of significant digital defects and primary closure of the donor site, resulting in minimal donor-site morbidity. We describe 3 illustrative cases to highlight the flaps versatility.

Coverage of dorsal-ulnar hand wounds with a reverse second dorsal metacarpal artery flap.

This article introduces the use of a modified reverse dorsal hand flap harvested from the radial portion of the dorsal hand and wrist and the distal portion of the dorsal forearm for reconstruction of a large defect involving the third to fifth metacarpophalangeal (MCP) joints and the proximal phalanges. From May 2005 to August 2008, a modified reverse dorsal hand flap was transferred in 12 hands in 12 patients (9 male and 3 female). The mean age at flap transfer was 34.2 years (range: 23 to 50 years) old. All flaps survived. At final follow-up (mean, 28 months; range: 25 to 32 months), the mean active range of motion arcs of the third, fourth, and fifth MCP joints were 85 degrees (range: 65 to 97 degrees), 84 degrees (range: 60 to 90 degrees), and 83 degrees (range: 58 to 94 degrees), respectively. Our technique is useful and reliable for coverage of a large defect involving the third to fifth MCP joints and the proximal phalanges.

Ipsilateral heterodigital artery transfer for finger revascularization.

We report a case of digital revascularization in a child's small finger by using a digital artery from the adjacent uninjured digit. Reconstruction of a defect in the digital artery with a vein graft is technically challenging in a child and has a higher risk of failure due to anastomoses at 2 levels and possible size mismatch. We detail the technique of heterodigital artery transfer from the ring finger to revascularize the small finger with segmental loss of both digital arteries. This technique has not been reported previously and offers a simpler alternative to vein grafting in select situations.

Histologic study of coronary, radial, ulnar, epigastric and internal thoracic arteries: application to coronary artery bypass grafts.

The biometry and the histology of coronary, radial, ulnar, epigastric and internal thoracic arteries were studied in order to investigate the cause of their occlusions in coronary bypass grafts and to improve the results of these bypass grafts. These various arteries were removed from 40 anatomical specimens (27 males and 13 females). We found a correlation between the internal calibers of the ulnar and coronary arteries in males. Intimal changes and the presence of atheromatous plaque were observed in coronary, radial and ulnar arteries, but never in the internal thoracic artery. Like coronary arteries and their branches, radial, ulnar and epigastric arteries are muscular arteries and ageing results in thickening of the intima, which becomes fibrotic with migration of myocytes from the media and duplication of the internal elastic lamina. The media becomes fibrous, hypertrophic or atrophic. In contrast, the internal thoracic artery is an elastic artery, like the aorta. Ageing is characterized by loss, over a variable extent, of one or several elastic laminae of the media and more marked intimal thickening. Although anatomically, the caliber of radial, ulnar, and epigastric arteries remains adapted to that of coronary arteries, the long-term patency of radial, ulnar and epigastric arteries used as grafts is related to their histological characteristics.

B-mode and color Doppler ultrasound of the forearm arteries in the preoperative screening prior to coronary artery bypass grafting.

The objective of this paper was to establish the normal findings of B-mode and color Doppler ultrasound of the forearm arteries in candidates for coronary artery bypass grafting with radial artery graft. Examination of radial and ulnar arteries was performed in 127 patients. The vessel diameters and peak systolic velocities were measured and the presence of atherosclerotic changes, calcifications and anatomical variants was assessed. Radial artery proved to be dominant forearm artery with non-significant side-to-side asymmetry. The luminal changes were present in 30% of the patients. Ulnar arteries were more prone to these changes than radial arteries (28.4% vs. 24.4%). The anatomical variants found included ulnar artery hypoplasia in 3.9% of patients and high brachial artery bifurcation in 2.4% of patients. No cases of high-grade stenosis or occlusion were found. The results of the present study indicate that B-mode and color Doppler are valuable methods for preoperative screening as they enable morphological and functional evaluation of the forearm circulation.

Limb trauma with arterial injury: long-term performance of venous interposition grafts.

BACKGROUND: In contrast to arterial occlusive disease, data on long-term outcomes after vein grafts in limb trauma with arterial injury are sparse. PATIENTS: From 1991 through 2001, 22 trauma victims received 23 interposition vein grafts performed by an interdisciplinary team of trauma and vascular surgeons. Indications included both blunt and penetrating injuries with critical limb ischemia in the majority of cases. RESULTS: Operative treatment of the injured vessels (brachial n = 5, radial/ulnar n = 7, popliteal n = 6, tibial n = 3, pedal n = 2) encompassed venous interposition graft of either saphenous (n = 15) or cephalic vein (n = 8). All patients survived the operative procedure. 4 graft occlusions were noted and 3 major amputations had to be performed (one despite patent graft). 13 patients (76%) were available for duplex ultrasound examination after a mean follow-up of 59 months where patent grafts could be detected in all cases. CONCLUSION: A multidisciplinary approach ensures optimal treatment strategy of arterial injury in extremity trauma. Interposition vein grafts provide durable long-term results and should be attempted even in single-vessel injuries of forearm and lower leg.

Two-stage reconstruction of four-digit amputation: distal ulnar artery flap and combined second- and third-toe transfer.

We report a case of combined two toe transfer after distal ulnar artery fasciocutaneous flap in a 10-year-old boy who has four-digit amputation. Four years after the operation, satisfactory results were obtained both functionally and cosmetically.