The dorsal scapular island flap: an alternative for head,neck, and chest reconstruction

The back has become an increasingly popular donor site for flaps because it can provide thin, pliable tissue, with minimal bulk, and the scar can be easily hidden under clothing. The authors performed a cadaveric and clinical study to evaluate the anatomy of the dorsal scapular vessels and their vascular contribution to the skin, fascia, and muscles of the back. On the basis of anatomical studies in 28 cadavers and clinical experience with 32 cases, it was concluded that the dorsal scapular vessels provide a reliable blood supply to the skin of the medial back, making it a versatile flap to use as an island flap. A flap raised on the dorsal scapular vessels can be harvested with a long pedicle and can be rotated to reach as far as the anterior regions of the head, neck, and chest wall. Delaying and expanding the flap may help to facilitate venous drainage. The authors recommend the use of this versatile island pedicle flap as an alternative to microvascular free-tissue transfer for the reconstruction of defects in the head, neck, and anterior chest.     

Distally based dorsal forearm fasciosubcutaneous flap

Use of a local flap is often required for the reconstruction of a skin defect on the dorsum of the hand. For this purpose, a distally based dorsal forearm fasciosubcutaneous flap based on the perforators of the posterior interosseous artery was developed. From 1997 until 2002, this flap was used to reconstruct skin defects on the dorsum of the hand in nine patients at Chonnam National University Medical School. The sizes of these flaps ranged from 10 to 14 cm in length and from 5 to 7 cm in width. The flaps survived in all patients. Marginal loss over the distal edge of the flap was noted in one patient. Three flaps that developed minimal skin-graft loss were treated successfully with a subsequent split-thickness skin graft. The long-term follow-up showed good flap durability and elasticity. The distally based dorsal forearm fasciosubcutaneous flap is a convenient and reliable alternative for reconstructing skin defects of the dorsum of the hand involving vital structure exposure. It obviates the need for more complicated and time-consuming procedures.     

The thin latissimus dorsi perforator-based free flap for resurfacing

The authors present their experience with "thin" latissimus dorsi perforator-based free flaps for resurfacing defects. Perforator-based free flaps have been used for various kinds of reconstruction by presenting important donor structures. The thin latissimus dorsi perforatorbased free flap included only the skin and superficial adipose layer to reduce its bulkiness by dissection through the superficial fascial plane. This flap was used in 12 clinical cases, without flap necrosis or other serious postoperative complications. All of the patients were examined by preoperative power Doppler ultrasound in the spectral Doppler mode to search for the most reliable perforator. This noninvasive ultrasound technique determines the exact location and course of and ensures the reliable flow of the perforators; therefore, it greatly assists microsurgeons in saving operation time and in selecting the most suitable design for perforator flap reconstruction. We used perforators that were identified several centimeters from the lateral border of the latissimus dorsi muscle. The thin flap dimensions could be safely designed for flaps measuring up to 20 cm in length and 8 cm in width for primary closure of the donor site. Generally, a long pedicle is not required for resurfacing reconstructions, where small recipient arteries in the bed are acceptable for anastomosis with pedicles. However, pedicle dissection to the proximal vessels through the latissimus dorsi muscle was required when it was necessary to match the recipient vein for anastomosis. The authors conclude that this thin latissimus dorsi perforator-based free flap has great potential for resurfacing because of its constant thickness, easy elevation with the help of power Doppler ultrasound information, and proper flap size for moderate defects caused by scar contracture release, superficial tumor ablation, and so on.     

De novo induction of island capsule flap by using two silastic sheets: Part 1. Generation

A new experimental model for de novo generation of an axial pattern island flap has been designed in a rat model. The purpose of this study was to make a sufficient vascular carrier, as an island capsule flap, with only vascular pedicles and addition of collagen fibers induced by foreign-body reaction. The femoral arteriovenous bundle was isolated and sandwiched between two 2.5 x 1.5 cm Silastic sheets. Eight weeks later, as a delay procedure, femoral vessels were ligated at the distal end of the Silastic sheets and the four margins of the sheets were divided except for the vascular pedicle. This capsule flap was raised as a secondary island flap connected only by its vascular pedicle, then it was sutured back in place. Ten days after the delay procedure, the upper Silastic sheet was removed and a full-thickness skin graft was performed on the capsular island flap. Animals were killed at 80 days. A total of 40 axial pattern capsulocutaneous flaps from 20 Sprague-Dawley rats were successfully achieved. Pathologic study revealed neovascularization, and abundantly impregnated vascular structures near the pedicle were observed with randomly developed collagen fibers. The skin graft took 100 percent on this newly formed capsular flap; therefore, the capsule structure was able to survive on its own and support skin grafts. This experiment, by using an isolated femoral artery and vein as the main pedicle, led to the formation of a capsule flap through a normal foreign body reaction between two Silastic sheet implants. This new flap can be used as a reliable vascular carrier for various needs with minimal donor morbidity.     

