Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 984e989

Palmar contracture release with arterializedvenous instep flap: An anatomical andclinical study

Fatih Zor a,*, Bulent Yalcın b, Levent Tekin c, Muhitdin Eski a,Selcuk Is‚ık

a, Mustafa S‚engezera

a Gulhane Military Medical Academy, Department of Plastic and Reconstructive Surgery,Ankara, Turkeyb Gulhane Military Medical Academy, Department of Anatomy, Ankara, Turkeyc Gulhane Military Medical Academy, Haydarpasa Training Hospital,Department of Physical Medicine and Rehabilitation, Istanbul, Turkey

Received 13 June 2014; accepted 19 March 2015

KEYWORDSArterialized venousflap;Instep flap;Palmar contracturerelease;Glabrous skin flap

* Corresponding author. GATA PlastiE-mail address: fatihzor@yahoo.co

http://dx.doi.org/10.1016/j.bjps.2015.01748-6815/ª 2015 British Association of

Summary Background: Plantar skin has similar histologic features to the palmar area and ap-pears to be the ideal tissue for reconstruction of the palmar region. In this study, an anatomicexamination was performed to determine the superficial venous architecture of the insteparea, and the use of arterialized venous instep flaps for palmar contracture release was as-sessed.Methods: The anatomical study was performed on 12 fresh cadaver feet. The arterializedvenous instep flap, including the skin, subcutaneous tissue and superficial venous plexus,was harvested. To determine the venous structure, dissection (n Z 6) and injection-corrosion (n Z 6) techniques were used. In the clinical study, nine arterialized venous instepflaps were used for palmar contracture release. All flaps were harvested above the deep fasciaand included skin, subcutaneous fat, and the superficial venous plexus. At the plantar site ofthe flap, two or three veins, one of which was used, were dissected for a sufficient length forthe arterial anastomosis. The saphenous vein was used for the venous anastomosis.Results: Dissection and injection-corrosion techniques revealed that the flap had 7e12 and4e6 veins at its plantar and superior edges, respectively, with numerous anastomoses and in-terconnections between the veins.

The flap dimensions were between 3 � 5 cm and 4� 6 cm. All flaps survived, with two partialflap necrosis that healed with spontaneous epithelization. No debulking procedures were un-dertaken and all flaps adapted well to the recipient site.

k Cerrahi Klini�gi, Etlik/Ankara, Turkey. Tel.: þ90 3125425406; fax: þ90 3125425402.m (F. Zor).

3.024Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Palmar contracture release with arterialized venous instep flap 985

Conclusions: The arterialized venous instep flap is a good alternative to reconstruct palmarcontractures by adding similar tissue that is thin and pliable with minimal donor site morbidity.ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Figure 1 The venous plexus of instep region.

Introduction

Patients with palmar contractures may encounter diffi-culties when performing normal daily activities. Althoughmild forms of palm contracture can be treated with graftsand local flaps,1 the only alternative for severe forms ofthis condition are distant or free flaps.2 The ideal flapshould have several features that facilitate the recon-struction of defects due to palmar contracture release. Inparticular, the ideal flap must have similar histologicalcharacteristics similar to those of the palmar region.Moreover, the ideal flap should be thin and pliable (but notwobbly) to adapt to the palmar region. Additionally, it mustcause minimal donor site morbidity while having anappropriate pedicle for microsurgical anastomosis.3,4

To date, several flaps have been used for this purpose,including the medial plantar flap.2,4e6 The glabrous skin ofthe plantar area is very similar to palmar skin. Theepidermis and dermis are much thicker, and the fibroussepta that binds the plantar skin to the plantar aponeurosisresults in the formation of fat loculations.7 However, theseflaps are bulky and require a major artery to be sacrificedfor harvesting.

An arterialized venous flap is a skin flap that has arterialinflow through an afferent vein, which allows perfusion ofthe flap, as well as venous outflow through the efferentveins, which permits drainage of the flap. The mainadvantage of arterialized venous flaps is that the sacrificeof a major artery is not required. Moreover, they are verythin and pliable and can be harvested easily in a shorttime.1,6 Based on the advantages of arterialized venousflaps the histologic similarity between plantar skin andpalmar skin, an arterialized venous flap harvested from anon-weight bearing area is considered to be a good alter-native for palmar reconstruction.

In this study, an anatomic examination was performed todetermine the superficial venous architecture of the insteparea, and the use of arterialized venous instep flaps forpalmar contracture release was assessed.

Materials and methods

Anatomical study

The study was performed on 12 feet obtained from fourmale and two female cadavers. The borders of the flapswere marked like the medial plantar flap, and flaps,including skin, subcutaneous tissue and the subcutaneousvenous network, were harvested from the non-weightbearing area of the feet. The dimensions of the flapswere 50e55 � 70e80 mm. To show the venous architectureof the flap, dissection and injection-corrosion techniqueswere used. Six flaps were carefully dissected with the aid of

a dissection microscope at 1.6 � magnification. Dissectionwas performed from the great saphenous vein to the veinsat the lower border of the flap. Exposed veins were coloredblue and then photographed (Figure 1). The remaining sixflaps were investigated via the injection-corrosion tech-nique. The veins at the lower border of the flap werechosen for injection and cannulated (Figure 2a). The veinswere flushed with a solution of sodium chloride (0.09%) andsodium citrate (3.8%). A polyester mix, consisting of poly-ester (10 mL), catalyst (0.5 mL), and accelerator (0.5 mL),was used for injection and diluted sulfuric acid (40%) wasused for corrosion.

The polyester mix was placed in a bottle and stirred witha glass rod for 20 s. The working life of the prepared solu-tion was about 7 min, which allowed enough time for in-jection. The solution was injected into the veins at astarting pressure of 50 mm Hg; however, after 2e3 min, thepressure increased to 80e100 mm Hg. The flaps were hungfor about 4e6 h to allow solidification of the polyester andthen carefully put in diluted sulfuric acid solution for24e48 h. When the corrosion was complete, they weregently washed under cold tap water until all remnant tissuewas removed. Finally, they were dried at room temperatureand photographed (Figure 2b). Measurements were per-formed with a Vernier caliper.

Clinical study

PatientsThe study was performed at the Gulhane Military MedicalAcademy, Department of Plastic and Reconstructive Sur-gery. The Local Ethics Committee approved the studyprotocol.

A total of nine patients were operated on for palmarcontracture release due to burns. The median age of the

Figure 2 a: The cannulation of superficial veins at theplantar border. b: The appearance of the venous plexus afterinjection and corrosion.

Figure 3 a: The planning of the arterialized venous instepflap. b: The appearance of the harvested flap, afferent (ar-rows) and efferent vessels.

986 F. Zor et al.

patients was 20 (18e24) years and all of them were male.All patients were suffering from palmar burn contracturedue to a burn during childhood. None had previousoperations.

Surgical techniqueFollowing the release of the palmar contracture, theresulting defect was measured. The flap harvest was per-formed under venous tourniquet (100 mm Hg) for bettervisualization of the superficial veins. The venous architec-ture was marked on the skin, and the skin island of the flapwas marked at the center of the area that had the mostabundant venous plexus (Figure 3a). The veins that were atthe plantar side of the skin island were designated asafferent, and the saphenous vein was prepared for theefferent anastomosis.

The cadaver study showed that the veins are superficialto superficial fascia. Thus, the flap was harvested in aplane, which is just above the superficial fascia. This planeprovided easy dissection and a thin flap. There were ver-tical septa in the flap and we thought that there could beadequate stability without fascia because of the presenceof the septae and the specific skin histology. The flaps weredissected superior to the muscle fascia and included skinand subcutaneous tissues with veins. During the dissection,the subcutaneous veins and venous plexus were protected.

Two or three veins of sufficient length that had large di-ameters were preserved during dissection for the arterialanastomosis, although only one of them was used. We al-ways chose one digital artery in the area of the flap torestore arterial circulation after the vein to be arterializedin the flap was selected. The saphenous vein was dissectedalong a length sufficient enough to enable the venousanastomosis (Figure 3b).

At the recipient site, a digital artery was prepared foranastomosis. Following the transfer of the flap, an efferentvein anastomosis was performed first between the saphe-nous vein and a superficial vein of the hand. Then an end-to-end anastomosis with 10/0 etilon sutures was performedbetween a proximal vein of the flap and the prepared dig-ital artery. The flow direction of this arterialized venousflap was not changed from the original blood flow in theveins. The flap was inserted into the recipient area and thedonor site was closed with a split thickness skin graft.