Clinical applications of free soleus and peroneal perforator flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.     

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.     

Extending the reach of the heterodigital arterialized flap by vein division and repair

The heterodigital arterialized flap is ideal for nonsensory reconstruction of sizable soft-tissue defects in the proximal fingers, web spaces, and the hand. The inclusion of a dorsal vein augments the venous drainage of this digital island flap and avoids the problem of postoperative venous congestion, which is a common problem in digital island flaps. However, the presence of a dorsal vein pedicle inhibits flap mobility somewhat, and the reach of the flap is mainly limited to adjacent fingers. In situations that demand a transfer from a nonadjacent donor finger or when the reach from the adjacent donor finger is inadequate, the dorsal vein pedicle can be temporarily divided and then anastomosed microsurgically after flap transfer is performed. This enables the reach of the flap to be extended up to two fingers from the donor finger. The authors performed this "partially free" heterodigital arterialized flap in 11 consecutive patients between 1991 and 2001. The average size of the defects was 4.4 x 2.3 cm. All of the flaps survived completely, without any evidence of postoperative flap congestion. Healing of all of the flaps was primary and did not result in any scarring. All of the donor fingers had "normal" two-point discrimination of 3 to 5 mm. All of the donor fingers retained excellent or good total active motion, as graded by the criteria of Strickland and Glogovac.     

Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand

A vascularized bone segment of the ulna together with a posterior interosseous fasciocutaneous flap is harvested, including a cuff of the extensor pollicis longus muscle. The authors treated five male patients with metacarpal bone and soft-tissue defects of the hand using a distally based island osteocutaneous posterior interosseous flap. Their ages at the time of surgery ranged from 15 to 37 years (mean, 24 years). The bone defects were in the first metacarpal in three cases, the fourth metacarpal in one, and the fifth metacarpal in one. The length of the donated ulna ranged from 3 to 7 cm (mean, 5 cm). The follow-up period ranged from 5 to 92 months (mean, 39 months). All flaps survived completely. The posterior interosseous flap provides thin skin of good texture, together with vascularized bone, for a one-stage reconstruction of the metacarpal bone and soft-tissue defects in the hand.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

The boomerang flap in managing injuries of the dorsum of the distal phalanx

Finding an appropriate soft-tissue grafting material to close a wound located over the dorsum of a finger, especially the distal phalanx, can be a difficult task. The boomerang flap mobilized from the dorsum of the proximal phalanx of an adjacent digit can be useful when applied as an island pedicle skin flap. The vascular supply to the skin flap is derived from the retrograde perfusion of the dorsal digital artery. Mobilization and lengthening of the vascular pedicle are achieved by dividing the distal end of the dorsal metacarpal artery at the bifurcation and incorporating two adjacent dorsal digital arteries into one. The boomerang flap was used in seven individuals with injuries involving the dorsal aspect of the distal phalanx over the past year. Skin defects in all patients were combined with bone,joint, or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-step procedure preserves the proper palmar digital artery to the fingertip and has proven valuable for the coverage of wide and distal defects because it has the advantages of an extended skin paddle and a lengthened vascular pedicle. When conventional local flaps are inadequate, the boomerang flap should be considered for its reliability and low associated morbidity.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.     