Postoperative follow-up and evaluationDuring the postoperative period, high molecular weightdextran was used at a dose of 0.5 mL/kg for five days. Thefollow-up of the flaps was performed with capillary refill,ultrasonic Doppler, and laser flowmeter. During the edem-atous phase of the flap we only used elevation and tulle

Palmar contracture release with arterialized venous instep flap 987

gras dressing. When the flap was congested and capillaryrefill was obscured, Doppler evaluation and bleeding pat-terns from the stab wounds in the flap were the most usefultools for differentiating typical congestion of the venousflaps from true thrombosis of the anastomosed vessels.

Passive and active motions of the hand were respec-tively started at 10 days and 21 days postoperatively. Adynamic splint was applied for three months. The medianfollow-up period was 9 (6e16) months. A two-pointdiscrimination test was performed at six months.

Results

Results of the anatomical study

In the dissection technique, seven to 12 veins wereobserved at the lower border of the flap. Their mean di-ameters, from anterior to posterior respectively, were0.78 � 0.24, 0.83 � 0.15, 0.76 � 0.35, 0.83 � 0.12,0.86 � 0.21, 0.79 � 0.13, 1.02 � 0.45, 0.79 � 0.27,

Figure 4 a: Measurement of venous architecture following thefollowing the injection-corrosion technique.

0.92 � 0.45, 0.95 � 0.62, 1.18 � 0.22, and 1.09 � 0.67 mm.During their course from proximal to distal, many anasto-moses were observed between adjacent veins. The meandiameter of the anastomotic branches was 1.05 � 0.65 mm.Four to six veins draining into the great saphenous veinwere observed at the upper border of the flap. Their meandiameters, from anterior to posterior respectively, were1.60 � 0.32, 1.25 � 0.25, 1.38 � 0.21, 1.33 � 0.47,0.98 � 0.37, and 1.45 � 0.90 mm (Figure 4a).

In the injection-corrosion technique, seven to 12 veinswere also observed at the lower border of the flap. Theirmean diameters, from anterior to posterior respectively,were 0.84 � 0.38, 0.85 � 0.23, 0.74 � 0.12, 0.84 � 0.23,0.88 � 0.21, 0.77 � 0.23, 1.05 � 0.37, 0.82 � 0.30,1.08 � 0.67, 1.27 � 0.56, 1.35 � 0.8, and 1.65 � 0.23 mm.As in the dissection technique, many anastomoses wereobserved between the veins, and the mean diameter of theanastomotic branches was 1.16 � 0.34 mm. Four to six veinsdraining into the great saphenous vein were observed at theupper border of the flap. Intravenous valves were generallypresent at the point where the veins joined with the great

dissection technique. b: Measurement of venous architecture

988 F. Zor et al.

saphenous vein. Mean diameters of the veins at the upperborder of the flap, from anterior to posterior respectively,were 1.55 � 0.09, 1.11 � 0.32, 1.18 � 0.15, 1.27 � 0.57,1.05 � 0.42, and 1.54 � 1.34 mm (Figure 4b).

Results of clinical study

All flaps survived with no total flap loss. Edema and venouscongestion were observed in all flaps with a peak at 48 hpostoperatively. Despite the venous congestion, the circu-lation of the flap was good. Partial flap necrosis wasencountered in two flaps. In three of the cases, followingthe venous congestion, bullae formation and epidermolysiswere observed. These areas healed with secondary inten-tion without additional surgical procedure. The flap di-mensions were between 3 � 5 cm and 4 � 6 cm, and theaverage surface area was 18 cm2.

The arterialized venous instep flaps were observed toadapt well to the recipient area with a good color andtexture match. None of the flaps needed the debulkingprocedure (Figure 5a,b). The donor sites healed withoutproblems.

The two-point discrimination test at six months post-operatively revealed averages of 5.7 mm and 9.7 mm in thehealthy hand and flaps, respectively.

Figure 5 Preoperative appearance and postoperative resultsat nine months.

Discussion

Various techniques have been described for reconstructingpalmar defects, and each technique possesses its own ad-vantages and disadvantages.5,7e9 Alhtough skin grafts are agood alternative for mild contractures, the release ofmoderate and severe contractures results in the exposureof tendons and other vital structures, which makes flapcoverage inevitable. In most cases, free tissue transferremains the only reconstructive option.2

The ideal flap for palmar reconstruction must have his-tological characteristics similar to the palmar region and bethin and pliable to adapt well to the contours of thehand.2,3 The currently used flaps do not fulfill thesereconstructive aims because of their bulkiness, whereassome alternatives have disadvantages related to the donorsite.10 Since the first study by Nakayama in 1981, variousstudies on arterialized venous flaps have been publish-ed.6,11,13e15 In addition to being thin and pliable, such flapsare easy to harvest and do not require the sacrifice of amajor artery during harvesting.6

Previous studies have shown that, for successful tissuetransfer, the skin island should be centered at the mostabundant part of the venous plexus.12 In the present study,an anatomical study was performed prior to the clinicalstudy to assess the venous architecture of the instep regionand to determine whether it could serve as a suitablevenous flap. The results showed that the instep region has arich venous plexus and that the calibers of the veins aresuitable for microsurgical tissue transfer. To our knowl-edge, no previous study has reported the structure of thevenous plexus of a venous flap.