The lateral forearm flap as a modification of the lateral arm flap: vascular anatomy and clinical implications

The forearm extension of the lateral arm flap was introduced on the basis of the vascular territory of the posterior radial collateral artery extending beyond the elbow into the forearm. However, there is controversy as to whether the posterior radial collateral artery extends as a single trunk below the elbow or if it terminates more proximally with only a rich vascular plexus extending beyond the elbow. The purpose of this study was to revisit the artery's anatomy in the region of the elbow and to study its distribution in the forearm. Using latex and barium-gelatin injections of the posterior radial collateral artery in ten cadaveric upper limbs, it was observed that terminal branching of the artery occurred 4.5 cm proximal to the lateral epicondyle of the humerus. Distal to the epicondyle, the terminal branches of the posterior radial collateral artery were seen to fan out as finely arborized branches supplying the lateral forearm skin. No single, constant vascular trunk to the forearm skin could be identified. Furthermore, in its distribution toward the periphery, the terminal branches of the posterior radial collateral artery took an increasingly superficial course. Proximal to the epicondyle, the vessels lay deep within the subcutaneous fat, whereas distal to the epicondyle, they were very close to skin. These findings suggest that lateral forearm skin cannot be islanded without risk of vascular disruption and that the distally sited flap should include skin proximal to the epicondyle for safety.     

Clinical applications of the posterior rectus sheath-peritoneal free flap

Soft-tissue injuries involving the dorsum of the hand and foot continue to pose complex reconstructive challenges in terms of function and contour. Requirements for coverage include thin, vascularized tissue that supports skin grafts and at the same time provides a gliding surface for tendon excursion. This article reports the authors' clinical experience with the free posterior rectus sheath-peritoneal flap foil dorsal coverage in three patients. Two patients required dorsal hand coverage; one following acute trauma and another for delayed reconstruction 1 year after near hand replantation. A third patient required dorsal foot coverage for exposed tendons resulting from skin loss secondary to vasculitis. In all three patients, the flap was harvested through a paramedian incision at the lateral border of the anterior rectus sheath. After opening the anterior rectus sheath, the rectus muscle was elevated off of the posterior rectus sheath and peritoneum. When elevating the muscle, the attachments of the inferior epigastric vessels to the posterior rectus sheath and peritoneum were preserved while ligating any branches of these vessels to the muscle. Segmental intercostal innervation to the muscle was preserved. The deep inferior epigastric vessels were then dissected to their origin to maximize pedicle length and diameter. The maximum dimension of the flaps harvested for the selected cases was 16 X 8 cm. The anterior rectus sheath was closed primarily with non-absorbable suture. Mean follow-up was 1 year, and all flaps survived with excellent contour and good function in all three patients. Complications included a postoperative ileus in one patient, which resolved after 5 days with nasogastric tube decompression.     

The tunneled supraclavicular island flap: an optimized technique for head and neck reconstruction

Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure. The methods range from local, mostly myocutaneous flaps and skin grafts to free microsurgical flaps. To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always essential. Moreover, the donor-site defect needs to be reduced, with no resulting functional or aesthetic impairment. We have found that the shoulder is a region providing an optimum skin texture match to the neck and face. In cadaver dissection, a vascular pedicle extending from the transversal cervical artery with two accompanying veins was found to vascularize a defined region around the shoulder cap. In line with these findings, the previously described fasciocutaneous island flap, nourished by the supraclavicular artery, was developed further and used purely as a subcutaneously tunneled island flap. The tunneling maneuver significantly improves the donor site by reducing scarring. The flap is characterized by a long subcutaneous pedicle of up to 20 cm. The pivot point is in the supraclavicular region and allows the flap to be used in the upper chest, neck, chin, and cheek. In this article, we introduce the anatomic features and present clinical cases underlining the surgical possibilities of the flap in reconstructive procedures with expanded indications.     

From the "charretera" to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap

Wide tissue defects located on the face and neck area often require distant flaps or free flaps to achieve a tension-free reconstruction together with an acceptable aesthetic result. The supraclavicular island flap surely represents a versatile and useful flap that can be used in case of large tissue losses. Because of its wide arc of rotation, which ensures a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of the transverse cervical artery or, less frequently, of the suprascapular artery, though reliable, is not a very large vessel. In some particular cases, when too much tension or angles that are too tight are present, the vascular supply of the flap can be difficult and special care must be taken to avoid flap failure. To avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial pedicle, thin and resistant, which ensures good reliability; also, when a higher tension rate is present, it avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with various defects located on the head, neck, and thorax area were treated in the past 2 years using the modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there was marginal skin deepithelialization in only two cases, which only required minor surgery. Postoperative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed donor sites, except for one case, and tension-free scars. The authors show how the modified supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing such as smokers or patients with complex medical histories.     