The average caliber of the proximal veins was 0.8 mm.Although an anastomosis between these veins might appearchallenging, the blood flows from high to low pressure inarterialized venous flaps, similar to that in an arteriovenousfistula. Accordingly, this type of blood flow makes theanastomoses reliable. Previous studies have not reportedany arterial problem in arterialized venous flaps, and thepresent study did not observe total flap necrosis due toanastomosis failure. Nonetheless, the major problem ofthese flaps is venous congestion. The literature advocatesperforming more than one efferent venous anastomosis tohelp reduce venous congestion.12 However, instead ofperforming more than one anastomosis, we preserved themain branches of the saphenous vein and used it as theefferent vein of the flap.

Fine movements are important in hand function, andreconstructing the palmar region with a thin and glabrousflap is crucial for good esthetic and functional results. Therecent advances in perforator free flaps make it possible toobtain wide and thin cutaneous free flaps for resurfacing ofthe hand.4 However, harvesting a perforator flap is muchmore complicated and time-consuming than harvestingvenous flaps. Moreover, debulking of perforator flaps re-quires expertise.6 Thus, it seems logical and advantageousto use venous flaps in particular situations. In our study, thearterialized venous flap was used successfully to recon-struct palmar contractures. The flap was histologicallysimilar to the palmar tissue with an excellent texture andcolor match, and was sufficiently thin to adapt well to the

Palmar contracture release with arterialized venous instep flap 989

contours of the hand. No debulking procedure was needed.For palmar reconstruction, an arterialized venous flapshares the advantages of the medial plantar flap but not itsdisadvantages, including bulkiness and the need for sacri-fice of a major artery of the foot.7,10

Protective sensory recovery is important for a successfulpalmar reconstruction.5 Anatomically, it is possible toinclude a cutaneous branch of the medial plantar nervewith the instep flap. However, studies in the literaturesuggest that venous flaps can achieve sensory restorationwithout neurorrhaphy.1,13,14 In our study, neural repair wasnot performed, but adequate protective sensation wasrestored. A flap can be harvested with an attached sensorynerve, but the flap then becomes thicker. We believe thatnerve coaptation may improve two-point discrimination.However, We believe that an ultra-thin flap is essential inpalmar reconstruction. Because of the thin pliable flappattern, possible nerve coaptation was not thought toimprove the result and therefore was not performed. Dur-ing follow up some restoration of sensation was observed inthe flap without nerve coaptation possibly due to the richvenous plexus that carries small nerve branches. However,no formal evaluation using for example Semmes WeinsteinMonofilament measurements was done.

Conclusion

An arterialized venous instep flap has an abundant venousnetwork, which makes it reliable. It is a good alternative toreconstruct palmar contractures by adding similar tissuethat is thin and pliable with minimal donor site morbidity.

Ethical approval

N/A.

Funding

None.

Conflict of interest

None.

References

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9. Yan H, Fan C, Zhang F, Gao W, Li Z, Zhang X. Reconstruction oflarge dorsal digital defects with arterialized venous flaps: ourexperience and comprehensive review of literature. Ann PlastSurg 2013;70(6):666e71.

10. Ninkovic MM, Weshselberger G, Schwabegger AH, Anderl H. Theinstep flap to resurface palmar defects of the hand. PlasticReconstr Surg 1996;97:1489e93.

11. Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterialinflow through the venous system: an experimental investiga-tion. Plastic Reconstr Surg 1981;67:328e34.

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13. Yokoyama T, Hosaka Y, Kusano T, Morita M, Takagi S. Fingerpalmar surface reconstruction using medial plantar venousflap. Possibility of sensory restoration without neurorrhaphy.Ann Plastic Surg 2006;57:552e6.

14. Hirase Y, Kojima T. The use of innervated digital island flaps forsensory recovery in fingertip reconstructions: considerationsfor the surgeon. Jpn J Plastic Reconstr Surg 1993;36:627e34.

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