The lateral intercostal neurovascular free flap

The lateral intercostal flap is a new neurovascular flap that may be used as a free or island flap. It is based on the lateral cutaneous branch of a single posterior intercostal neurovascular bundle. The donor area of the flap is the anterolateral skin of the abdomen. The flap is large, thin, and has a long pedicle that contains the lateral cutaneous nerve. The donor pedicles of the flap are multiple, and its venous drainage is adequate. The detection and design of this flap were based on information gained from the dissection of 95 intercostal spaces in 40 fresh cadavers. The flap was then applied 12 times in 11 patients. Ten flaps were successful, one flap was partially lost, and one was completely lost. The flap was used as a noninnervated flap to resurface six defects in the neck and one facial defect, and it was used as an innervated flap to cover two hand defects and two heel defects.     

The vascular supply of the extended tensor fasciae latae flap: how far can the skin paddle extend?

The vascular supply of the tensor fasciae latae flap and of the lateral thigh skin was studied in 10 cadavers to evaluate whether the lateral thigh skin toward the knee could be incorporated into an extended tensor fasciae latae flap. Within each cadaver, vascular injection of radiopaque material preceded flap elevation in one limb and followed flap elevation in the contralateral limb. Flaps raised after vascular injection were examined radiographically to evaluate the vascular anatomy of the lateral thigh skin independent of flap elevation. When vascular injection was made into the profunda femoris, the upper two-thirds of the flaps was better visualized than the distal third. When the injection was made into the popliteal artery, the vasculature of the distal third of the flaps was better visualized. Flaps raised before vascular injection were examined radiographically to delineate the anatomical territory of the vascular pedicle that had been injected. In these flaps, consistent cutaneous vascular supply was only seen in the skin overlying the tensor fasciae latae muscle, confirming that musculocutaneous perforators are the predominant means by which the pedicle of the tensor fasciae latae flap supplies the skin of the lateral thigh. Extended tensor fasciae latae flaps were elevated bilaterally in one cadaver, and selective methylene blue injections were made into the lateral circumflex femoral artery on one side and into the superior lateral genicular artery on the contralateral side. Methylene blue was observed in the proximal and distal thirds of the skin paddles, respectively, leaving unstained midzones. The vascular network of the lateral thigh skin could be divided into three zones. The lateral circumflex femoral artery and the third perforating branches of the profunda femoris artery perfuse the proximal and middle zones of the lateral thigh skin, respectively. The superior lateral genicular artery branch of the popliteal artery perfuses the distal zone. The middle and distal zones meet 8 to 10 cm above the knee joint, where the skin paddle of the tensor fasciae latae flap becomes unreliable. These data indicate that if the aim is to incorporate the skin over the distal thigh in an extended tensor fasciae latae flap without resorting to free-tissue transfer, then either a carefully planned delay procedure or an additional anastomosis to the superior lateral genicular artery is required.     

The revascularization of pedicle skin flaps in pigs: a functional and morphologic study

Functional and morphologic changes occurring during the revascularization of pedicle flaps have been investigated in the skin of pigs. The skin flaps, 16 cm long by 4 cm wide, were based on a row of segmental vessels arising from the internal mammary artery. Comparative measurements were made in flapped and normal skin. The inherent blood supply in the pedicle of the flap was unable to maintain the whole of the flap in a viable state. Flap viability was ascertained at surgery by the use of the intravital dye Disulphine blue. Injections of the dye after surgery gave a less accurate prediction of viability than when dye was injected prior to surgery. Revascularization between the flap and surrounding skin was evident 3 to 4 days postoperatively at the distal, most hypoxic part of the viable flap. The whole flap had a collateral vascular supply 7 to 10 days after surgery. Isotope clearance studies showed that the greatest functional changes occurred in the distal third of the viable flap, where, after initially slowing, the clearance rate became faster than in normal skin (day 5). Potassium extraction studies indicated similar changes. However, an increase in the red-cell volume on day 1 suggested that vascular shunting was occurring. The results of the morphologic studies indicated a correlation between the number of blood vessels per unit area, the thickness of the dermis, and the recorded functional changes. Seven days after surgery, when isotope clearance rates were very rapid, there was a significant increase in the vascular density and dermal thickness.     

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.